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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and not protected from avoidable harm.

The provider was in breach of the legal regulations relating to person-centred care and safe care and treatment.

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 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, open, honest and positive culture towards safety. They did not listen to concerns about safety. Lessons were not learnt to continually identify and embed good practice.

The provider had failed to continuously improve the homes environment to reduce the risk of people injuring themselves. This was raised with the provider at our last assessment of the service.

Risks to people were often overlooked and we saw there had been an increase in weight loss, wounds and infections in November and December 2024, which had not been thoroughly investigated and lessons learned. The provider was not proactively identifying strategies to support people to gain and maintain weight. Care records did not always identify where diets could be fortified to reduce the risk of malnutrition. 17 people lost over 3 kilograms in November 2024 and 16 people lost over 3 kilograms in December 2024.

Thirty-six people were identified with wounds in November 2024 and 34 people were identified with wounds in December 2024. Older people are at high risk of developing wounds due to aging and reduced mobility and the provider had not proactively identified preventative measures such as using pressure cushions on chairs, eating a healthy, balanced and nutritious diet and good skin care. We reviewed several daily care records for people who were at risk of developing wounds and pressure sores and found they were not being supported with regular baths or showers to assist in maintaining hygiene and keeping their skin clean and healthy.

Accidents and incidents were recorded but we found where unexplained bruising had occurred, the provider was not always able to explain how the injury had been caused.

We received mixed feedback from relatives about being kept informed of any incidents. Some relatives told us, staff would contact them, but others advised they were not always told, and said they had to chase the provider for further information.

The provider did not work well with people living at the home and health system partners to establish and maintain safe systems of care. This does not change the rating for the quality statement. 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 received negative feedback from relatives regarding safe systems, pathways and transitions. A relative told us, their relation had waited a considerable amount of time to be discharged back to the home from hospital and staff had arranged to meet with the family at the hospital to complete a reassessment. The staff did not attend which then delayed the discharge. Another relative told us, their relation had stopped eating and drinking for 5 days and they were not informed until a GP visited and referred their relation to the hospital. One person had been discharged from hospital and required a medical device to enable a newly prescribed medicine to be administrated. The provider had delayed consulting with a pharmacist or other professionals to check if the medicine could be administered in an alternative form. In addition, the provider had not considered purchasing the medical device in the best interests of the person who required the medicine.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. There was no focus on improving people’s lives or protecting their right to live in safety and free from abuse and neglect.

We observed poor interactions from staff towards people living at the home. This included neglecting people’s dietary needs, skin integrity needs and ensuring people’s basic hygiene needs were being met.

Several people looked unkempt, and we found people were not supported to have their nails trimmed or regular footcare.

We noted there had been an increase in infections, wounds, falls, weight loss and incidents across the home which had impacted on people’s wellbeing for several months, however, there was little evidence, any timely action was being taken to reduce risks to people.

Five relatives told us, their relation had experienced unexplained bruising. We did find some concerns had been reported to the local authority safeguarding team for further investigation but not all. Some relatives told us, they didn’t always receive a response when they raised such concerns. We raised several safeguarding concerns following this.

Where people lacked capacity to make decisions for themselves, an application was made to deprive them of their liberty. Mental capacity care plans were in place, but these were not person centred and focused on what people were unable to do rather than what the person would like to achieve with their care and support. The care plans were reviewed monthly but there was no evidence people and their families were involved.

Staff received training in safeguarding vulnerable people from abuse and said they felt they could report any concerns to the management team.

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 reviewed several people who were at risk of developing pressure sores due to the frailty of their skin and reduced mobility. People required support to be repositioned at regular intervals to prevent their skin breaking down. On the first day of our assessment, we observed 3 people who were being cared for in bed. We found staff were recording repositioning had taken place on the electronic care planning system, however, when we checked on the person in their room, they had remained in the same position. We found one person who had a pressure sore to their foot, was prescribed pressure relieving boots. We observed the person lay in bed with their feet pushed up against the foot of the bed and not wearing the boots. This meant the person’s skin integrity was placed at further risk.

People at risk of choking were not safely supported as staff were not using the correct amount of fluid thickener per ratio of fluids. Staff were regularly recording people were given various amounts of fluids without considering if the fluid had been thickened to the prescribed consistency. This increased the risk of a person aspirating. For one person who was prescribed thickener to aid swallowing, we saw staff were recording they received 280mls of fluid with thickener, but we measured the contents of the cup which could only hold 250mls. Staff had not correctly calculated the amount of thickener to be used to assist in preventing choking.

One relative told us, their relation had been regularly falling and falls monitoring equipment such as a sensor or crash mat were delayed being put into place.

The provider did not ensure people were cared for in a safe environment. There were not always effective arrangements in place to monitor the safety and upkeep of the premises. Several bedrooms across the home contained defective or ill-fitting wardrobe doors. We found some wardrobe doors were hanging via the hinge or were damaged which meant they did not fully close. Several drawers in people’s rooms were missing, damaged or unable to be closed. We found some bedroom sink unit seals to be cracked and broken. Flooring in some bedrooms was damaged and discoloured, and many bedroom curtains were defective and often did not fully close to ensure people’s privacy. The provider had not identified any of the concerns in relation to the environment and we were informed, a programme of redecoration had been signed off as completed. An internal maintenance team was responsible for assessing safety. We checked the hot water temperature in some bedrooms and found temperatures to be in line with the recommended 44° C. The radiators in communal areas were also noticeably hot to touch and we were not assured, the risk of being scalded by a radiator had been mitigated as there were no regular checks of radiator temperatures, which should not exceed 43° C. These temperature ranges are recommended to safeguard vulnerable people from burns and scalds.

People and relatives raised concerns with us regarding the care home environment. Comments included, “I took [Name] to the toilet which was horrendous and filthy”; “There are drawers missing in [Name’s] room”, and “There are times when [Name] and I want to clean the room ourselves. We looked under the bed a few weeks ago and there were 3 bottles under there. I have asked for a brush now and again and done it myself.”

The provider did not ensure there were sufficient staff on duty to meet people’s needs. The provider did not ensure recruitment was robust

A dependency tool was used which should assist the provider in ensuring the home was safely staffed at all times. However, the provider had implemented a fixed ratio of staff to be on duty dependent on how many people were residing in each household. The provider had not holistically considered people’s health, medical and emotional needs and this meant people did not receive care and support when they needed it.

We saw multiple examples of where staff were providing poor levels of care due to inadequate staffing levels. On Melland house, a staff member was regularly pushing a side table towards a person sat in an armchair which restricted the person from moving. We observed people not being offered food, drink and snacks for several hours and people were not being regularly repositioned to prevent their skin from breaking down. We found staff had recorded in the electronic care planning system, people had been provided with fluids, but the information was not consistent with our observations.

People and relatives told us there was not enough staff on duty and one relative told us they had to search for a staff member for 20 minutes during one visit.

We saw one to one meeting’s were recorded with staff in relation to improving documentation in the electronic care planning system. The one to ones had been completed by the deputy manager with many of the meetings being held on the same date. Staff told us, one-to-one meetings had been held as a group supervision rather than on a one-to-one basis.

The provider was not always following safe recruitment processes. We found one new employee did not have a full employment history and some new employees had references provided by friends of the applicant.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of infection spreading.

The home had an outbreak of COVID-19 and respiratory illness on two of the houses. We found staff were visiting the unaffected houses and not wearing personal protective equipment to assist in preventing the spread of the illnesses. We found one staff member was actively providing personal care and support to people on both the affected and unaffected houses.

The home was unclean in parts and posed a risk to people’s health and safety. On Abbey Hey House, there were used, discarded tissues and falls mats were dusty and stained. We found several people’s bedding to be stained, or unclean and bedroom walls were stained or had been damaged. Some bedroom floors felt sticky and were unclean. One person reported to us, they had seen a mouse on Debdale House and we found another person in the same house, had biscuits scattered on their floor.

Parts of the gardens contained rubbish, and we found staff were extinguishing their cigarettes outside a person’s bedroom window into a planter.

We observed people were not supported to wash their hands prior to eating. We observed staff did not always wash their hands prior to supporting people to eat and drink.

Monthly infection control audits were ineffective as they were not capturing the information required to ensure the provider made the improvements necessary. For example, the audit completed on 24 January 2025 recorded staff had been noted not to wash their hands in the kitchen area and residents were not offered hand hygiene after using the toilet or before meals. There were no further actions to ensure effective hand washing was promoted.

The audit also recorded, furniture, fixtures and fittings were visibly clean with no bodily substances, dirt dust or damage. However, we identified defects in 8 bedrooms which we immediately fed back to the provider.

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 their care. People did not always have their medicines administered safely or at the right times either because the manufacturers’ and or prescribers’ directions were not followed or because there were errors in recording the prescribers’ directions. For example, one person was given wrong doses of a prescribed injection; another person was given a double dose of one of their medicines for a week and a third person was given too many doses of a medicine. Records showed that medicines prescribed to manage Parkinson’s symptoms were not aways given at the right times which meant that people may not have their symptoms properly controlled. Records did not demonstrate medicated skin patches or insulin injections had always been applied or injected safely because the site locations were not always recoded. Records about the application of creams were not always consistent and did not show creams were applied safely. Three people needed to be given their medicines covertly, by hiding the medicines in food or drinks, but there was a lack of information from a healthcare professional how to do this safely, placing people at risk of not receiving their medicines safely. Blood sugar levels were not always monitored which meant that one person’s diabetes was at risk of not being safely managed. The temperatures for one medicines’ fridge were not monitored properly so there was a risk that some medicines such as insulin might not be safe to use. The door to the medicine’s room did not always close properly so medicines were accessible to others. Waste medicines were not stored in accordance with current good practice. There was no evidence people were harmed as the harm is not always immediate, but people were placed at increased risk of harm by not managing medicines safely.