Archived: Gorton Parks Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to person centred care, safe care and treatment, meeting nutrition and hydration needs, good governance and fit and proper persons employed. The provider did not do everything reasonably practical to make sure people received person-centred care and treatment. The provider did not fully mitigate risks or ensure medicines were safely managed. People’s nutrition and hydration needs were not always met. Oversight of safety was ineffective. Staffing levels were not always sufficient to meet people’s needs. There was a failure to ensure staff had the qualifications, competence and skills to provide safe care.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Several incidents of aggression between people living at the home, as well as towards staff, had occurred without being proactively reviewed or monitored. This meant there was no assurance people were being supported safely, or effective control measures in place to minimise escalating agitation. Although the incidents had been recorded, the provider had not identified or implemented suitable de‑escalation strategies, despite the recurring nature of the events. One incident had resulted in a staff member sustaining an injury. Opportunities to analyse incidents, learn from patterns, and embed safer practices were not being used to drive continuous improvement or strengthen the safety of people and staff.

Risks to people were frequently overlooked. Although the Care Quality Commission (CQC) had highlighted these concerns at the previous inspection, we continued to find the provider lacked effective oversight of unplanned weight loss and risks associated with skin integrity. A nutrition plan had been developed for people prescribed nutritional supplements, such as high‑calorie shakes. This plan instructed staff to administer supplements at least two hours apart from main meals to support weight management, as these products are not intended to replace food. Despite this guidance, staff were not consistently following the plan. People were often given supplements shortly before or after mealtimes, which reduced their appetite and negatively affected their overall food intake.

At the last inspection, we identified staff were not accurately recording the repositioning of people who were unable to mobilise themselves, placing them at increased risk of skin breakdown. During this inspection, although staff documented in the electronic care records, repositioning had taken place, our observations showed 3 people remained in the same position in their beds for prolonged periods. This demonstrated, records were not a reliable reflection of care delivered, and previous feedback had not been embedded into practice.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

We were not assured clinical staff had the skills or competence to recognise and assess when a person was becoming acutely unwell. We reviewed 2 recent incidents in which people’s health had deteriorated rapidly and nurses had not responded promptly. Although the provider had investigated each event, we remained concerned about nurses’ ability to work effectively and swiftly with health system partners to ensure people received the right care at the right time.

During the inspection, we observed a person becoming increasingly agitated. A review of their daily records showed, their blood sugar levels had fallen to a dangerously low level and this had occurred on several previous occasions. Despite these repeated indicators of clinical risk, the provider had not taken prompt action to identify the underlying cause or ensure the person received safe and appropriate care. Following our visit, the person was reviewed by health professionals.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Despite raising concerns about people’s general wellbeing at the last inspection, we found people continued to be at risk of neglect. Care records indicated people had been supported with their oral hygiene on the morning of the first day of the inspection; however, toothbrushes in almost every room were dry and toothpaste remained unopened. Three relatives told us they had noticed a deterioration in their family members’ dental health and expressed concerns about the lack of oral care. A person living at the home told us, “Eight of my teeth have come out. They just fell out because I find it hard to swallow my tablets, so I have started to chew the tablets. The dentist says my teeth have fallen out due to chewing my medication as it is strong.” We found no further preventative action had been taken to reduce the risk of further oral health decline.

Some relatives raised concerns about their family members’ general hygiene, with several reporting, people were only able to have a bath or shower once per week. Care records stated, people were supported with a wash or bed bath; however, for one person, we observed they remained in bed for most of the day, despite records indicating they had received personal care and washing. This inconsistency suggested that care was not always being delivered as recorded.

We observed people on Abbey Hey House who were visibly agitated, being left without appropriate monitoring or support. Staff did not appear to recognise or respond to signs of escalating distress. One person was seen pacing the floor and raising their voice at others, yet no staff member intervened to reassure them or de‑escalate the situation.

Although staff had completed safeguarding training and told us they felt confident to raise concerns, they did not always demonstrate a clear understanding of what constituted neglect. This lack of awareness resulted in some people not receiving support with their basic hygiene needs, placing them at risk of avoidable harm.

People’s capacity was not always assessed in relation to specific decisions, and best‑interests processes were not consistently documented. The provider had recently decided to move people from Melland House to Sunny Brow House and Debdale House to facilitate a programme of redecoration. However, there was no evidence capacity assessments had been completed, or best‑interests’ decisions had been made to ensure the move was appropriate for each individual.

Care plans had been updated to state people were moved to consolidate the houses due to a reduced number of residents, rather than reflecting the actual reason for the relocation. Although relatives were informed of the move and asked if they wished to be present, this did not replace the requirement to assess capacity or for the provider to follow a lawful best‑interests’ decision‑making process.

Staff had completed e‑learning training on the Mental Capacity Act; however, it was evident in practice that they did not fully understand its principles or how to apply them. This lack of understanding contributed to decisions being made without appropriate capacity assessments or best‑interests processes, placing people at risk of having their rights overlooked

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We highlighted several risks which the provider had overlooked when ensuring safe care and treatment were assessed, monitored and mitigated. The management of people who were insulin dependent diabetic was unsafe, with one person regularly not receiving adequate support with nutrition and hydration or having their blood sugar levels checked at regular intervals as per their care plan.

We reviewed the care of a person who received nutrition via a Percutaneous Endoscopic Gastrostomy (PEG), which delivers liquids and medicines directly into the stomach. The hygiene and environment within the person’s bedroom placed them at risk. An unused PEG tube was found under the bed in a dusty area, and the crash mat positioned beside the bed was saturated with water. The person’s bed was set at its lowest height, meaning that if they had fallen onto the wet crash mat, there was a risk they could have become entangled in the PEG tubing, potentially causing it to dislodge. These environmental hazards demonstrated a lack of safe oversight and increased the risk of avoidable harm.

The management of skin conditions required further improvement. We observed one person with a significant wound, and staff were not following the correct guidance for cleansing and dressing it. There was inconsistency and confusion among staff about whether the wound required dressing; some records stated it had been dressed when it had not, while other staff told us it did not require dressing at all.

Another person required pressure‑relieving boots to support healing and reduce the risk of further skin breakdown to their feet. Their care plan was detailed and clearly outlined the need for the boots to be worn regularly when the person was in bed. However, during our observations, the boots were not fitted correctly, which reduced their effectiveness and placed the person at continued risk.

Staff told us they were aware of the risks people presented and could access care plans and risk assessments through the electronic care planning system. They were able to describe these risks when asked; however, we found that staff did not always follow the guidance set out in the care plans and risk assessments. As a result, measures intended to reduce risks to the lowest practicable level were not consistently implemented, leaving people exposed to avoidable harm.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

There had been some improvements to the households, including the replacement of bedroom furniture and a programme of redecoration. However, significant environmental risks remained. In several rooms on Abbey Hey House and Sunny Brow House, technology such as sensors were unplugged, broken or left on the floor, meaning essential safety equipment was not functioning as intended. On the first day of the inspection, we found emergency call alarms were broken, and parts of wall‑mounted units were missing buttons, creating a risk of finger injuries.

Emergency call alarms in communal bathrooms were either reduced in size or tied up, leaving them out of reach. We requested that these be repaired while we were on site; however, by the third day of the inspection, a further communal bathroom still did not have functioning emergency alarms. This meant that, should an incident occur, people attending to their own personal care or staff responding to an emergency would be unable to summon urgent help.

Parts of the households remained unclean and dusty. One unoccupied bedroom on Abbey Hey House was unlocked, and the window restrictor was broken, creating a potential safety risk.

Several bathrooms on Abbey Hey House and Sunny Brow House were out of use. As a result, one person with mobility difficulties had to walk across the household to access a functioning bathroom. In addition, radiators in bathrooms had exposed wires underneath them, although we were told they were not in use, and pipework beneath sinks were exposed.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

One staff member had been recruited since the last inspection, and both the manager and clinical deputy had been appointed directly from an agency. When we requested the recruitment records for these senior roles, there was no evidence of essential employment documentation, including application forms, agency profiles or induction records. The references provided were dated during 2024 and had been completed either by the agency or by the 2 individuals for each other.

Nursing staff did not consistently demonstrate the clinical training or competency required to deliver complex care. Several members of the team had not received appropriate or ongoing training in diabetes management or the safe use of insulin. Competency assessments for insulin administration and adherence to prescriber instructions had not been completed for all nurses. In addition, care plans were not being followed consistently, resulting in some people not having their blood glucose levels checked before meals.

Not all nurses had received the necessary training or competency assessments required to safely support people with complex health conditions, including Parkinson’s disease or those requiring a percutaneous endoscopic gastrostomy (PEG).

Staff confirmed they had received training in relation to their job role. Most training had been delivered via e-Learning, however, some staff shared face to face training was being rolled out as well as the option to attend vocational qualifications.

Nursing staff were not receiving regular supervision, and several nurses had not had any supervision within the previous 12 months. Although some care staff did receive supervision more frequently, these sessions were predominantly conducted in groups, which limited opportunities for personalised, individual support. A staff member said, “No supervision has been offered of late, however, a well-being email was sent following the last CQC inspection.”

Feedback from people and their relatives on staffing levels was variable. Comments included, “At busy times, they could probably do with a few more staff.” and “Some days there are enough staff and other’s there aren’t.”

We received mixed feedback from staff, with approximately half reporting that they were often working short‑staffed. Comments included, “Staffing levels fluctuate depending on the number of people present at the service. It is based on numbers more than dependency.” and “I think there is a difference between head counts and residents’ needs and the needs should be more important than head count.”

The provider completed a monthly assessment of dependency levels to determine the level of support each person required and the corresponding staffing needed. However, it was not clear how the provider reached their conclusions, as the rationale and calculations behind the assessments were not transparent.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There had been some improvements to the overall cleanliness of the environment, but parts of the households remained unclean and unhygienic. On the first day of the inspection. We entered a bathroom on Abbey Hey House to find an amount of faeces in the middle of the floor.

Improvements had been made to the cleanliness of curtains and bedding; however, we continued to find stained bedroom walls and skirting boards ingrained with dirt. Although some bathrooms had been refitted with easy‑clean wall coverings, the flooring remained unclean, and there were visible gaps where previous toilet basins had been removed, which had accumulated ingrained debris.

We observed several staff members serving food without the use of disposable gloves.

On Abbey Hey House, people were picking other people’s drinks up, drinking from them and placing them back. This increased the risk of spreading virus and bacteria.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

At the previous inspection there were significant concerns medicines were not managed safely. At this inspection very few improvements had been made and there remained significant concerns medicines were unsafely managed.

Some people missed doses of their medicines because there was no stock available to administer, this was due to a failure to re-order medicines on time. The missed doses included medicines prescribed to treat epilepsy, water retention, diabetes, dementia and constipation.

People still did not always have their medicines administered safely or at the right times because the manufacturers’ and/or prescribers’ directions were not followed. Two people were not given their antibiotic safely because the manufacturer’s directions to give it on an empty stomach were not followed. A third person was not always given their Parkinson’s medicines at the times prescribed. This put people at risk of not having their symptoms treated or controlled.

One person was given double their prescribed dose of 1 of their medicines for 4 days because the records about their prescribed dose were not accurate which placed their health at risk of harm.

Some people were given medicines which were out of date with 1 person being given a medicine which was almost 2 weeks out of date. A second person was given their antibiotic for almost a week when it was out of date which meant the medicine may not have worked effectively.

People who were insulin dependent still did not always have their insulin or diabetes managed safely. People’s care plans did not always contain information for staff to follow about how to recognise and treat a person in the event of their blood sugars becoming very low. One person’s insulin dose was dependent on how much food they ate, and they were not always administered the correct dose of insulin. Quality control solutions used to calibrate the blood glucose meters for accurate readings, were 3 months out of date and other test strips used to monitor blood glucose control were 6 months out of date which meant the readings for diabetic monitoring may not have been correct. Insulin was not always stored at safely at the correct temperatures which meant it may not have worked as it should.

When people’s Parkinson’s and pain relief medicines were prescribed as patches, the records showed the patches were not rotated as advised by the manufacturer which placed people at risk the medicines not being absorbed properly and skin irritation.

Records about the application of creams were not always consistent and did not always evidence, creams were applied safely.

When people needed to be given their medicines covertly, by hiding the medicines in food or drinks, or via a feeding tube in the stomach, there was a lack of information from healthcare professionals about how to do this safely. Nurses did not always follow safe practices when giving people their medicines covertly or via a feeding tube, placing people at risk of not receiving their medicines safely. We observed 1 person had their medicines dispensed into a cup of tea and the drink was left in the communal lounge and risked being consumed by someone else.

Where people were prescribed medicines and creams to be taken or used ‘when required’ or with a choice of dose, the protocols to support their administration were still not detailed enough to ensure they could be administered safely.

People who needed their fluids thickened to make sure they could swallow them safely, were given ice cream which placed them at risk of aspiration and chest infections, because ice cream melts in the mouth to a thin fluid. Some people needed to have their food pureed without lumps, but no checks were made to see if they were able to swallow their tablets and capsules safely without choking.

The arrangements in place to make sure all medicines could be accounted for were not always effective. Staff frequently adjusted stock levels because there was either more or less medicine than expected. Managers could not explain why three were so many stock adjustments.

People were placed at increased risk of harm because their medicines were not managed safely. Safeguarding referrals were made to protect people from unsafe medicine’s management. There was no evidence people were immediately and directly harmed, but harm is not always immediate.