- Care home
Balmoral Care Home
Assessment report published 4 November 2025
Contents
Ratings
Our view of the service
This inspection was undertaken with site visits on the 10th, 11th, and 15th of September 2025.
Balmoral Care Home is a residential service providing personal care for up to 33 people aged 65 and over. At the time of the inspection, 27 people were living at the home. The inspection was brought forward due to concerns regarding the management of falls.
While we did not find evidence to suggest that falls were being managed inappropriately, we identified areas for improvement in record-keeping and oversight related to this aspect of care.
During the inspection, we found breaches of legal regulations relating to the management of risk associated with medicines and the environment. We also identified concerns regarding governance and oversight, including the monitoring of care records, maintaining contemporaneous documentation, and taking timely action in response to identified shortfalls.
Whilst people felt safe, there was a lack of oversight to ensure action was taken in response to shortfalls. Care plans were in place but were not always detailed, consistent or personalised and daily records did not reflect that care was being given in line with agreed plans. There was limited evidence that people or families had been involved in decisions around care. Staff were not always readily available to provide timely support to people, and this impacted on the levels of care, mental stimulation and activities people could engage with.
People spoke positively about the food and people’s weight was generally stable. There was evidence that the provider and staff worked closely with other stakeholders to meet people’s needs. Staff knew people well and were able to identify changes in their health and make appropriate referrals. There was limited evidence of how consent was sought from people in terms of decisions around care or daily life.
People spoke highly of the staff team, and we observed kind and caring interactions between staff and people. Whilst staff knew people well, they were often very busy and forgot to consider people’s dignity when providing support, for example by moving a person in a toileting sling in the communal areas, not removing the sling whilst people were sat in lounge chairs, or forgetting to remove clothes protector after people had eaten.
Care plans were not always sufficiently personalised and there was a lack of opportunities for staff to engage with people and provide stimulation and activities. Staff worked hard to try and fill shortfalls due to the challenge of recruiting an activity worker. People were supported to have access to visiting community groups and occasional trips out into the community and the provider worked with other health services to meet people’s needs. There were numerous compliments from families whose relatives had been cared for at the home prior to their death.
There were some shortfalls in the oversight maintained from the provider and registered manager. Audits were completed but these did not always cover relevant areas or lead to the required action being completed in a timely way. Staff had mixed experiences and had not always felt supported by the management team. Whilst a recent survey had been completed there was limited evidence of action taken in response, at the time of our visit. The registered manager was working with the local stakeholders to develop an action plan and was committed to driving improvements where these were needed.
People's experience of this service
People appeared well settled at the home and staff knew them well. People had developed friendships with each other and there was as sense of community within the home.
Feedback from people about the staff team was positive with one person commenting, “The staff have been very good, and they’ve looked after me.” A relative told us, “The staff are nice and caring. [Family member] was going downhill before they came in here and it has given her a decent life back.”
We received some mixed feedback about staffing levels and observed staff were not always able to support people in a timely way, which at times led to people becoming distressed. However, when staff did attend to people, they did so with kindness although they did not always ask explicitly for consent to provide care. We observed people were supported to make choices about aspects of daily life such as what they ate, but there was limited evidence of how people and their families had been involved in making decisions around care.
There was limited evidence of how people’s feedback was sought but people told us they felt able to raise concerns and knew the registered manager and management team.
People had limited access to activities and mental stimulation, and whilst staff engaged people in activities, when possible, the lack of a staff member specifically to organise and deliver activities meant there was no structure or consistency to how people were supported in this area. One relative commented, “We were led to believe they would be doing activities every day. I feel family member needs more activities than they have been getting over the last few months. I don’t know if its staffing issues, but I haven’t seen anything proper for some time.” Where we saw activities being undertaken, people were encouraged to engage with staff support and appeared to thoroughly enjoy a music quiz.