Balmoral Court Care Home

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improvements had been made to the medication management and the treatment rooms were now clean, and the issues such as out-of-date equipment and dirty treatment rooms had been resolved.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.