During an assessment under our new approach
Date of Assessment: 5 January 2026 to 28 January 2026.
Gorton Parks Care Home is a nursing home providing personal care and accommodation to 57 older and younger adults, people with physical disabilities and people living with dementia at the time of the inspection. The service can support up to 120 people.
This inspection was planned in response to the concerns found at the last inspection (published 20 June 2025) and to check for improvements. We found 6 breaches of regulations which included a failure to provide person-centred care; risks to people’s safe care and treatment; failure to ensure people received adequate nutrition and hydration’, poor governance; and a failure to ensure leaders had the skills and competence required and sufficient staffing were allocated.
The provider did not manage risks to people effectively, particularly for people with complex health conditions. Failures in the safe management of medicines placed people at increased risk of harm. People who were known to experience agitation or aggression did not have sufficiently detailed or robust risk management plans in place. Although staff were familiar with safeguarding procedures and felt confident to report concerns, they did not always recognise when poor practice or omissions constituted neglect. Decisions were not consistently made in line with people’s best interests. Environmental safety required further improvement to ensure hazards were identified and addressed promptly. Staff competency was variable, and many did not receive regular or adequate training and supervision to support safe, high‑quality care.
Assessments of people’s needs were not consistently updated or reflective of their current circumstances, preferences, or aspirations. Support with nutrition and hydration was poorly managed, and people were not always provided with a healthy or nutritionally appropriate diet. There were delays in securing necessary medical interventions for some individuals, increasing the risk of avoidable harm. Monitoring of oral hygiene was insufficient, and there were notable gaps in weight management and oversight, limiting the service’s ability to identify and respond to emerging health concerns. Concerns were also identified regarding consent and record‑keeping practices. Some staff were providing consent on behalf of people and signing care documentation without having the legal authority to do so, which compromised the lawfulness and accuracy of care records.
While staff were observed to be kind and respectful in their approach, there was a notable lack of meaningful engagement with people. Many individuals spent long periods isolated in their bedrooms, and staff did not consistently ensure that people’s basic comfort needs were met, including regular access to food and fluids.
Staff lacked clarity and confidence in how to support people who became agitated or aggressive. People were not always supported to maintain their personal appearance or wellbeing; some were unable to have their hair cut or receive podiatry care when they wished. There was a failure to respond promptly to people’s urgent and immediate needs. Delays in recognising and addressing situations where people required swift support placed people at risk of avoidable harm.
Care was not person‑centred, and people’s individual needs, preferences, and experiences were not consistently reflected in the support they received. Care records were often completed retrospectively and did not align with observations or the actual care delivered. The provider had not ensured that people’s health needs were supported holistically. Information was not always presented in formats, people could understand, limiting their ability to be involved in decisions about their care. Although concerns were raised, many people and their relatives preferred to speak with frontline staff rather than leaders. People with cognitive impairments were not adequately considered during a programme of redecoration across the home. The environment lacked appropriate visual cues to support orientation and independence. Additionally, people’s future needs were not consistently identified or reviewed, limiting the service’s ability to plan proactive and responsive care.
The provider had not demonstrated sustained improvement across consecutive inspections. Leaders in post had not undergone appropriate pre‑employment checks to assure their suitability and capability to manage the service safely. Governance systems remained ineffective and failed to identify ongoing shortfalls in care quality or address areas of unsafe practice. These processes were not used effectively to monitor performance or drive meaningful improvement. Staff reported feeling pressured and overstretched, and staffing levels were determined by the number of people living in the home rather than by individuals’ assessed needs. This approach limited the service’s ability to provide safe, responsive care. The provider had not established a culture of accountability, learning, or continuous improvement, which contributed to repeated failings and a lack of progress over time.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.