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 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.

We found the provider was in breach of the legal regulations relating to medicines management, and good governance.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had made improvements to developing a more open and positive culture of safety, but these arrangements were not yet fully embedded. Staff reported feeling more confident to raise concerns, and incidents were usually reviewed to identify learning and improvements. However, records relating to physical interventions were limited, incidents were not always recorded consistently, and there was no evidence of debriefs taking place following restrictive interventions. This meant there were missed opportunities to demonstrate learning, identify trends and ensure changes in practice reduced future risks. The new manager had worked extensively with staff to address a previously closed culture and encourage openness, reflection and continuous learning.

Staff worked with partner agencies to support safe pathways, transitions and continuity of care, but further improvement was needed to ensure records consistently supported safe delivery of care. Staff worked closely with healthcare professionals including GPs, mental health teams and specialist services. Visiting professionals praised the service’s communication and support during admissions and discharge planning. People received timely access to healthcare support when their needs changed. However, some care records, risk assessments and capacity documentation lacked sufficient detail, which reduced assurance that information was always recorded consistently to support safe care delivery.

The provider had systems in place to protect people from abuse and neglect, and most people told us they felt safe living at the service. Staff understood safeguarding responsibilities and said they felt more confident in trying to challenge poor practice and raise concerns. However, governance systems had failed to identify serious medicines errors, including missed medicines, which placed people at risk of avoidable harm. The new manager responded promptly to concerns identified during the inspection and took immediate action to reduce risks and inform relevant parties.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Staff understood when Deprivation of Liberty Safeguards (DoLS) authorisations would need to be sought, the impact of the recent Supreme Court judgement and what to do if there were conditions imposed.

People were involved in decisions about their care and most risk assessments reflected their needs and preferences. Staff knew people well and people told us they felt safe and supported. However, improvements were still required to ensure risk assessments fully reflected all known risks and clearly recorded actions staff should follow. Records relating to physical interventions, capacity assessments and some restrictions were not always sufficiently detailed or person specific. The management team recognised these shortfalls and had started work to strengthen risk management documentation and staff understanding.

The provider had improved the safety and quality of the environment and people were cared for in premises that were now maintained and safe. Significant refurbishment work had taken place since the previous inspection, including improvements to bathrooms, communal areas, lifts and décor. Environmental risks were routinely monitored, and maintenance checks were completed. During the inspection a small number of environmental issues were identified and addressed promptly. People and professionals were generally positive about the improvements made to the cleanliness, presentation and upkeep of the service.

People were supported by staff who knew them well and had received relevant training and support. Staff reported improvements in leadership, morale and opportunities for training, supervision and development. Recruitment practices had improved, and professionals spoke positively about staff knowledge and engagement. The provider used tools to monitor staffing such as a dependency tool.However, some staff and relatives continued to express concerns about staffing levels and whether there were always enough skilled staff available to meet the needs of people with increasing levels of dependency. Feedback showed there were staffing pressures in some areas of the service.

The provider had made significant improvements to infection prevention and control arrangements. The home was clean, well-presented and staff followed systems designed to reduce the risk of infection. The provider had strengthened housekeeping arrangements, introduced additional checks and sought support from infection prevention specialists. External professionals reported good engagement from the management team and described maintaining hygiene standards as a clear priority. We observed a clean environment and found previous concerns regarding infection control had been addressed.

The provider failed to ensure medicines were managed safely and effectively. Although some improvements had been made since the previous inspection, significant medicines concerns remained. We identified missed depot medicines, missed pain relief medication, inaccurate records, poor oversight of topical medicines, inappropriate medicine crushing practices, weaknesses in covert administration arrangements and ineffective monitoring systems. We had to ask the manager to get the doctor to review a person who had not received their pain medication as they looked unwell. Creams were still not being applied in line with the guidance and the charts for the administration of creams were inaccurate. Thickeners were not appropriately monitored, and care records did not contain accurate information. Also, the staff continued to follow covert plans when people were accepting medicines and had not reviewed this practice. The clinical leads regular audits had not identified these medicines issues. Following feedback, the provider took immediate action to investigate the concerns, review systems and reduce risks, but people could not always be assured they were receiving their medicines safely and as prescribed.