Balmoral Court Care 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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At the last inspection we rated this key question requires improvement. At this inspection the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

We found the provider was in breach of the legal regulation relating to the skills of the manager and good governance.

This service scored 36 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. They had created a work ethos based on control through the use of intimidation and bullying. People we spoke with had been very frightened to share concerns as they found the registered manager was “vindictive,” would shout and “belittle anyone” who said something different to them or raised concerns. The registered manager had not acted on concerns raised with them and was dismissive of them. Staff told us the registered manager would threaten them with dismissal if staff did choose to raise issues. We discussed these concerns with the provider and they took immediate action to make improvements. They were supporting the staff to start to change the close culture which had developed. A staff member said, “The staff are actively bullied and threatened on a regular basis, with the manager proudly calling themself the P45 lady when staff needed to discuss negatives.”

The provider did not have inclusive leaders at some levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. The registered manager did not run the service with integrity, openness and honesty. Staff consistently reported the registered manager was unapproachable, intimidating and bullied them. They felt unable to work to their potential and run an effective service. A staff member said, “I make an impact when I can, but often manager will make their own decision regardless of input. The manager’s conduct and professionalism is appalling. They swear, make rude jokes and threats about people’s jobs.”

People did not feel they could speak up and that their voice would be heard. People, did not confident to raise concerns with the registered manager and felt any issues would remain unresolved. A staff member said, “I have noticed residents don't have a choice of food, they don't choose things for themselves they are given what is there on that day. I raised it but the manager dismissed this and made me feel wrong for raising it. The manager doesn't care about the residents and staff.”

The registered manager did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. We observed there seemed to be a demarcation in workload, as overseas workers tended to complete majority of personal care tasks and serving meals whereas the other staff sat completing observations of the corridors or completing notes. The registered manager did not ensure staff who had visa and sponsorship restrictions in relation to the number of hours they worked were followed. They did not appreciate the effect this could have on the staff members. We discussed these issues with the provider who ensured they were immediately addressed.

The provider’s governance systems had not identified the registered manager had adopted a very controlling management style and bullied those who presented a different view to them. The provider had failed to identify the registered manager lacked the ability to critically review practice and was unable to consider where practices may need to be improved. The provider had not identified the service continued to fail to meet the requirements of the regulations and no improvements had been made to the service since our last inspection visit.

Staff understood their duty to collaborate and work in partnership, so services worked seamlessly for people. On the whole staff were passionate about providing good care outcomes and understood their duty to collaborate and work in partnership, so services. They, when needed, shared information and learning with partners and collaborated for improvement. A professional said, “We visit every week and find the staff raise relevant issues and work well with us.”

The registered manager did not focus on continuous learning, innovation and improvement. They had not ensured there was a system in place to encourage continuous learning, innovation and improvement across the service. We found audits completed by staff all suggested everything was working in line with requirements, but this was not the case. For example, the medicine audit showed everything was okay. However, we found treatment units were dirty, medicine could not be accounted for, and there were items of equipment which were out of date. The registered manager had used this information to complete their own audits and had not ensured they were accurate. The registered manager had not checked the accuracy of their own view of how the service ran and believed the service was extremely effective despite being shown evidence to the contrary. They had not identified this gap in knowledge could adversely affect how they managed all aspects of the service from recruitment and day-to-day operations through to ensuring staff received appropriate training.