Sternhill Paddock

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Sternhill Paddock promoted a strong and positive learning culture. Leaders and staff placed clear value on reflection, improvement and continual learning, and this was evident in the way the team approached risk, challenges and change.

The service had effective systems in place to identify trends and patterns across incidents, daily records and safeguarding concerns. Staff understood why learning from these trends was important and could explain how this information helped them improve practice and prevent issues from recurring. This demonstrated that learning was embedded rather than reactive.

Positive risk‑taking was encouraged and supported. Staff told me that people were not restricted unnecessarily and that risk was approached in a balanced and person‑centred way. Where things did not go to plan, setbacks were not viewed as failures. Instead, they were treated as opportunities to gain further insight into what worked well and what needed to be adapted. This approach helped staff feel confident in promoting independence while maintaining safety.

The service had effective mechanisms for sharing lessons learned. Staff received feedback through team meetings, reflective discussions, formal supervision and ongoing mentoring provided by the registered manager. This ensured learning was communicated consistently and that staff had the opportunity to discuss how it applied to their day‑to‑day work. Staff reported that they felt supported, valued and encouraged to develop their skills.

The registered manager worked safely and effectively with people and healthcare partners to establish and maintain safe systems of care. Safety was monitored well, and systems were in place to ensure that people experienced continuity of care, including when moving between different services.

The provider had clear processes to assess and plan for people’s needs before admission. For example, they used an ‘enablement panel’ meeting for individuals who required additional support with managing specific health conditions. This process enabled the registered manager to consult with senior managers who had specialist knowledge, ensuring that the service fully understood the person’s needs and could meet them safely before any transition took place. This helped prevent avoidable or inappropriate admissions and promoted smooth, well‑managed moves into the service.

People also had important documents in place, such as hospital passports. These included personalised information about how individuals wished to be supported, their health needs and their preferred communication methods. This meant that if people needed to access other services, professionals had essential information immediately available. It helped people communicate their story without having to repeat information and reduced the risk of inconsistent or unsafe care during transitions.

People were supported by staff who were vigilant, compassionate, and confident in their responsibilities. This resulted in a service where risks were well managed, concerns were identified early, and safeguarding processes were consistently effective.

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 staff had a good understanding of people’s personalised risks and safeguarding needs. Staff were able to clearly describe the specific vulnerabilities of each person they supported, including risks related to communication, health conditions, behaviour, and social situations. Issues were identified quickly and staff followed the organisation’s procedures correctly and informed the registered manager without delay. The registered manager demonstrated strong oversight of safeguarding. They assessed concerns promptly, took proportionate action based on level of risk, and made timely referrals to the relevant external agencies, including the local authority safeguarding team, health professionals, and the Care Quality Commission. Lessons learned were shared with staff, which strengthened the service’s safeguarding culture.

Staff involved people when understanding and managing risks associated with their care and daily lives. The provider used recognised tools, including baseline risk assessments, to identify potential hazards and establish a clear starting point for safety planning. These assessments considered a wide range of factors, such as environmental risks, health‑related concerns, behavioural triggers and safeguarding issues, ensuring staff had a comprehensive understanding of each person’s needs.

Staff used this information to work collaboratively with people, helping them understand identified risks and agree on practical strategies to keep themselves and others safe. People were encouraged to express their views, preferences and concerns, and staff supported them to make informed decisions about how risks should be managed.

We saw that staff applied risk management plans consistently and reviewed them regularly with people. This included discussing any changes in behaviour, health or circumstances and updating plans to reflect new information. A team leader explained to us how the baseline risk assessment helped them recognise early signs of change and respond proactively.

The registered manager maintained a safe and well‑managed environment, even when people’s behaviours in times of distress resulted in unplanned damage to the home. Staff responded promptly to maintenance requests, and repairs were carried out in a timely manner to ensure the environment remained safe, functional and comfortable for people.

Where immediate repair was not possible, the registered manager had robust risk assessments in place to maintain safety during the interim period. These assessments were detailed and person‑centred, identifying any potential hazards linked to the damaged area and clearly outlining the measures staff needed to take to reduce risk. Staff understood and followed these interim controls well, demonstrating consistent awareness of how to keep people safe without imposing unnecessary restrictions.

This approach ensured that environmental risks were managed proactively and proportionately. People were able to continue using their home safely and with minimal disruption, and staff were confident in responding to changes quickly and effectively. The registered manager demonstrated good practice in maintaining a safe environment through prompt action, effective risk management and strong leadership oversight.

The provider had safe and effective staffing arrangements in place. Safe recruitment practices were followed consistently, including carrying out background checks, verifying employment histories and obtaining appropriate references before staff began working at the service. This helped ensure only suitable and trustworthy individuals were employed to support people.

The provider made sure there were enough qualified, skilled and experienced staff on duty to meet people’s needs safely. Staff told us they felt confident in their roles and had access to regular supervision, support and development opportunities. Training records showed staff received the learning they needed to carry out their responsibilities effectively, and new staff were supported through a structured induction.

We observed staff working well together as a team, communicating clearly and sharing information to ensure people received consistent, safe care. One staff member said, “Managers and team leaders will always help, especially if someone is off sick.”

The registered manager had effective systems in place to assess, monitor and manage the risk of infection. They demonstrated a clear understanding of current infection prevention and control (IPC) guidance and had measures in place to prevent infections from spreading throughout the service. Risks were reviewed regularly, and the manager acted promptly when concerns were identified, ensuring that appropriate agencies were informed without delay.

Staff understood their responsibilities and followed safe practices such as good hand hygiene, correct use of personal protective equipment (PPE), and appropriate cleaning routines. Records showed that infections were monitored closely, and any patterns or emerging risks were escalated for further investigation. This ensured that action could be taken early to minimise the likelihood of outbreaks.

Sternhill Paddock had successfully integrated IPC measures without compromising the homely environment. For example, cleaning products and PPE were stored discreetly but remained accessible to staff when needed. Communal areas were kept clean and hygienic, yet still warm, personalised and comfortable. People’s bedrooms retained their individuality whilst maintaining high cleanliness standards.

People were given their medicines safely and in a timely manner. This was recorded on their medicines administration record (MAR) and medicines were stored safely and securely. There were processes in place to ensure the safe and effective use of medicines. Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN”, was available to staff. There were no gaps in medicines administration in the records we reviewed. We checked the quantities and stock balances for each resident and found them to be correct. This meant that we could be assured that the correct doses of medicines had been administered as signed for by staff.

The use of topical creams and ointments were recorded on the medicines administration records (MARs). Body maps were in place to show staff the site of application. Staff were knowledgeable about medicines with additional requirements and how the service ensured these were administered safely and effectively. Temperature records to ensure the safe storage of medicines were completed in accordance with national guidance.

Staff told us that the medicines rounds were conducted at the same time each day for most people living at the service. If someone had a different routine, this was accommodated to ensure they were kept safe, but that treatment also met their individual preferences. People were seen by their GP at least annually for a routine check-up in line with national guidance. Hospital Passports were in place for each resident.

There was evidence that there was a process in place to record medicines related incidents or errors. Staff were trained and supported in their role to administer medicines. A formal observation of medicines administration was conducted and recorded at least annually. Managers and members of staff qualified to handle medicines regularly completed audits (checks) to make sure that procedures were followed.