Balmoral 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 good. At this assessment the rating has changed to 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed safely.

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 did not consistently maintain a proactive and positive culture of safety based on openness and honesty. Concerns about safety were not consistently investigated and as a result, lessons were not always learned, and good practice was not continually identified or embedded.

Although systems were in place for the analysis of accidents and incidents, these systems did not always demonstrate how lessons were effectively learned. Identified themes were often generic and did not lead to specific actions. The registered manager reported that they had requested CCTV in communal areas, hoping this would help clarify incidents that occurred when staff were not present. The home used equipment such as sensormats for people at risk, but these were only in use when people were in bed, and they were not always suitably placed.

The provider collaborated with people and healthcare partners to establish and maintain safe systems of care, to ensure safety was managed and monitored. Continuity of care was supported, including when people moved between different services.

The provider engaged with local healthcare initiatives, which helped people access the services they needed. The home supported joint working with other services, including the coordination of palliative care. Staff sought medical support and emergency services when required.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff protected people’s their right to live in safety, free from bullying, harassment, abuse, discrimination, and neglect. The provider shared concerns appropriately.

People and families generally felt the home was safe. We observed people living at the service had built genuine friendships with one another and there was a positive communal spirit at the home. One family member commented, “[Family member] is definitely very safe here. They were becoming a danger to themself at home, and I am pleased with how they have settled and how good the staff are.” The registered manager worked closely with the local commissioners and supported any safeguarding investigations. Whilst appropriate action was taken in response to immediate concerns, there was limited evidence of how lessons were learnt and embedded into practice.

The provider did not consistently work in partnership with people to understand and manage risks effectively. While a range of risk assessments were in place, these were not always relevant to individuals’ current needs and were not consistently linked to care plans. As a result, staff lacked clear guidance on how to mitigate identified risks.

There was limited evidence that people or their families were meaningfully involved in decisions about risk management. Additionally, information about individual risks was not always clear, accurate, or consistently recorded across care records. Risk assessments and care plans were not reliably reviewed following incidents or changes in people’s needs.

Evacuation plans were also found to be inaccurate or outdated in some cases, which could compromise people’s safety in an emergency.

Despite these issues, staff generally demonstrated a good understanding of the risks people faced and showed commitment to keeping them safe.

Checks to ensure the safety of the care environment were not always effective, and some risks had not been identified or addressed in a timely manner. This included unsecured large furniture, exposed hot surfaces, and delays in completing actions from a fire risk assessment. These issues could compromise people’s safety and indicated that systems for monitoring environmental risks required strengthening.

Although people’s bedrooms were personalised and reflected individual preferences, some areas of the home showed signs of wear and tear, such as damaged bathroom tiles and scuffed paintwork. However, improvements were underway, with some bedrooms, a shower room, and the kitchen having been recently redecorated or in the process of being refurbished.

The provider did not consistently ensure safe and effective staffing. There were not always enough qualified, skilled, and experienced staff available to meet people’s needs safely and promptly.

Staff deployment throughout the day showed shortfalls, particularly during busy periods such as mornings and mealtimes, resulting in delays for individuals requiring personal care. People and families raised some concerns about staffing levels with one person commenting, “They could do with a few more staff at busy times.” Staff reported feeling understaffed, especially when two-person support was required, which sometimes compromised the safety of others. Although staff worked hard and supported each other well, they were often rushed, impacting the timeliness of care.

Recruitment processes were in place and generally followed, but improvements were needed to ensure appropriate character references were consistently obtained. Staff received induction and training and spoke positively about these aspects. However, feedback on supervision and appraisal was mixed, indicating inconsistency in staff development and support.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The home was generally tidy and free from odours, but several areas of the home were in need of updating to promote good infection control. Whilst the domestic staff team worked hard throughout the shift to clean all areas of the home, some areas, including people’s bedrooms and equipment, were in need of a deep clean. Good infection control practice around hand hygiene was not always being followed. We observed staff used personal protective equipment (PPE) appropriately when supporting people with care.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Allergies were not always accurately recorded on people’s medicines records.

Records for adding thickening powder to drinks, for people who have difficulty swallowing, were inconsistent and not always completed. Therefore, we could not be assured people were safe from the risk of choking.

Training records for staff authorised to give medicines were not all up to date. We were not given assurance that staff had had their competency to administer medicines recently checked as outlined by National Institute of Health and Care Excellence Managing Medicines in Care Homes (NICE SC1). We were not provided with evidence that delegated healthcare tasks, for example, insulin administration was managed safely.

Medicines were not always stored safely and in accordance with manufacturer’s instructions. Emollient creams were kept in people’s rooms without appropriate storage assessments being completed. There was a risk that they could be inappropriately accessed. The fire risk associated with the use of emollient creams was not assessed and recorded to ensure the safety of the people prescribed these products.

Records to show when topical preparations such as creams were being applied were not always completed, so we could not be assured they were being applied safely.

Medicines audits were not always effective in identifying medicines related issues occurring in the service. Proposed actions from these audits were not always completed in a timely manner.

We were not provided with evidence that medicines incidents were recorded, analysed and learnt from. Therefore, we could not be assured that a good safety culture was in place.