- Care home
Balmoral Court Care Home
Assessment report published 30 July 2025
Contents
Ratings
Our view of the service
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requirements, but the service was dirty, medicine could not be accounted for, there were items of equipment which were out of date and medicine administration protocols were inaccurate.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.
People's experience of this service
People were happy with the support staff provided and spoke positively about them. Some relatives found at times staff needed to be more attentive when supporting people to attend to their personal care. Some people discussed the management of the service being concerning as they heard the registered manager ‘shouting and screaming’ at staff. A person said, “The staff, they are good and really kind but mood can really change depending on how the manager is behaving.”
We used a structured observation tool to assess whether people received good care. This approach showed some staff tended completed the personal care tasks and served meals, whilst other staff were often engaged in conversations and horseplay. Care staff tended not to engage people in any meaningful conversation or activity. We observed staff missed things, for example a person tripped, and the activities co-ordinator intervened to stop them falling. A staff came into the room asked the code to the lift but did not react or assist the activity co-ordinator to support the person to a chair. We observed staff on 1:1 support draw in colouring books without speaking to the person they were with or encouraging the individual to join in the activity.
A relative said, “[Person’s name] seems happy enough but at times they aren’t particularly clean and look quite untidy. Mind the staff from abroad do a very good job.” A person said, “The staff are good at their jobs and [named carer] always takes me out when I want.” Another person said, “[Named activities coordinator] does a cracking job and is always thinking of things we can do. We often go on trips or out into town and that.”