Balmoral Court

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The service was not always well-led and has moved to requires improvement in this key question. We identified 2 breaches of regulation. Whilst a range of audits were undertaken as part of a quality assurance process including systems like daily walkarounds, these did not identify or address the issues of concern we found on our visit relating to cleanliness, equipment, staff records, care records and medicines. There was a lack of understanding from the registered manager about the actions to take to be compliant with the duty of candour regulation. There was a policy, however this did not define what a notifiable safety incident was and there were no records to demonstrate follow up actions and appropriate apologies were provided. Feedback from people was generally positive although feedback from relatives was mixed. Feedback we received from statutory partners were of good relationships with staff and management and that the service was responsive and managed people with risks well. Staff told us they felt comfortable raising concerns with managers.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager described a positive culture which was reflected in comments made by staff and interactions they had with people at the home. A staff nurse we spoke to told us, "I would recommend it as a place to work, it has a good reputation." Some feedback from people and relatives mentioned that at times the language barrier with staff members could be problematic. Generally our feedback was people and staff had positive relationships and people were free to follow and express their religious and cultural beliefs.

The service provided a range of information about itself in a variety of formats. The service had a vision and values document in place which included how the service worked collaboratively with other partners. The service had an easy read dementia strategy document that detailed how it set out its provision for people living with dementia. The service also had a relatives guide containing key information about the service such as contact details information on complaints and safeguarding.

Staff we spoke with said they felt supported by the management team. The registered manager described good relationships and support systems between on-site and remote leadership.

Whilst a range of audits were undertaken as part of a quality assurance process including systems like daily walkarounds, these did not identify or address the issues of concern we found on our visit relating to cleanliness, faulty equipment, staff records, care records and medicines. Recruitment checks were not robust and the provider could not be assured that all leaders had honesty, openness and integrity and were fit for their role. Restriction on practice conditions had not been followed to confirm a person was suitable for the role and there had been a failure to ensure all relevant background information was scrutinised, with appropriate risk assessments completed. Medicines records required improvement relating to covert medicines, 'as and when required' medicines administration and guidance protocols, as well as processes to manage topical medicines. We highlighted to the management team that some care plans were not reflective of people’s needs and some information relating to medicines in care plans was incorrect, which was a risk. High risk items such as hot kettles were left in communal areas despite risk assessments saying they should be put away. A room being used to store equipment was not always locked and we saw 3 tubs of thickener stored in an unlocked kitchen cupboard.

The registered manager had an open door policy in place and staff told us they felt comfortable raising concerns with managers. Additionally, the registered manager told us, "We have whistleblowing policies displayed and a 24hr manned whistleblowing internal number and its discussed at their induction." Staff we spoke to also gave examples of raising concerns with the registered manager and that action had been taken on their concerns.

We reviewed the evidence from surveys that had been completed in January 2024. This showed that surveys had been undertaken with professionals, people, staff and relatives on a rolling month by month basis. We saw that questionnaires were generally positive in feedback although some areas in relation to activities what marked as neutral from relatives but there was no negative feedback from visitors relatives or residents in the surveys we viewed. Staff feedback was generally positive with some small areas of feedback regarding cleanliness and confidentiality mentioned in a negative way but these were far outweighed by positive feedback.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager understood the statutory and regulatory requirements of their role relating to notifying the CQC of a relevant safeguarding incidents. The registered manager told us they completed quality audits and walk-arounds (including PPE and phone use spot checks) as well as having meetings with the provider's quality manager. The regional manager visited the service weekly and full quality audits were completed by an external quality manager. Business continuity plans were in place and staff had access to these at each nursing station, this included on-call staff which gave consideration to the advantages and disadvantages over using agency staff who would not know the people who used the service as well.

There were areas of improvement needed regarding the actions to take to be compliant with the duty of candour regulation. The provider had a duty of candour policy, however, this did not define what a notifiable safety incident was. There was no documentation provided to us to show what actions had been taken in response to notifiable safety incidents and no evidence that an apology had been provided in writing when a notifiable safety incident had occurred. From a review of serious injury statutory notifications there have been a number of incidents where serious users have suffered an injury which would come under this regulation. The provider’s systems had not ensured records were accurate, complete and contemporaneous. Records for wheelchair checks had not identified the issues with damaged/faulty wheelchairs. Infection control audits had identified some issues but actions had not been followed through and there were numerous infection control issues across the service. Care plans did not always describe in detail key information about people to ensure staff supported people consistently and safely. For example, one person had a textured diet but the plan did not record at what level this should be. We reviewed 4 staff recruitment files and there were issues with each file including lack of employment history, lack of interview records, conflicting dates and restrictions on practice not recorded. There were gaps in the training matrix to show that all staff had completed training which had been identified as mandatory by the provider and gaps where it was not evidenced that all staff had received supervision in line with the provider’s policy.

The registered manager explained to us that they managed their time to allow them to attend a local provider meeting, had good working relationships with the local authority and had offered assistance to other homes in caring for people with challenging behaviour. A staff member we spoke to said, "We take feedback and share information with visiting health professionals, such as social workers."

We attended a multi-disciplinary meeting (MDT) that was held weekly at the service and was attended by a variety of partners such as a pharmacist, GP, mental health nurse and an advanced nurse practitioner. The meeting enabled each unit of the service to discuss any concerns or follow up on actions from previous meetings. There was opportunity for all to have input, staff did not talk over each other or ignore any views. The meeting was respectful and feedback we received from partners was it was a productive MDT, there was a good response from the staff team to any input professionals raised and peoples views and opinions were listened to.

The service worked in conjunction with other health professionals to ensure people's needs were being met and care was appropriately co-ordinated with everyone involved. Transitions were planned and there was a regular multidisciplinary meeting each week were people's needs and views were discussed. This meeting participants told us, "The teams are good at implementing agreed strategies for residents" and "The staff are very dedicated."

Debriefs and lessons learnt were shared with staff following accidents and incidents including with night staff. The registered manager told us, "I have worked nights to try and include night staff more." This included learnings from interventions and when providing CPR. This information was also discussed during handover meetings. The registered manager had also introduced an initiative called "Flamingo" to help staff communicate to each other or a leader if they felt overwhelmed and needed assistance to keep someone safe.

We saw systems were in place for learning lessons from event at the service.