Archived: Gorton Parks Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to safe care and treatment, good governance and fit and proper persons employed. The provider has not assessed the risk of people receiving unsafe care. Governance processes were ineffective in monitoring and improving the quality and safety of the service. The provider had not ensured leaders had the competence to undertake the role given.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider had not made the necessary improvements in response to the concerns identified at the last inspection. Although the number of people living at the home had significantly reduced, we continued to identify issues relating to unsafe care and poor outcomes for people.

An interim new manager was appointed in September 2025, followed by an interim clinical deputy manager and an operations director. However, it was evident no meaningful improvements had been made in the period between the previous inspection and the new management team taking up their posts. Managers reported they were not always able to focus on improving outcomes for people because they were consistently required to address ongoing operational issues and undertake disciplinary processes with staff.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There was no evidence the provider had assured themselves, the manager or the clinical deputy manager had the appropriate experience, qualifications or competence to manage a large nursing home. This demonstrated significant weaknesses in the provider’s recruitment and verification processes and placed the service at risk of being led by staff who may not be suitably skilled or experienced to carry out their roles safely and effectively.

Managers did not have sufficient assurance of nurses’ clinical capabilities, and clinical staff had not received ongoing or adequate training to ensure they could carry out their roles safely. Where competency assessments had been completed, these were often signed off by other nurses without any evidence that the assessors themselves had the appropriate training, competence or authority to validate skills. Some nurses were not taking accountability for their actions, which further undermined safe practice. We also identified repeated errors in the safe management of medicines, including the management of diabetes, the care of a person requiring support with a Percutaneous Endoscopic Gastrostomy (PEG), the response to agitated and aggressive behaviour, the support of people at risk of choking, and wound management. These ongoing issues demonstrated that previous concerns had not been addressed and that significant risks to people remained

People did not always feel they could speak up and that their voice would be heard.

People and their relatives reported feeling comfortable raising concerns; however, they generally chose to discuss these issues with the staff team rather than escalating them to senior management. One person said, “I don’t think there is a manager at the moment. It doesn’t really affect me, as I can just ask the staff for the things I need,”

Staff members stated they felt able to speak up and were aware of the policies that support freedom to raise concerns. Despite this, they felt their views were not always acknowledged, particularly when highlighting issues related to staffing levels. A staff member told us, “We all work hard and want to improve but there is a lot of pressure at the moment.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Workforce equality, diversity and inclusion required further development. Although the service had policies in place, these were not consistently embedded in practice. Staff understanding of equality, diversity and inclusion varied, and there was limited evidence that leaders actively promoted an inclusive culture.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems intended to monitor quality, risk and performance were not consistently effective, and leaders did not always have clear oversight of key areas of the service. There had been a continued systemic failure in governance. Although audits and monitoring processes were in place, they were not robust, and actions identified were not consistently followed through to ensure sustained improvement.

Governance processes had not identified the concerns we found with the safe management of medicines. Audits had failed to highlight issues such as inconsistent record‑keeping gaps in stock checks and weaknesses in oversight of medicines administration. This meant leaders were not aware of emerging risks and were unable to take timely action to prevent avoidable errors.

Care plans, risk assessments and daily notes were not always accurate, contemporaneous or reflective of people’s current needs. The provider had not identified; staff were not consistently keeping an accurate and up‑to‑date record of people’s care and support. This lack of oversight limited the service’s ability to ensure safe, consistent and person‑centred care.

There was a lack of assurance regarding leaders’ ability to carry out effective audits and governance processes. Leaders were frequently operating in a reactive, fire‑fighting manner, responding to immediate issues rather than addressing the underlying causes. This limited their capacity to implement and sustain meaningful improvements, leaving the service vulnerable to repeated shortfalls and ongoing risks.

Leadership arrangements did not fully support a culture of accountability or continuous learning. Managers were visible and approachable, but they had not ensured that governance systems were embedded well enough to drive reliable, long‑term improvements.

During the inspection, the electronic care planning system and the electronic medicines management system were unavailable for periods of time. Some staff told us this was a usual issue, and managers acknowledged that system outages could impact on the accuracy and timeliness of recording. There were no effective contingency arrangements in place, such as the use of handwritten notes or alternative documentation, to ensure staff could continue to record people’s care and medicines safely when the systems were down. This created further risk of incomplete, delayed or inaccurate records and limited the provider’s ability to maintain oversight of people’s care during these periods.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider had been working with partner agencies to support improvements within the home. This included commissioning an audit by an independent care consultant. While the audit identified several areas requiring improvement, it did not highlight the wider concerns we found during this inspection. This meant some significant risks and shortfalls remained unidentified and unaddressed.

Regular reviews of the improvement plan were completed by commissioning teams; however, despite this external oversight, there was a continued failure to achieve and sustain the required improvements. Progress was limited, and actions were not embedded effectively into day‑to‑day practice.

These gaps indicated that partnership working, although present, was not sufficiently effective in driving meaningful or lasting change within the service.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Although some improvement activity had taken place, this was not embedded or effective in driving sustained change. Leaders did not demonstrate a systematic approach to learning from incidents, audits or external feedback, and opportunities to improve the quality and safety of the service were repeatedly missed. We had raised several of the same concerns at previous inspections. At this inspection, we again identified issues relating to swallowing risks, including people being placed at increased risk when eating ice cream. Despite these concerns being known to the provider, the required improvements had not been made.

The provider as a whole had not improved over consecutive inspections. This demonstrated a pattern of systemic failings, a lack of effective oversight at provider level, and failure to learn lessons.

Following the inspection, the provider shared a “Lessons learned” document intended to be rolled out to staff. However, the content was not aligned with national guidance. The document recommended gelato and sorbet for people with swallowing difficulties, which is not appropriate for those requiring modified‑texture diets. We found the information had been taken from an American lifestyle website rather than evidence‑based clinical sources. We requested the provider review the content against current national guidance before sharing it with staff.

Learning, improvement and innovation required significant strengthening. Leaders did not demonstrate a systematic approach to learning from incidents, audits or external feedback, and opportunities to improve the quality and safety of the service were repeatedly missed.

Systems to review and learn from care records, documentation and medicines management were not effective. The provider had not identified that staff were not consistently keeping accurate, contemporaneous records of people’s care and support. This limited the service’s ability to learn from practice, monitor quality or implement improvements based on reliable information.

Overall, the service lacked a culture of continuous learning and innovation. Improvements were not sustained, lessons were not consistently embedded, and the service remained at risk of repeated shortfalls.