About the service: Balmoral Care Home is a residential home that was providing personal care for up to 33 people aged 65 and over at the time of the inspection. At the time of the inspection there were 29 people living in the home.

People’s experience of using this service:

The service had appropriate checks in place to ensure all equipment was maintained and suitable for people to use. This included legionella checks and risk assessments.

There were a variety of environmental and individual risk assessments in place which guided staff on actions to take to reduce risk for the people living at Balmoral care home.

People told us they were happy living at Balmoral care home. They told us they would like more activities and we have recommended that the service review the activities available for people to engage with.

People and relatives told us the staff were kind and caring and treated them with dignity and respect.

People were encouraged to be independent and choice in daily life was promoted.

Care plans covered a wide variety of areas and provided staff with details about the individual, their support needs and their preferences.

The service worked closely with other health care professionals and had good working relationships with other services.

A programme of updating and redecoration was planned following the inspection and provided an opportunity to adapt the premises and ensure it met the needs of the people living in the service.

Accidents, incidents, complaints and concerns were fully investigated and action taken to reduce the risk of future reoccurrence.

Staff were positive about the registered manager and felt well supported and able to raise any concerns.

More information is in the full report.

Rating at last inspection: At the last inspection the service was rated as Requires Improvement overall (09 February 2018). At that inspection we rated the service as requires improvement in the safe and well led domain and good in the effective, caring and responsive domains. At this inspection we found that sufficient improvements have been made and the overall rating for the service is good.

Why we inspected: This was a planned inspection based on the rating of the service at the last inspection.

Follow up: We will continue to monitor the service through information we receive and future inspections.

This inspection took place on 4 and 6 December 2017 and was unannounced on the first day.

We last inspected Balmoral Care home on 9, 10 and 19 May 2017 when we rated the service as Inadequate overall and identified continuing breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to safe care and treatment, Deprivation of Liberty Safeguards, good governance and staffing.

This inspection was to check improvements had been made following the last inspection and to review the ratings. At this inspection we found improvements had been made. However we identified a continuing breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to assessing, preventing, detecting and controlling the spread of infection in relation to records completed for Legionella.

Balmoral Care Home is situated in the Mottram-in-Longdendale area of Tameside. The home is registered with the Care Quality Commission to provide care, support and accommodation for up to 32 people who require personal care without nursing. At the time of the inspection 31 people were living at the home. The home is a large detached house with an extension and 32 single rooms that contain either washing or en-suite facilities. Bedrooms are located over two floors and are accessible using a passenger lift or staircase. There are several communal bathrooms and toilets. The first floor has a lounge, small dining area and kitchenette. The ground floor has a dining area, main kitchen, administration office and a quiet room. There is a steep driveway leading to the car park and the main entrance door is at the rear of the building.

We found that actions had not been taken in a timely way to rectify some areas in relation to records completed for Legionella.

Systems to make sure the safekeeping and administration of medicines were followed and monitored were in place and reviewed regularly. Medicines were stored safely and administered by designated trained care workers. Any specific requirements or risks in relation to people taking particular medicines were clearly documented in people’s care records.

Risk assessments were in place where risks to people had been identified. Strategies to manage and minimise environmental risks found were in place. Risk findings were actioned and recorded.

People were supported by sufficient numbers of care workers. Staff told us they had undergone a thorough recruitment process and had undertaken employee induction and training appropriate to their job role. Staff training was kept up to date to ensure best practice.

People’s daily records showed particular attention was paid to their dietary requirements and indicated the type and amount of food people had eaten and what they had drank. Care records were reviewed frequently and reflected people’s current support needs.

Records in relation to the Mental Capacity Act 2005 were complete and up to date. Any restrictions were deemed to be in people’s best interest and the least restrictive.

Systems to manage infection control and prevention at the home were in place. Records showed the home was compliant with infection prevention and control requirements.

Auditing systems in place to monitor the quality of services provided were being used effectively.

We observed care worker interactions with people living at the home were caring, patient, and empathetic. Care workers had developed a good rapport and understanding of the people who used the service and treated people with kindness and respect.

This inspection took place on 9, 10 and 19 May 2017 and was unannounced on the first day.

We last inspected Balmoral Care home on 27 June 2016 when we rated the service as requires improvement overall and identified breaches of six regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to person centred care, dignity and respect, need for consent, good governance and staffing. This inspection was to check improvements had been made following the last inspection and to review the ratings. At this inspection we found improvements had not been made and the service remained in breach of the regulations.

At this inspection we identified continuous breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which were in relation to, safe care and treatment, Deprivation of Liberty safeguards, good governance and staffing. We have made a recommendation about staffing levels and arrangements in place to ensure the laundry room and ventilation equipment are fit for purpose. We are currently considering our options in relation to enforcement and will update the section at the back of this report once any enforcement action has concluded. The overall rating for this service is inadequate which means it will be placed into special measures.

Balmoral Care Home is situated in the Mottram-in-Longdendale area of Tameside. The home is registered with the Care Quality Commission to provide care, support and accommodation for up to 32 people who require personal care without nursing. At the time of the inspection 30 people were living at the home. The home is a large detached house with an extension. The home has 32 single rooms with either washing facilities or an en-suite. Bedrooms are located over two floors and are accessible using a passenger lift or staircase. There are several communal bathrooms and toilets. The first floor has a lounge, small dining area and kitchenette. The ground floor has a dining area, main kitchen, administration office and a quiet room. There is a steep driveway leading to the car park and the main entrance door is at the rear of the building.

We found medicines were not being managed safely. We also raised our findings with the National Health Service (NHS) Clinical Commissioning Group (CCG). The CCG made arrangements with the provider to carry out medicines management audit at the home following this inspection.

Staff training in some areas had not been kept up to date to ensure best practice.

People’s care records had been regularly reviewed, and were reflective of their current support needs.

People’s daily records showed particular attention was paid to their dietary requirements and indicated the type and amount of food people had eaten and what they had drank.

Some risk assessments did not always fully identify strategies to manage and minimise any risks found.

Auditing systems in place to monitor the quality of services provided were not robust and effective.

We observed care worker interactions with people living at the home were caring, patient, and empathetic. Care workers had developed a good rapport and understanding of the people who used the service and treated people with kindness and respect.

A registered manager was in place at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The e

The inspection of Balmoral Care Home took place on 24 and 27 of June 2016. Our visit on 24 June was unannounced.

We last inspected Balmoral Care Home on 20 September 2013. At that inspection we found the service was meeting the regulations we assessed.

Balmoral Care Home is situated in the Mottram-in-Longdendale area of Tameside. The home provides care, support and accommodation for up to 32 people who require personal care without nursing.

The building is a large, detached house with an extension. The home has 32 single rooms with either washing facilities or an en-suite. Bedrooms are located over two floors and are accessible using a passenger lift or staircase. There are several communal bathrooms and toilets. The first floor has a lounge, small dining area and kitchenette. The ground floor has a separate lounge leading to the outside patio area, a large dining area, main kitchen, administration office and a quiet room. There is a steep driveway leading to the car park and the main entrance door is at the rear of the building.

At the time of our inspection 30 people were living at Balmoral Care Home.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that although the registered manager was employed by the provider full time, they had 10 hours per week provision to carry out the role of home manager. For the remaining hours the registered manager was employed as a senior carer.

At this inspection we found breaches of six of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to the safe storage and administration of medicines; assessing risks associated to the health and safety of people; effective recording, monitoring and analysis of accidents and incidents to prevent reoccurrence; preventing and controlling the risk of infection. Staff had not received refresher training. Best interests meetings had not been held to ensure decisions made were being made in the best interest of the person, particularly in the administration of covert medicines. People were not always treated with dignity and respect during care delivery observed during the inspection.

People were not actively involved in their care assessment and reviews. There was a lack of sufficient and effective systems in place to ensure a robust overview of the quality and safety of the services provided. Information was not stored securely and confidentially. We are considering our options in relation to enforcement for some of these breaches of the regulations and will update the section at the back of this report once any action has been concluded.

We have made four recommendations. That the registered manager records all concerns in the complaints file. All meals, whether to specific dietary requirements or not, are served to people in the same appetising way. There is an increase in both group and individual activities for people living at the home. The registered manager to arrange to have a fire safety check.

People, their relatives and staff spoke highly of the service; one person’s relative told us, “It’s fantastic”.

Documentation at the home showed that people received appropriate input from other health care professionals, such as dentistry and podiatry, to ensure they received the care and support they needed from community healthcare services.

The staff files we looked at showed us that safe and appropriate recruitment and selection practices had been used to ensure that suitable staff were employed to care for vulnerable people. However, we found that not all staff had received or refreshed the necessary trainin

We looked at this outcome during our last review of Balmoral Care Home in April 2013. At that time, we found that people's personal records including details on care plans were not accurate or up to date. This meant that there was a potential for people's care needs to be overlooked because staff did not have the correct information to provide care and support in a safe and appropriate manner.

During this visit we found that improvements had been made to care records. We looked at four care plans and found that these were accurate and reflected the individual needs of people living in the home.

The staff we spoke with had a good understanding of how to use care plans and of the importance of reviewing them regularly and keeping them updated.

People living in the home and their relatives told us they were confident that staff had the necessary information to assist them in providing care and support in a safe and effective way. Relatives told us that the staff team involved them in care planning and kept them updated about any changes in care needs.

All care records were securely stored.

We spoke to several people living in the home and some relatives who were visiting. All the people we spoke with were complimentary about the care and support they received from staff.

Comments included:

"I am very happy here, the staff are helpful and friendly."

"If we have a suggestion, we can put it to the staff and they listen."

"I have never had to complain, but if I did and things didn't suit me I know the staff will put it right."

"There are always staff around to help when you need it, and if you ring the bell they come quickly."

Through our observations and by talking with staff, we saw that they had a good understanding of individual care needs. Staff treated people living in the home with respect and took time to listen to what people were saying.

Routines appeared flexible and people were offered the opportunity to join in leisure and social activities.

Whilst we noted that staff had a good understanding of people's individual needs, we saw that care plan records were not up to standard. Records were out of date and did not include the necessary information to support and guide staff in meeting individual care needs in a safe and appropriate way.

During our visit we saw staff providing support and care to people in a kind and caring manner. We observed good interactions between the staff and people living in the home.

Some of the people using this service were able to express their views about the care and support they were receiving at Balmoral Care Home. Comments included:

"The staff are very good, they always listen to me"

"I want to be as independent as possible and they help to do this."

One person told us, "Balmoral is a nice homely and friendly place. The staff are first class and they keep me and my family involved and informed, they are very caring. They know the individuals very well, what upsets them and what makes them happy. I am confident in their ability to look after my relative."