Archived: Gorton Parks Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The provider was in breach of the legal regulations relating to person-centred care and meeting nutrition and hydration needs.

The provider was previously in breach of the legal regulation in relation to person-centred care, safe care and treatment, good governance and staffing. At this assessment, we found the provider remained in breach of the regulation.

This service scored 38 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Assessments were not always up to date. Several assessments were overdue, reviews, and some assessments were not reflective of people’s current needs. We observed one person being spoon-fed a meal by a staff member. The person’s assessment recorded they could eat and drink independently.

We found one person had been admitted to hospital where the family had raised concerns about oral care. On discharge from the hospital, we found the persons oral health assessment had not been updated to reflect the support they needed to maximise their oral care. Several people were regularly refusing support with oral care and no further strategies had been implemented by the provider to reduce the risk of deterioration in their oral health.

A third person was found with an unexplained bruise under their eye on the first day of our visit. We reviewed the behavioural care plan which had assessed they could become distressed and ‘fight with the staff’, but there were no strategies recorded to enable the person’s agitation to be reduced before it escalated, thus reducing their risk of injury occurring.

Initial assessments were completed on people when they moved into the home and people and their relatives were involved, however, there was no on-going involvement of people and their families when assessments were reviewed. This meant we were not assured; all assessments were factual and captured peoples wishes and needs.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards. Nutrition and hydration needs were not met in line with current guidance.

People had their risk of malnutrition assessed but assessments did not identify where weight loss had impacted on the person’s body mass index. One person regularly had a body mass index of under 20 and their weight fluctuated. Their care plan recorded they needed to be weighed weekly, but this was not occurring, and the person required a high calorie diet and was on a fluid and nutrition watch. We reviewed the person’s care records and found they did not have lunch or evening meal recorded on 4 occasions within 7 days. We also found; they were not offered fluids at regular intervals.

We observed lunch times and found people were not supported effectively to receive a healthy, nutritious and balanced diet. One person had swallowing difficulties and required a modified diet. We reviewed the person’s nutritional intake and found they had been provided with mashed potato on 10 occasions in a 7-day period as their main meal. Often their meal had not been accompanied with any vegetables, and they were given mincemeat in gravy on 3 occasions.

We found other people in receipt of a modified diet were also regularly receiving a mashed potato, sometimes twice a day. The provider had not considered providing other textures of foods most suitable for people with swallowing difficulties.

Best practice to promote effective communication for people whose first language was not English was not followed. Several people living at the home were unable to communicate in English and despite this being raised at the last assessment, the provider had not implemented additional or modified ways of communicating.

The provider did not always work well across teams and services to support people.

Some relatives told us, they had difficulties in understanding why their relation had been sent to hospital and they had not always been informed when professionals had been discussing their relations care. Other relatives feared the provider would not admit their relation back to the home following a period in hospital. One relative told us, “Communication with the family isn’t great. [Name] ended up in hospital a while ago and they (the provider) wouldn’t take [name] back. They eventually did but it scared me, I don’t want to cause trouble with them in case they don’t let [Name] stay there.”

A second relative told us, “Sometimes they inform me, sometimes not” in relation to being informed of any changes to the delivering of care and treatment by other services.

The provider did work with other services such as the GP (General practitioner) and district nurses to review people’s health needs. A GP visited the home weekly and staff identified people for a potential review of their health.

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support. People were not supported to receive a healthy, nutritious and balanced diet. There was a lack of fresh fruit available on the houses for regular consumption and we did not observe people being offered any fresh fruit during our visit. The only snacks offered were biscuits and there was a lack of evidence of regular nutritious snacks recorded in daily care notes. Some relatives told us they were concerned about their relations weight loss and support to eat and drink. One relative told us, they were supporting their relation to eat and was only provided with a spoon for 3 meals. When they asked for additional cutlery, they were told, it wasn’t available. People didn’t have regular access to fresh air. The external gardens were inaccessible and required some modification to enable people to safely access the area. A relative told us, they wished for their relation to take a walk outside each day, but this had not occurred. People were reviewed weekly by the GP if required but changes to people’s health was not always communicated to people’s families. People were not supported with effective oral care. We found 3 people were not wearing their dentures which could have impacted on their ability to eat. Dentures were left in bedrooms and had not always been cleaned. Some people were recorded as resistant to oral care, but the provider had not considered additional strategies to support good dental hygiene such as using distraction techniques, photographs or adaptive tools which may make brushing easier.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. Care records were not routinely screened to ensure information being inputted into the electronic care planned system was factual and correct. Where people required monitoring for nutrition and hydration intake, records were not always evidencing this. One person had been identified in their nutrition care plan as ‘Seeing the GP for (their) massive weight loss’. The care plan identified the person needed to be weighed weekly, but this was not occurring. Another person was record as being high risk of malnutrition. The care plan stated staff should offer the person snacks in between meals and encouragement to eat and drink. We reviewed the persons meal chart over a 7-day period and found no meal had been recorded on 5 occasions and the only snacks served had been biscuits on 3 out of 7 days. Systems to monitor people’s care against outcomes were ineffective.The clinical audit had recorded a person as losing 7.25kg in weight, however, we observed staff were not always encouraging the person to eat and drink and no further strategies had been implemented as a result of the audit.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.