Balmoral Court Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

At the last inspection the registered manager did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The registered manager sent safeguarding alerts in when concerns were raised with them. However, at times there was a lack of oversight, which had led to incidents that should have triggered safeguarding alerts, being missed. During this inspection we found systems in place were being used more effectively, enabling the provider to have improved oversight of safeguarding reports. These were reviewed to identify themes and trends, ensuring that appropriate action was taken.

Staff had received training around what to do to make sure people were protected from harm or abuse. Staff ensured Deprivation of Liberty Safeguard (DoLS) authorisations were applied for when needed and any conditions were followed. During the inspection, we identified with the regional manager that some Deprivation of Liberty Safeguards (DoLS) paperwork appeared to be out of date. However, upon cross-referencing with the electronic records, we found the necessary reviews and reapplications had been completed on an annual basis. The regional manager acknowledged this and confirmed that action would be taken to ensure documentation is consistently updated and accurately maintained.

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.

At the last inspection we identified that whilst risk assessments were in place and assisted staff identify how to mitigate risks, at times, the potential for distressed behaviours had not been fully assessed and there was limited information on what people’s behaviour may look like or the triggers.

During the inspection, we identified that some care plans still required updating to ensure all relevant information was included. We discussed this with the regional manager and assistant manager, who confirmed they were in the process of updating care plans to ensure they accurately reflected people’s assessed needs.

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.

At the last inspection the provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. At this inspection we found the provider had started to make improvements to the environment. One unit had been redecorated, and a programme of refurbishment was ongoing.

Health and safety checks were regularly completed. A plan was in place to ensure people had continuity of care in the event of an emergency.

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.

At the last inspection the provider did not always make sure there were enough qualified, skilled, and experienced staff. They did not always make sure staff received effective support, supervision and development or ensure safe recruitment practices were followed. At this inspection we found new documentation and processes had been introduced to ensure appropriate checks were completed. However, the processes had not been established and tested as only one new staff member had been recruited.

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.

People were supported by a consistent staff team. Staffing levels were determined by the needs of the people who used the service.

At the last inspection the provider did not always assess or manage the risk of infection or share concerns with appropriate agencies promptly. We found areas of the home were dirty and had not been adequately cleaned.

During this inspection some improvements had been made in relation to the cleanliness of the home. Domestic staff were present through our inspection. However, chipped paint on handrails was still evident. This meant these areas could not be cleaned effectively and increased the risk of spreading infection.

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.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.