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

Following this assessment, we found breaches of regulations in relation to person-centred care, safe care and treatment, good governance and staffing. The provider was not always keeping people safe. Several health and safety risks with the decoration and furnishings of the home had not been recognised and rectified in a timely manner. Risks to people were not always robustly assessed and strategies were not always identified to mitigate risk. Staff were not supported following incidents of agitation and aggression. Staffing levels impacted on the quality of care and the safety of people. Staffing levels were increased following the Care Quality Commission feeding back to the provider. Nursing staff had not received sufficient clinical training to support their role. Staff had not received training in supporting people to manage distress and agitation. People, their relatives and staff felt they could raise any concerning information with the provider, but they were not assured they would always receive a response. Staff were recruited safely, and pre-employment checks confirmed their suitability to support vulnerable people. Care records were sometimes inaccurate and recorded incorrect information about people’s needs. People who required repositioning to protect their skin integrity were not always supported effectively. Parts of the home were unclean and required further redecoration.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most people told us they felt safe living at Gorton Parks Care Home, however, it was evident some risks were overlooked or ignored which placed people at the risk of harm. Where people required support to manage their agitation, behavioural triggers were not recorded, and strategies were not developed. The provider was not proactive in managing the risk before it occurred. We observed one person putting their fist towards another person’s face and being verbally abusive to other people living at the home and staff. The care records for the period we observed, recorded the person was walking around the unit, swearing and was content. The person was prescribed a medicine to reduce their agitation and staff had not considered administering this. An incident report was not completed, and the care records did not record the severity of the situation. We saw complaints were acknowledged but found when people or their families had complained informally, little or no action was taken. We saw a relative had regularly been complaining to staff about broken drawers in their relations bedroom and no action was taken until the relative submitted an official complaint. Another relative told us they regularly complained about their relation not receiving enough support with fluid intake. They told us they brought in drinks for their relation but found they are left unopened despite reminding staff to provide the person with additional fluids. Other relatives told us they raised concerns with staff but often felt no action was taken. We saw further evidence of this when reviewing the homes formal complaints and found a relative had raised concerns regarding their relation’s health and no action had been immediately taken. There had been multiple concerns raised to the CQC during the assessment about people’s teeth, glasses and personal belongings going missing as well as people not wearing their glasses. Despite glasses now being named, they continued to go missing.

Staff told us, due to staffing levels; it was difficult to ensure all risks were monitored and managed. One staff member told us staff were regularly exposed to agitation and aggression and they reported incidents to the senior staff within Gorton Parks Care Home, but they knew no action would be taken. It was evident staff had accepted supporting people with agitation and putting themselves at risk of injury was now considered as part of their job role. Staff told us they were not given any feedback or supportive briefings following an incident to be able to learn lessons, nor were they provided with any emotional support. We received mixed feedback from staff about being encouraged to share any concerns or to share and embed good practices. One staff member told us, information was shared in daily huddles, but they no longer occurred each day. Other staff members felt there was no point in sharing concerns as nothing would change, this included when people were aggressive or being racially abusive to staff. One staff member said, “If we report things, for example, people being aggressive, nothing happens so I don’t see the reason to report things.” Some staff members felt the current management team were more responsive and they were hopeful for change. Staff were aware of their responsibility to record any accidents and incidents within the electronic care planning system, but we were not assured all incidents were being recorded as often information was verbally passed to the senior or nurse.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Some people and their relatives told us they felt they could raise any concerning information with the staff or nurses at the home. People and relatives were not always sure who they should speak to in the management team as there had been several recent changes. We received mixed feedback on how the provider ensured they identified and shared concerns promptly. While some people told us staff were vigilant and they felt safe living at the home, others reported they often had their glasses, teeth and clothes go missing and no action was taken. A relative also told us they had raised their concerns with the social work team as the provider had not taken any action after they had raised concerns with the home.

Staff told us they knew how to raise concerns they had about people’s safety and felt the current management team would listen and act upon. However, we found staff did not always report any safety concerns which may have put people at risk. This included damage to wardrobes, drawers and bedroom surfaces as well as when vulnerable people were put at risk of agitation and aggression. Staff told us they had received training to understand the mental capacity act and that they sought consent before providing any support by explaining what they were doing.

We observed staff attempting to support people when they were distressed but it was evident staff did not have a clear understanding of good practices to ensure other people were free from harassment and abuse. For example, when 1 person was agitated in the communal area and verbally aggressive to other people living at the home, the person was removed from the environment, but no checks were made on the other people in the communal area to ensure they were supported and felt safe. We observed staff gaining consent from people to deliver care interventions but did not see staff supporting choices and balancing risks due to other restrictions across the home such as staffing, and the complexities of other people’s needs. One person was actively trying to leave the home and waited by the door to be let out. The home had extensive gardens which had become inaccessible and overgrown, and the provider had not considered how the secure gardens could be used for a person to walk around to promote their freedom and wellbeing.

There was no evidence people, and their relatives were involved in best interests’ decision making. Where people lacked capacity to make a decision, an application was made to deprive the person of their liberty. We reviewed the mental capacity assessments for 4 people and found assessments generally were completed as people did not have the capacity to consent to living in the home or to consent to photographs being taken. We reviewed a capacity assessment for the administration of covert medicines for one person. The assessment had not included a multi-disciplinary team to ensure covert medicines was in the person’s best interests. The assessor had not identified the need of each medicine required to be administered covertly and there were no regular reviews to ensure the decision remained in the best interests of the person. Capacity assessments and best interests’ decisions did not incorporate how people important to the individual could support decision making in the person’s best interests. We did see safeguarding concerns were being reported to the local authority for further investigation once they had been identified.

It was not always clear how often people were involved in managing risks. People told us they felt safe when staff were supporting them. People who required moving and handling told us staff did so safely. One person told us, “The staff support me with my mobility. They help me in and out of bed, into a chair or wheelchair. I have got used to being hoisted and feel safe and in good hands.” Some relatives felt fluid intake was not always pushed by staff which put people at risk of dehydration. Some relatives told us they had been involved in initial care planning when their relation moved into the home. It was apparent many people did not understand the risks they were exposed to but in addition, the provider had not explored any positive risk taking, especially in supporting people’s passions or hobbies which may have reduced agitation or aggression. We were told one person was a keen gardener and staff felt they would have loved to be involved in gardening which may have reduced some of the agitation they were experiencing but this had not been explored. We spoke with a health professional who told us, 1 person had been prescribed a specialist pressure area support to assist in the healing of a pressure ulcer. The health professional told us the staff had been applying the support the wrong way around so this may have impacted on the healing of the wound.

Staff did not always feel involved in managing risk, especially when trying to support people who were at risk of agitation and aggression. We were informed by several staff they had sustained injuries from trying to support people who were distressed. This included being punched, kicked, and scratched. Some staff had scratch marks to their skin which had caused scarring and we found staff had not been supported following these incidents. There were no reports of staff injuries being recorded in the accident and incident book. Staff told us, they reported any incidents to the senior person on duty, but they were not informed of any further actions they should take. One staff member told us they had reported aggressive and racist behaviour from a person living at the home towards staff and they were scratched on the morning of the assessment, but they were not provided with any reassurance or follow up. Staff told us they did not always have the time to reposition people at the required intervals. This put people at risk of pressure injuries occurring or worsening. Staff told us the risks people presented were recorded in the electronic care planning system and nurses and seniors spoke with people’s families when they initially moved into the home and information was updated following each monthly review. However, we found this was not always the case. We found one person was diagnosed with a pressure sore to their heel and the care plan and risk assessment contained no information nor had the injury been updated in the pressure sore and treatment plan.

Care records did not always capture immediate risks presented by people living at the home. Where people were at risk of choking, they were not always supervised when eating and we found one person was lying flat in their bed, eating their lunch alone. Their care plan recorded they should be sat in an upright position before offering diet and fluids to prevent choking. The same person was at risk of falls, and we found their sensor mat which alerted staff they were mobile was pushed under their bed and not plugged in. There was also a movement sensor in the room which was not working during our visit. We observed another person who was required to have an easy to chew diet given a chicken burger which was cold and had become difficult to eat. We observed some people were cared for in bed. One person was sleeping with their feet pushed up against the wooden base of the bed. This risked the individuals skin breaking down and no pressure relieving equipment had been considered. Another person had reduced mobility and was unable to reposition themselves. Staff had not considered using equipment to reduce the risk of pressure points breaking down such as cushions. A third person was observed to be sat in a chair all day despite their care records recording they could only sit out for 15 minutes at a time. We observed one person become verbally and physically aggressive towards people living at the home and staff. Staff were trying their best to support both the individual and other people, but this was difficult given reduced staffing levels and the complexities of other people living within that part of the home. Following this feedback, staffing levels were increased.

Care records were often inaccurate and not representative of the current risks people presented. One person was mobile with a zimmer frame, but their mobility assessment recorded them as unable to weight bear and needed 2 staff to support them to use a hoist. Some staff were regularly recording bed rails were checked for people who did not have bed rails in place. Care records lacked detail for staff to support people who became agitated or aggressive. They lacked evidence of distraction techniques which staff could effectively deploy and often behaviours were not being recorded in detail. We reviewed the care records for a person we had observed being verbally and physically aggressive and found they did not capture the seriousness and severity of the situation. Another person who could become agitated and aggressive did not have clear strategies recorded for staff to support them. The care plan recorded for staff to look for signs of challenging behaviour but did not explicitly record what the signs were and what strategies were to be used to reduce levels of agitation. Several care records contained mixed information regarding food and fluid consistency to prevent people from choking. One person’s record, recorded 3 different food consistencies and another person was recorded as receiving a mince and moist diet when they were prescribed a soft and bite sized diet. However, staff could correctly describe the correct consistency. There were gaps in repositioning records for multiple people. One person was due to be repositioned to protect their skin integrity, every 4 hours but we found the records recorded they were repositioned sometimes at 5 -6 hourly intervals. We also found repositioning records were only recording people being repositioned onto their back instead of other positions to reduce the risk of pressure injuries occurring.

People were generally satisfied with the environment. Some people told us they had broken drawers and we saw a relative had been required to make a complaint after requesting for some drawers to be fixed for many months. Some of the houses had been recently decorated and some people told us they felt safe in their rooms, however, there was a general state of disrepair in several rooms on Abbey Hey House and some parts of the communal area’s required decorating and maintaining.

Staff told us they reported any concerns with safety in the maintenance book, but they were not always aware of any actions taken. It wasn’t clear if staff were aware of the condition of some wardrobes and drawers on some of the houses or whether it was a culture of accepting that was the way it was. When we asked 1 staff member why there was a lack of waste bins on some houses, they told us it was because people broke them.

Some bedrooms posed risks to people, particularly on Abbey Hey House. There were jagged edges around some sink units which had not been identified by the provider. One bedroom had a wardrobe door hanging from the bracket. Several rooms had broken drawer units and drawers which did not close. One person was struggling to sleep due to the sun coming into their bedroom and we found their curtains were too small for the window. We observed another person to be cold while lying on their bed and found the blanket was very thin. We asked a staff member to bring a warmer blanket for the individual which was done so promptly. Some of the nurse call units were either broken or missing from the bedrooms. Staff told us, some people would not be able to use them. We did observe floor and movement sensors in bedrooms, but they were not always plugged in when people were in their room. We found a fire extinguisher in a bathroom on Abbey Hey House which posed a risk to people as it had not been secured. We asked for the extinguisher to be removed immediately. There had been QR codes placed on people’s bedrooms door which staff scanned to record they had completed room checks. We observed one staff member scanning the QR code but not checking if the person was well, in their bedroom. Following feedback to the provider, the QR codes were moved into people’s bedrooms. On the second day of our visit, contractors were painting the hallways on Abbey House, but we found this had not been robustly planned for and risk assessed. We found one person had paint on their clothing from continually walking by the freshly painted walls and other people were put at risk of injury from tripping or slipping on or near the decorator’s equipment.

People told us the staff were good and treated them well. One person told us, “It’s alright here, they (staff) are very nice people and are trying their very best to look after us. They are sometimes short on staff, but the girls are really lovely.” Another person said, “I feel very safe here. I am happy to be here. The staff look after me well. Grand people here.” Generally, people and relatives felt there was not enough staff. People told us staff could not always respond quickly as they were busy with other people. Comments included, “I have mixed feelings about the staff and would like to be informed of what [Name] is eating daily. I bring sandwiches in each day as I am unsure what they are eating. I find some of the staff boisterous, pushy and grating”; “I am restricted in my mobility and require help from staff. The staff can take forever to answer the call bell and if I require pain relief, I can wait hours” and “I would like to see more staff on duty, they are run ragged.”

Staff told us there was not always enough staff and staff were taken from other houses to cover staff absences. One staff member told us, “The staffing is not enough and by 4pm (after working for 8 hours), I haven’t had a break.” Another staff member told us, “There is not enough staff. The senior is needed to support the nurse and there is no one in the lounge. We have a lot of people in bed and 15 feeds to assist, so it takes up a lot of time.” Staff told us they did receive training, but they had to come to the home on their days off to complete the training otherwise they would not be paid. Nursing staff told us they hadn’t received many opportunities to undertake clinical training and they required further training around wounds. Staff told us they had not received any in-depth training in supporting people who were agitated or becoming aggressive.

We observed staff being kind and caring and responding to people’s needs when required. However, staff did not always have the time to spend with people unless they needed something. Communal areas across the home were not always monitored. Staff were responsible for multiple roles including serving food, supporting and monitoring people eating and then washing the dishes. Following this feedback, kitchen staff were deployed to assist with mealtimes. We observed nursing staff were taking phone calls, speaking with visiting professionals, overseeing medication and wound management while trying to provide wider support to the staff team without being able to take a break.

Staff were recruited safely. Staff were provided with training but the take up of training was variable due to staff having to attend the home on their days off to complete training. A dependency tool was in use to calculate staffing levels, but the tool had not considered the layout of the houses and the location of communal areas. Staff had not been provided with supervision and appraisal in line with organisation policies. We did see some supervision records which had been pre-printed for several staff with the same information on and they were not supporting staff to develop in their job role, nor was the record personal to the staff member.

People felt their rooms were clean and told us cleaning staff were on duty each day. Some relatives told us there could be improvements on the cleanliness.

Parts of the home were unclean and posed infection control risks to people, staff and visitors. We observed some of the floors on Abbey Hey house to be dirty and there were several rooms which had dried foods on surfaces as well as stains on the walls. We found most bedrooms and bathrooms did not have a waste bin. Staff told us, bins had been taken from bedrooms as people destroyed them and they disposed of any waste in the sluice room. For people who used the bathroom independently, we were not assured they were washing and drying their hands due to lack of waste facilities. We did observe bathrooms to be clean and there was no waste left in any of the bathrooms.

People’s allergies (or none known) and their preference on how they liked their medicines to be offered to them were documented on their electronic medicines records (eMAR). Medicines records showed that people did not always receive their medicines at the right time. Paracetamol was not always administered safely with the required 4-hour interval between doses. Records for adding thickening powder to drinks, for people who have difficulty swallowing, were inconsistent and occasionally incorrect. Therefore, we could not be assured people were safe from the risk of choking. One person was prescribed a medicine to be gradually reduced over several months. We found that this dose reduction had been done incorrectly, and there was a risk that this person could have come to harm.

Staff had dedicated time to manage medicines processes such as ordering and receiving. Managers told us that staff had completed medicines training and had been assessed to ensure that they gave medicines safely. We were shown evidence of training records to confirm this. Medicines audits were not always effective in identifying medicines related issues occurring in the service. Following the assessment, the service sent an action plan detailing improvements made. Staff were not following a healthcare professional’s instructions for one person’s care. Consequently, the person’s condition had deteriorated. We asked staff how instructions from visiting healthcare professionals were communicated and were shown the handover record system. A staff member said that information was not always copied to the communication section of a person’s care plan and could therefore be ‘lost’.

Medicines that are controlled drugs were managed safely. Instructions for staff about the application of people’s non medicated creams, gels, ointments and sprays, and records of their use, were inadequate. Storage arrangements had not been risk assessed. We found a cream that is classified as a prescription only medicine (POM) in one person’s room and an emollient cream within easy reach of anyone entering the room. Medicine storage facilities were secure, clean and tidy. However, the minimum and maximum temperatures for one medicines’ fridge were not monitored properly. This meant there was a risk that some refrigerated medicines (for example, insulin) might not be safe to use. When people had their medicines covertly, hidden in food or drink, information to support staff to safely give medicines this way was not always available. Therefore, there was a risk that people were not given their medicines safely.