The Care Quality Commission
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Balmoral Court Care Home

Overall: Requires improvement read more about inspection ratings

Ayton Street, Newcastle Upon Tyne, Tyne And Wear, NE6 2DB (0191) 265 2666

Provided and run by:
Crown Care IV Limited

Important: The provider of this service changed - see old profile

All Inspections

During an assessment under our new approach

Date of Inspection: 15 July to 3 August 2026. Balmoral Court is a nursing home providing accommodation and support for up to 99 people. Most people at the service are living with a dementia related condition and some younger adults with mental health needs live there. At the time of this inspection, 71 people were living at the service.

At the last rated inspection in July 2025, we rated the service as requires improvement and identified multiple breaches of regulation. These were related to having a competent registered manager, person-centred care, treating people with dignity and respect, medicines management, infection control, good governance, recruitment and duty of candour. We used our enforcement powers to cancel the manager’s registration, and the provider submitted action plans detailing how they would make improvements. A new manager is now in post and is taking action to become registered.

At this inspectiona wide range of improvements had been made, andthe provider was no longer in breach of regulations other than ones relating to medicine management and good governance.

Albeit a wide range of improvements had been made to the medication management and the treatment rooms were now clean, and the issues such as out-of-date equipment and dirty treatment rooms had been resolved. There continued to be issues with the administration of medicine. For example, we found 2 medicines which needed to be injected and a person’s patch pain relief were not administered appropriately. When staff crushed people’s medicines, they were not crushing each medication separately. Staff had not considered whether each medicine could be mixed with another, what means such as food or fluid each one could be given with or their own health. When these issues were raised the provider and manager took immediate action to ensure people received appropriate care.

People now received care from staff who knew them well and understood their individual needs, preferences and life experiences. On the whole risk assessments were in place and assisted all to mitigate risks. We discussed where these could be enhanced and improved, which the manager acted upon. Accidents and incidents were recorded and now consistently reviewed to identify lessons that could be learned to improve the service. People told us they felt safe and described staff as kind, caring and supportive.

Feedback from professionals was largely positive. Healthcare professionals told us the manager was proactive, engaged well with external agencies and sought advice to improve care. They said staff supported them with the information they needed, communicated effectively and worked collaboratively to achieve positive outcomes for people. Professionals also described improvements in the home environment, staff practice and the overall atmosphere within the service.

Many staff described improvements since the current manager took over and said they felt supported, listened to and able to raise concerns. Staff spoke positively about the person-centred approach taken within the service and said people were treated with dignity and compassion. However, some staff expressed concerns about staffing levels and the pressure this could place on the team at busy times.

Staff on occasions used physical interventions but the current records did not show what holds can be applied for each person and in each situation. When recording incidents staff often recorded limited information, which did not explain the exact hold or note if any deviations occurred. Also, from discussions with staff, it became evident they were not always recording incidents and how these were managed. We saw no evidence of debrief sessions being completed. The management team described how they had supported staff to consider alternative approaches to manage distress behaviours, but the current records do not support them to show this or look at the trends in use.

Staff had now received additional training around how to meet the requirements of the Mental Capacity Act 2005 (MCA) and the code of practice. Some improvements had been made to capacity assessments and ‘best interests’ decisions were in place for restrictions such as people not being able to go out on their own or staff managing their monies. For people with capacity, they had not always signed records to show they consented to the restrictions in place such as not being able to leave a unit unless accompanied by staff. The new manager undertook to immediately address these matters.

The provider and manager had completed a thorough review of the service and identified the actions needed to ensure it operated in line with expected practice. They had made significant improvements to the culture, leadership, staff engagement and people’s quality of life. They recognised the scale of change required and how further work was needed to embed improvements.

Staff described receiving regular support through supervision, appraisals and informal discussions. Staff worked closely with healthcare professionals to ensure changes in people’s conditions were addressed in a timely manner and a way that met the person’s needs. Staff supported people to stay independent, take part in activities and maintain links with their community.

During an assessment under our new approach

Dates of assessment 23 October 2025. At the last inspection in June 2025, we rated this service overall Requires Improvement. Balmoral Court is a care home providing nursing and personal care for up to 99 people whose presenting needs relate to their physical and mental health needs. This includes people living with a dementia related condition and people completing alcohol reduction programmes. At the time of this inspection, 75 people were living at the service.

The inspection was prompted by the notification of an incident following which a person using the service sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with the CQC about the incident indicated potential concerns regarding the management of the risk of falls from height. This inspection was a responsive inspection, focusing on key quality statements in order to examine those risks.

During this inspection, we reviewed the priority quality statements relating to safeguarding and involving people in managing risks to ensure people were safe. We also looked at the environment to check that potential risks were identified and addressed, and that infection prevention and control practices were being followed. In addition, we reviewed how the provider promoted people’s independence, ensured people were listened to, and that care and support led to positive outcomes and experiences for those using the service.

Since the last inspection, the provider had begun to implement the required improvements identified. While progress had been made and some improvements were underway, these had not yet been fully completed or embedded within the service. As a result, we were unable to assess whether the improvements were sustainable. Therefore, the ratings for the quality statements inspected have remained the same.

During an assessment under our new approach

Date of Assessment: 25 April to 11 June 2025. Balmoral Court is a care home providing nursing and personal care for up to 99 people whose presenting needs relate to their physical and mental health needs. This includes people living with a dementia related condition and people completing alcohol reduction programmes. At the time of this inspection, 84 people were living at the service.

At the last inspection in April 2024, we rated the service as requires improvement and identified breaches of regulation. These were related to medicine management, infection control, staff recruitment, duty of candour and the oversight of the service. At this inspection we found no improvements had been made in relation to these breaches and identified other areas of practice which were not meeting the legal requirements.

Following the last inspection the registered manager introduced their own audit. This indicated all aspects of the service were operating in line with requirements. The judgement was based on information they had taken from the main audits, which staff members on each unit had completed. None of the audits picked up the large volume of concerns found during this inspection.

At the last inspection we found recruitment practices failed to meet legal requirements. They did not always contain information about employees’ full employment history nor evidence that any gaps in employment histories had been explored. Right to work checks had not been completed and when nurses had restrictions on their practice there was no evidence to demonstrate how these were met. At this inspection we found the same issues.

When staff were promoted internally the registered manager had not followed the provider’s recruitment process. There was no evidence to show applications were submitted and the staff were interviewed. The staff files merely contained information from their original appointments. The registered manager regularly employed nurses who were being investigated by the NMC, had warnings or restrictions imposed. This was not within their company policy.

The infection control and medicine audits had everything ticked as meeting requirements, but the service was dirty, medicine could not be accounted for, there were items of equipment which were out of date and medicine administration protocols were inaccurate. These issues were the same as we found last time.

The registered manager believed nursing staff, if not care staff, fully understood the needs of the people who used the service. We found none of the staff could explain people’s need, their conditions or tell us why they had been admitted. Albeit the registered manager could discuss people’s needs they did not always have this information to hand.

Staff working in every unit in the service told us it was the most challenging as people could be unpredictable. There was no discernible rationale around which unit people were admitted to and at times where they resided was contrary to meeting their needs.

Care records were in place and regularly reviewed. These did not always contain specific information staff would need to effectively assist people to manage risks they may face or to protect others.

The provider’s governance systems had not identified issues with the registered manager practices we identified. Nor did it identify the service was failing to meet expected requirements and previous concerns had not been addressed.

The registered manager stated the refurbishment plans commenced prior to the last inspection had been fully completed even though many areas of the home need to be repaired and the units looked very sparse. The provider and managing director north explained this was not the case, as a lot of the work had not yet been completed due to major repairs needing to be completed to fix the lift. However, wall murals and new furniture had been purchased, and they were systematically renovating units, windows, bathrooms and showers.

There was a comprehensive training programme in place for care staff, which included the use of physical interventions. The provider had proactively supported staff to complete qualifications to be healthcare associates and to train as nurses.

Staff worked with local healthcare professionals and sought advice when required.

We found there were breaches in legal regulations relating to the registered manager’s skills, person-centred care, dignity and respect, safe care and treatment, good governance, recruitment and duty of candour. Following the inspection, the managing director north sent over information to show how they were addressing the issues and making the necessary improvements. We have asked the provider for action plans detailing how these concerns will continue to be resolved.

During an assessment under our new approach

Balmoral Court is a care home providing accommodation and nursing and personal care to older people and younger adults. The service can support up to 99 people. People are accommodated in four units, including a male only and a female only unit. People are supported with physical and mental health needs, including people living with a dementia related condition. We carried out an onsite and off-site assessment. At the time of the inspection the service supported 92 people with personal and or nursing care. Activity started on 12 March 2024 and ended on 19 April 2024. We spoke with 7 people, 13 relatives, staff and management and received feedback from health and social care professionals. We looked at 25 quality statements.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it. At this assessment we found 4 breaches of regulation where improvements were needed to the environment, records, medicines, staff recruitment and the duty of candour. Areas of the home were dirty and some equipment was not safe for use, staff recruitment was not always carried out safely, and risk assessments and care plans were in place but the information recorded was not always detailed. Medicines records required improvement relating to covert medicines, ‘as and when required’ administration protocols, as well as processes to manage topical medicines. There was a lack of understanding about the actions to take in response to a notifiable safety incident. A system of quality audits were in place, but these had not identified the issues we found at our visits.

26 November 2020

During an inspection looking at part of the service

Balmoral Court is a care home providing accommodation and nursing and personal care to older people and younger adults. The service can support up to 99 people. People are accommodated in four units, including a male only and a female only unit. People are supported with physical and mental health needs, including people living with a dementia related condition. At the time of inspection 93 people were using the service.

People’s experience of using this service and what we found

The service was exceptionally well led. The provider's vision and values were person-centred to make sure people were at the heart of the service. This vision was driven by the exceptional leadership of the registered manager.

The service supported some people with complex needs. There was clear evidence of collaborative working and excellent communication with other professionals to help meet people's needs and maintain their placement wherever possible. A healthcare professional commented, “I continue to enjoy working with the team at Balmoral. The management maintains a stable staff team and communicates well with my practice.”

People's equality and diversity as unique individuals with their own needs was respected by staff. The service was flexible and adapted to people's changing needs and wishes and promoted their independence. People’s care records were well-personalised and up-to-date.

There was a strong and effective governance system in place. Processes were in place to manage and respond to complaints and concerns. People and relatives recognised that their views were valued and respected.

People and relatives stated staff were kind, caring and supportive of people and their families. Comments included, “Carers are amazing, I take my hat off to the staff” and "I like the way staff do things, they are very polite, very friendly and always have a smile.”

People were involved in decisions about their care. They were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People said they felt safe with the care they received. One relative commented, "Staff have a nice attitude with people, they are safe the way staff support them.” There were enough appropriately skilled staff to meet people’s assessed needs. Robust vetting procedures were in place when recruiting new staff. Staff training was up-to-date.

The service was following safe infection prevention and control procedures to keep people safe.

Medicines management procedures were in place. People did not report any concerns with their medicines.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published July 2019).

Why we inspected

This focused inspection was prompted by the notification of a specific incident, following which a person using the service died. This incident was subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident. The information CQC received about the incident indicated concerns about the management of people’s safety. This inspection examined those risks and we reviewed the key questions of safe and well-led and parts of effective and responsive. We found no evidence during this inspection that people were at risk of harm from this concern. Please see the relevant domains of this report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service.

Ratings from previous comprehensive inspections for those key questions inspected but not rated were used in calculating the overall rating at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Balmoral Court on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

28 March 2019

During a routine inspection

About the service

Balmoral Court is a residential care home that was providing personal and nursing care to 88 people at the time of the inspection. The service can support up to 99 people. People are accommodated in four units, including a male only and a female only unit. Care is provided to both older people and younger adults. People are supported with physical and mental health needs, including people living with a dementia-related condition.

People’s experience of using this service and what we found

The service was exceptionally well led. The provider had invested in developing an experienced and motivated management structure. The registered manager was extremely knowledgeable, proactive and driven in striving for people to receive better care. Staff were proud to work for the company. Their commitment was recognised, and their suggestions listened to. The service had excellent links with the local community and used these to enhance the lives of the people who used the service.

People told us they felt safe. The home was well maintained. There were enough staff to meet people’s needs and medicines were well managed. The home was clean.

Staff received training relevant to their role. They were given opportunities to develop their skills and were well supported. People’s care was planned and delivered to meet their individual needs. Staff had clear information about how to support people. They effectively diffused situations where people became agitated. The service was well designed to enable people to be as independent as possible.

Staff were caring and put people at ease. Relatives told us staff knew them and their family member’s well. People were valued, and their differences were celebrated. People’s dignity was respected and their independence was promoted.

People’s care was designed around their needs, choices and preferences. People could take part in activities both inside and outside the home. People and relatives were asked for their views, and these were used to drive improvements. Complaints had been well managed.

People were supported to have maximum choice and control of their lives and staff supported people in the least restrictive way possible; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

At the last inspection the service was rated good (published January 2018).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

1 December 2017

During a routine inspection

Balmoral Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Balmoral Court provides nursing and personal care for up to 58 mainly older people with dementia-related conditions and other mental illnesses. The home is set out over two floors, one designated for accommodating females and the other for males. At the time of our inspection there were 46 people living at the home.

The service was last inspected in August 2016 and rated as ‘Requires Improvement’. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective and well-led to at least good. At this inspection we found the necessary improvements had been made in the management of medicines, upholding people’s rights under mental capacity law, and to the governance of the service. The service had improved to good and met each of the fundamental standards we inspected.

A new manager was in post who had applied to be registered. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Systems were in place to safeguard people against the risks of harm and abuse. The home had been enhanced and the environment was clean, comfortable and equipped to meet people’s needs.

There were enough skilled and experienced staff who provided continuity of care. The staff received training and support that enabled them to care for people effectively. People were appropriately supported in maintaining their health and nutritional needs.

Staff were caring in their approach and had formed supportive relationships with people and their families. They respected privacy and dignity and encouraged people to make choices about their care. Formal decision-making processes were undertaken with the involvement of advocates, when necessary.

People’s needs were assessed and care planned, guiding staff about the care and support the individual required. A range of activities and access to the community was provided to support people in meeting their social needs. Good arrangements were made when people were cared for at the end of their lives.

The manager promoted an inclusive culture and provided leadership to the staff team. Feedback was sought and any complaints received were taken seriously and responded to. The quality of the service was continuously monitored to check that standards were maintained and improved.

Further information is in the detailed findings below.

8 August 2016

During a routine inspection

The inspection took place on 8, 22, 25 August and 3, 4 October 2016 and the first day was unannounced. This was the first inspection of Balmoral Court following a change in registration in February 2016 relating to the provider’s brand. An earlier inspection was carried out to check the safety and welfare of people using the service following a serious incident that had occurred at the home.

Balmoral Court is a care home that provides nursing and personal care for up to 58 mainly older people who have dementia-related conditions and other mental illnesses. At the time of our inspection there were 41 people living at the home.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that the ongoing personal safety of people living at the home was not compromised. Appropriate steps were taken to safeguard people against the risks of avoidable harm and abuse. Measures were in place to reduce the risks associated with people’s care and to ensure there were safe working practices.

Safety-related checks were carried out and there was improved maintenance of the building. A decorating and refurbishment programme was nearing completion and more efforts were being made to enhance the environment. Accidents and incidents were suitably reported, analysed and acted on.

New staff were properly checked and vetted before they started working with vulnerable people. There was a full staff team and enough staff to provide people with safe and consistent care. Comprehensive training had been delivered to support staff in developing their skills and enable them to provide people with effective care.

Choices of meals were offered and people were given support with eating and drinking, where needed. Nutrition was assessed and, when necessary, dietetic and other specialist advice was obtained. People were supported in meeting their physical and mental health needs and accessed a range of health care services. However, the management of medicines was not fully robust and required improvement.

The principles of mental capacity law were not always being applied to make sure people’s rights were upheld. Formal processes had not been undertaken for making specific decisions about people’s care and treatment where they were unable to give their consent.

People and their representatives were provided with information about the service and had opportunities to give their feedback. We observed positive interactions and good relationships between people and the staff who cared for them. This was confirmed by people and their relatives who told us staff were caring and respectful.

Individualised care plans had been developed to guide staff on meeting people’s identified needs and preferences. Care was regularly evaluated and adapted in response to any changes in a person’s needs, though reviews of care to consult with people and their relatives had lapsed. A variety of activities were arranged for social stimulation and to help people be included in their local community.

The management team provided leadership and support to the staff. They were promoting an open culture in the service and aimed to work more inclusively with people, their relatives and staff. Any complaints raised were taken seriously and promptly addressed. A more structured approach was being taken to monitoring standards in the home, though this had not highlighted the shortfalls we found during the inspection. The governance arrangements needed to be improved to keep closer scrutiny of the quality and safety of the service.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to medicines management, consent and governance of the service. You can see what action we told the provider to take at the back of the full version of this report.