Balmoral Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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 lacked a clear, shared vision and strategy focused on transparency, equity, equality, human rights, diversity, inclusion, and engagement.

Although a recent staff survey had been completed and analysed, there was no action plan in place to address the issues raised. The registered manager was working with the local authority to develop a plan, but this had not yet been finalised, and limited action had been taken in response to the feedback. Feedback from staff also indicated conflicting views about how the service was being run. There was no clear strategy to ensure people and families were meaningfully involved in shaping service development. Despite these challenges, the registered manager and staff team remained fully committed to delivering safe, high-quality care.

While a stable management team was in place, there were some gaps in oversight that affected how care, treatment, and support were delivered.

Evidence of consistent oversight across all aspects of the service was limited, which influenced how effectively the provider demonstrated the organisation’s culture and values.

At the time of our visit, there was limited evidence of how people, families, and staff were involved in decisions about how the service was run. Although people were generally satisfied with the care they received, there were areas for improvement in how safety and quality were monitored and maintained.

We noted that the management team covered roles and responsibilities for other staff members during periods of leave, which reduced the time available to complete their own tasks. Senior staff did not always have protected time to carry out duties such as fully reviewing care plans.

One person told us, “The manager is very easy to talk to, and I have no complaints about anything.” Staff feedback about support was mixed, although all staff expressed a strong commitment to providing care and reported being happy working at the service. The registered manager spoke positively about the staff team and the support they provided to people.

People generally felt able to raise concerns, but further improvements are needed to ensure all voices are heard and acted upon. While many people told us they felt confident speaking up, and the registered manager described having an open-door policy to address concerns informally with individuals and families, not all staff shared this confidence.

A recent staff survey indicated that some staff were unsure whether concerns would be taken seriously or lead to action. The inspection team received similar feedback, although other staff spoke positively about the registered manager, describing them as approachable and supportive. There was no documented evidence of whistleblowing or formal concerns being raised in the service’s records. Continued work is needed to build a culture where all staff feel safe and supported to report concerns, with assurance that appropriate action will follow.

People working for the provider did not always feel valued or included, highlighting the need for improved communication and team cohesion.

A recent staff survey indicated that not all staff felt part of a team or that their contributions were recognised. Feedback during the site visit was mixed: some staff spoke positively about the support they received from the provider and registered manager, while others felt less involved or confident to raise concerns.

The registered manager acknowledged that communication needed improvement and shared plans to hold more regular staff meetings to promote two-way dialogue and staff involvement. They also described maintaining an open-door policy and a flexible, supportive approach to addressing concerns raised by staff. The provider demonstrated a commitment to diversity and was working towards a more inclusive and equitable culture, but further action is needed to ensure all staff feel heard, supported, and valued.

The provider did not consistently demonstrate clear responsibilities, roles, systems of accountability, or effective governance.

Although systems for auditing and oversight were in place, they were not always completed effectively, resulting in delays in addressing identified shortfalls. For example, concerns identified during the inspection regarding the premises had not been picked up through the provider’s own checks. Some areas of safety lacked evidence of oversight from the registered provider, including actions required following a recent fire risk assessment, the quality and accuracy of care plans and records, and the robustness of recruitment processes.

However, the registered manager was responsive to feedback, and maintenance staff took immediate action to address issues such as the water temperature and securing large furniture. The registered manager informed us that further action had been taken following the last day of our site visit which we will review when we next assess the service.

The provider demonstrated a commitment to partnership working, but there were areas where community engagement could be strengthened. They understood their duty to collaborate and worked with partners to ensure services operated seamlessly for people. Information was shared, and collaboration was used to drive improvement.

The provider worked with stakeholders to support the wider health and care system, including taking on delegated tasks where appropriate to reduce pressure on other services. Staff worked effectively with health professionals to support people’s access to the services they needed and made appropriate referrals. Feedback from professionals was generally positive, with comments indicating that staff knew and understood the people they supported. Some community groups were involved with the home, but access to trips out and wider community engagement remained limited.

The provider did not consistently promote continuous learning, innovation, or improvement across the organisation and local system.

At the time of our visit, the registered manager was working with local services to develop an action plan to address identified shortfalls. However, in some areas, such as the management of medicines, limited action had been taken. The lack of protected time for staff to complete tasks was cited as a significant barrier to progress. While systems were in place to capture and analyse feedback, it was unclear whether these were being used effectively. For example, records of complaints, concerns, and whistleblowing were limited, despite feedback indicating that issues had been raised.

A recent staff survey had been completed and analysed, but there was little evidence of action taken in response at the time of our visit. Despite these challenges, the registered manager spoke positively about the support received from stakeholders and demonstrated a clear commitment to making the necessary improvements.