The Paddocks 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 were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, the safe management of people’s medicines, safe staffing and governance relating to safety. The service was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the service remained in breach of this regulation.

This service scored 34 (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 and positive culture of safety based on openness and honesty. Staff did not listen to concerns about safety and did not investigate and report safety events. Lessons were not learnt to continually identify and embed good practice.

Systems designed to investigate and reflect on accidents and incidents were not robust. Not all safety incidents had been fully investigated, and where they had been investigated, learning had not always been shared with all staff. For example, a fire drill had identified a very poor response by staff, and a follow-up drill was scheduled but did not take place. We found some staff’s understanding of fire procedures was poor.

During our assessment we observed one person repeatedly exhibiting a behaviour which put others at potential risk. Staff were aware of the behaviour, but it was not clearly recorded in the person’s care plan and effective measures were not in place to mitigate the risk. A second person was observed throwing food and drink at others. This distressed other people who used the service but lessons relating to this known behaviour were not embedded and the area was left without staff for many minutes at a time. During such a period of no staff oversight, a further incident occurred.

The provider did not work well with people and healthcare partners to establish and maintain safe systems of care. 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 healthcare professionals about the lack of effective systems and poor communication which had, at times, impacted people’s care. Handovers did not always ensure key information was communicated about people’s changing needs.We were aware of an incident where one person moved to another service and communication relating to their medicines did not include information about their allergies to particular medicines.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately.

We identified some safeguarding incidents which had not been appropriately reported or shared with the local authority. However, the new management team in place at the time of our onsite visit, demonstrated an understanding of when to report incidents and we noted some improvements to safeguarding processes in recent weeks. A faulty lift had not been fully assessed in terms of the potential effect this might have on people’s care and wellbeing, whilst it was out of action.There was no robust plan to assess and mitigate risks relating to some people not being able to access appointments, receive visitors, access the garden in the very hot weather to cool down or calm down if a change of scene was needed, which was the case for one person.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that where people had been deprived of their liberty under the DoLS in order to be safe, some records were due for review. Appropriate authorisations had been submitted to the local authority, but action was not always clearly documented when authorisations had been delayed.

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.

Some risks were poorly managed, even when clearly identified in care plans. Fire evacuation procedures were not understood by all staff, despite having received training. Management of people’s fluids was very poor. We assessed the service during a heatwave during which an amber alert was in place. Fluid targets were not clear to staff, and recording was inaccurate. Fluids were not promoted despite the very high temperatures. We observed one person had no record of having had a drink for over 5 hours and had received only 1 litre of fluids in the last 12 hours. Staff asked them if they wanted a drink and they said yes. They were clearly very thirsty and immediately asked for a second drink. People who used the service told us drinks were not brought round often enough and they were thirsty.

In addition to a lack of fluids, the dementia unit upstairs had only 3 portable fans for 14 people's rooms and communal areas. People were clearly distressed by the heat, and we did not observe any additional cooling measures in place to ease this. We fed our concerns back to the provider and measures were immediately put in place to increase and monitor people’s fluids and additional fans were purchased.

Other risks such as falls, choking and the risk of developing a pressure ulcer were not always well managed. Oversight of these risks required improvement to ensure patterns and trends were identified and recording was accurate.

The provider did not detect and control potential risks in the care environment. They did not make sure that all equipment, facilities and technology supported the delivery of safe care.

We identified scalding hot pipes in the residential unit which posed a risk to people who used the service. We fed this back to the provider who took prompt action to address this. We also noted the kitchen upstairs on the dementia unit was unlocked on 3 occasions and was easily accessible to people and no staff were in the area each time. The kitchen contained a boiling water tap.

The environment was mostly appropriate to people’s needs, given the challenges presented by the older part of the service. However, the additional risks and challenges presented by the lift being out of action in the dementia unit had not been well managed. Some people had missed medical appointments. The potential impact of this and of some people not being able to leave the upstairs unit and access the garden or another space, had not been fully considered or risk assessed.

We also observed toiletries were not all kept securely. This posed a risk to those people living with dementia who might believe them to be something to eat or drink.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

We found there was a reliance on agency staff. These staff did not always receive an appropriate induction and support for staff in general required improvement. We observed 2 senior agency night staff who had not been made aware of fundamental safety information such as the location of the fire exits and fire procedures. These staff were not able to tell us about people’s care needs and specific risks. Agency staff did not have access to the electronic care record system which meant they had no effective oversight of people during the shift as they had to rely on other staff to do this. This also meant electronic care records were not always accurate or timely. This made it impossible to be fully assured people’s needs had been met.

Some care staff we spoke with told us there were not enough staff. One staff member said, ‘The permanent staff are overwhelmed. [Agency staff] don’t know the residents. The issue is that there are not enough staff.’ 5 people who used the service also made this point to us. One person commented, ‘They do seem to be short staffed, but they don’t rush me when they do arrive. A couple of times in the last 6 months I have waited over 3 hours for assistance. Once I rang for help before lunch and it was left to the night shift to help me. I was very uncomfortable.’

People living with advanced dementia could not express how they felt about the staffing, but we observed people being left without staff when they needed them. One lounge was left unstaffed for several minutes at a time throughout the day and evening. This placed people at increased risk of harm.

New staff received a comprehensive induction and were positive about this. Established staff received training including refresher training in core skills.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service had an infection prevention and control policy, and staff had received relevant training. The service was clean but not odour free and on the dementia unit there was a powerful and unpleasant odour present on all visits. During our assessment the lounge area upstairs was deep cleaned, and furnishings were thoroughly cleaned. However, some chairs were not wipe clean and we noted on our third visit one had become soiled again where a person had been incontinent of urine. This may have contributed to the malodour, as did the presence of carpet in some bedrooms.Communal jugs of juice were not dated, and staff could not tell us when they had last been refreshed.

Infection prevention and control audits were in place, but these had not identified the issues we found and had not been completed since April 2025. A structured programme of cleaning was in place. However, there was no head of housekeeping in post at the time of our assessment and staff told us they were very stretched. We understand this post has now been filled.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Some medicines had specific instructions, such as administering them separately or at a particular time, which were not being followed. For medicines administered when required, there was always a protocol in place to assist staff, but some lacked detail. Where medicines were being crushed to aid administration, with the person’s knowledge, the instructions were not up to date and didn’t include all the medicines being taken. This meant some agency staff were not clear about the process. Controlled drugs were stored and recorded appropriately although there were gaps in the weekly check in which was not in line with policy. This had also been identified during the provider’s audit.

The administration records completed when district nurses came in to administer medicines such as insulin or vitamin injections were good. However, we received negative feedback from the local GP surgery about the service’s failure to secure urgently needed medicines in a timely manner, including end of life medicines. This was viewed as an issue of poor communication and lack of effective systems. We were not assured that all medicines incidents were being recorded, investigated and lessons learnt.

Senior carers were able to tell us about people’s medication needs in relation to their diabetes and demonstrated a good understanding. Carers were trained and had medicines available to be able to respond to episodes of low blood glucose. We observed staff administering medicines treating people with care and dignity during medicines administration. Systems were in place to safely store medicines, including in the extreme hot weather.