The Paddocks Care Home

Updated 1 August 2025

Date of assessment: 12 August to 2 September 2025. We undertook 2 out of hours unannounced site visits and one announced daytime visit followed by a feedback session. We carried out this assessment to review escalating risks which had been reported to us and to follow up on our previous assessment published 17 March 2021 when conditions were added to the provider’s registration. Special measures have been in place at this service since 17 April 2020.

At the time of our assessment there were 51 people using the service. The service is a residential care home providing care and support to older people, some of whom are living with dementia. The service is split into 2 separate buildings, with one being used to support those people living with more advanced dementia.

At our last assessment in 2021 the provider had been in breach of 4 regulations relating to safe care, safeguarding, good governance and failing to notify CQC about significant events. At this assessment we identified continued breaches of regulation relating to safe care and good governance. We also identified new breaches relating to safe and effective staffing and meeting people’s nutritional and hydration needs.

Staffing levels did not ensure people were kept safe and a high level of agency cover meant staff were not always able to meet people’s needs. Medicines needed more robust management and communication required improvement to ensure people received medicines, including end of life medicines, in a timely way. The environment required some improvements to make it safer for people and reduce risks from fire and scalding.

Our assessment coincided with an amber alert heatwave, and we found people’s fluids were not well managed leaving some people noticeably thirsty. Recording of people’s fluids could not be relied on to give an accurate picture. Oversight of this and management of the heatwave in general was very poor.

People were treated with kindness, and we observed some compassionate care. However, the high number of new and agency staff and poor communication systems meant people’s needs were not always fully understood and some care was task focused.

Management and oversight of the service was not effective, and audits and improvement plans had not identified the serious issues we found. Management of the service was not robust, and some key posts were vacant which meant it was difficult to bring about the required changes and improvements. Some of these posts have been filled since our assessment concluded. The culture at the service was not always viewed as a supportive one, with some staff describing it as punitive. Considerable work is needed to address the issues we found and give staff and people who use the service full confidence in the leadership of the service. The provider gave us some assurances that they were already taking steps to make the required changes. The service remains in special measures.

Updated 1 August 2025

We received some mixed feedback from the people who used the service, some in person and some from surveys conducted by the provider. People praised individual staff and overall found the staff kind and caring. They praised the skills of the permanent staff and said they did not feel rushed despite staff being very busy. One person told us,’ Most of the staff know what they are doing, but if they don’t, they will send a more experienced person with them.’ People’s main negative comments related to the high use of agency staff, lack of activities and food and drink. Typical comments about staffing focused on new and agency staff. One person said, ‘The staff aren’t always together on things. They don’t always work together very well. Some of the agency people don’t seem to have a clue about what to do.’ Another person made a comment which represented the majority of the feedback we received about staffing saying, ‘There have been quite a few changes of staff and a lot of agency staff. The agency staff are not so good. You have to tell them what to do and how to do it. They just don’t know you. The regular staff know me, and we can have some banter.’ Several people also mentioned some staff, who are not native English speakers, speak to each other in their own language and people found this upsetting and rude.

People also spoke about the poor management of the heatwave with 4 people mentioning being thirsty as drinks were not brought round often enough. One person said, ‘There is a definite shortage of drinks in the room. If I ask for a drink, they will get me one, but you have to ask. They don’t seem to bring drinks round very often.’

Whilst people felt they had some say over when to get up and go to bed and were able to choose meals etc, most did not feel fully involved in their care and had not seen or reviewed their care plan. Activities were not varied, and some people were unhappy about the provision. We saw no activities taking place for people living with dementia during our onsite visits.