Balmoral Rest Home

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff told us they felt supported and involved in improving the service and they considered they worked well as part of a team. The registered manager supported staff to understand the aims of the service, sharing information on best practice either in scheduled or daily handover meetings. One staff member told us, “[Registered manager,] She’s made a big improvement here. She’s approachable and I can say what I think.”

The registered manager and staff worked with families and health and social care professionals to build a culture that focused on enabling to people to enjoy their lives. Staff spoke positively about the people they supported, and our observations showed people were happy.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

Feedback on the management team was very positive. One person described the registered manager as, “Very caring and dedicated.” They explained Balmoral Rest home had a happy atmosphere, was clean and well organised.”

Staff told us management had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. One staff member told us, “You can chat with [registered manager,] they will listen and will help you.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they were aware of the whistleblowing policy and the path to take should they need to raise concerns. They told us they were able to challenge poor practice, and the registered manager was open to feedback. A staff member told us, “[Registered manager] would listen and act on complaints.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had policies and procedures around equality, diversity and inclusion. Staff felt the registered manager considered their equality, diversity and inclusion and treated people equally and fairly.

The provider had clear responsibilities, roles, systems of accountability and good governance. They sought to use these to manage and deliver good quality, sustainable care, treatment and support.

Refurbishment was taking place during our visit, however environmental concerns we found had not been identified through internal governance processes. For example, some radiators would have benefited from being covered to minimise the risk of scalding. Some doors did not close flush into their frames. Having flush fit is critical for preventing the spread of fire and smoke.

Some care plans did not guide staff on people’s health conditions and when to act if they needed support. Personal care records related to 1 person had not been consistently completed. The registered manager took immediate action to mitigate the risks.

Staff told us the service was organised and well managed and the management team had oversight of people’s needs. The registered manager was in the process of reviewing all documentation and had made significant changes since we last visited.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Records showed the management team and staff worked with relevant professionals and agencies. For example, advocates, social workers, district nurses and general practitioners. Staff communicated and recorded information provided from health professionals when they visited people.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe and effective practice.

The provider encouraged staff to speak up with ideas for improvement. Staff confirmed they were able to contribute to team meetings, present new ideas and the service had improved under the leadership of the current registered manager.

The registered manager was responsive to the feedback shared at this assessment and acted to address current concerns. They had made positive changes and were planning to introduce new technology to improve outcomes for people.