- Care home
Balmoral Court Care Home
Assessment report published 3 September 2026
Contents
Ratings
Our view of the service
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improvements had been made to the medication management and the treatment rooms were now clean, and the issues such as out-of-date equipment and dirty treatment rooms had been resolved.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.
People's experience of this service
People were positive about the care and support they received and told us they felt safe, happy and well supported. People consistently described staff as kind, respectful and responsive. They told us the service had improved and that the new management team listened to them, acted on concerns and helped create a more positive environment. A person said, “It is a completely different home now the old manager has gone. The new manager listens to you, and I’m not frightened to speak to them.” Another person said, “It’s lovely here now, the staff are so much nicer now.” People said staff knew them well, respected their choices and supported them to make decisions about their daily lives.
People told us staff supported them in ways that met their individual needs. They said they could choose how they spent their time, when they went to bed and what they ate. People were positive about the food provided and said there was a good choice of meals, snacks and drinks throughout the day. They also spoke positively about activities and opportunities to go out into the community, including meals out, entertainment and social events. A person said, “Most of the staff know what I like. I can go to my room and go to bed when I want to. The staff ask me what I want to do. I'm asked what I want to eat when food is been given out. I have a care plan. Sometimes staff talk to me about my care plan.” Another person told us, “I feel safe here, there is plenty to eat, the staff are nice and talk to me.” Another person said, “There is lots to eat. Staff are nice and they help me. They look after me. The staff give me my tablets.”
People felt able to raise concerns and were confident they would be listened to. Feedback indicated that relationships between people and staff had improved and people felt more involved in discussions about their care and support.
We used structured observation to understand the experiences of people who could not easily tell us about their care. We observed a warm and friendly atmosphere. People appeared comfortable in the presence of staff and were supported in a respectful manner. Staff offered people choices and engaged with them positively throughout the day. A person said, “There are activities and entertainment often. Some people go out for dinner; we sometime have singers and other entertainment, and you can go out with staff here.”
Relatives provided mixed feedback. One relative praised the management team, describing them as supportive and helpful, particularly when assisting with arrangements for their family member to move to another service. However, they also raised concerns about aspects of the environment and whether staffing levels were always sufficient to meet everyone’s needs. Another contact reported difficulties receiving a response to a request regarding visits.
Overall, people’s experience had improved significantly since the previous inspection. People were positive about staff, activities, food and the support they received. While concerns remained regarding some aspects of safety, record keeping and staffing, people generally described the service as a place where they felt safe, respected and supported to live as independently as possible.