The inspection visit at Balmoral took place on 25 September 2018 and was unannounced.

Balmoral provides personal care for a maximum of 32 older people. At the time of our inspection there were 30 people living at the home. It accommodates people in single bedrooms, some of which have ensuite facilities. There are communal areas for the use of people living at the home, including two lounges and a dining area. There is a lift to all floors and the service is fully wheelchair accessible. The Balmoral has onsite parking and is close to local amenities.

Balmoral is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, both of which we looked at during this inspection.

A registered manager was 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.

At our last comprehensive inspection of Balmoral on 16 July 2017, we rated the service as requires improvement. This was because the home was in the process of making ongoing improvements, which required time to embed, in people’s safety and staff responsiveness to care delivery. We further made recommendations about dependency models to assess staffing level requirements against people's ongoing needs. Also, that the provider enhanced and improved its activity provision to increase opportunities for people's stimulation.

During this inspection, people we spoke with told us they felt safe living at Balmoral. One person said, “The most important thing to me is my safety and, although I wish I could go back home, this is the next best thing because I feel safe.” When we discussed principles relevant to safeguarding people from unsafe or inappropriate care with staff, we found they had a good level of awareness.

We observed staff administered medication with a skilled and secure approach, which the registered manager strengthened through training and competency checks. They had good oversight of relevant procedures through regular auditing to ensure they remained safe.

Care records included an assessment of the level of risk and actions to guide staff to manage people’s safety. The registered manager retained an accident book and analysed patterns to assess control measures reduced the risk of incidents. One person commented, “I feel comfy here, do you know what I mean? I feel settled and at home.”

People and their relatives stated they felt staffing levels met their requirements. The registered manager measured levels against their needs and deployed staff well, such as one employee started at 7am to manage busy periods. We saw staff files contained important records obtained before staff employment. This ensured recruited staff were able to support vulnerable adults.

Those who lived at Balmoral and their relatives commented staff were skilled and experienced. One person told us, “The staff are well trained. I have [a medical condition] and they were able to give me a lot of advice and information about it.”

We saw staff supported people with their meals discreetly, checked they had enough to eat and what condiments they desired. One person said, “The meals are really good and I like that you can have as much as you want.”

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. A staff member stated, “It’s very important to give the residents choices before you do anything. They should be in control of what’s going on.”

We saw people were supported to develop their living space into their own style. One person s

The inspection visit at Balmoral Rest Home was undertaken on 16 May 2017 and was unannounced.

Balmoral provides care and support for a maximum of 27 older people. At the time of our inspection there were 25 people living at the home. Balmoral is situated in a residential area of Thornton close to local amenities. All bedrooms offer single room accommodation and there are two lounges and a dining area. There are gardens available so people can choose where to relax.

At the last inspection on 06 and 07 April 2016, we asked the provider to take action to make improvements to people’s environmental safety. We requested they ensured the home’s electrical safety certification was up-to-date. We further requested all windows had restrictors and risk assessments processes were enhanced to protect people from potential harm or injury. We also noted staff training was out-of-date. At the follow-up inspection on 30 November 2016, the provider completed improvements and had met the requirements of the regulations.

During this inspection, people and relatives gave us mixed messages about staffing levels. For example, one person said, “There seems to be enough staff.” A relative commented, “They are sometimes short staffed.” When we discussed methods of measuring staffing levels against people’s requirements, we found the provider did not have a model in place. There had been no assessment of whether current staffing levels were sufficient to meet each person’s agreed needs.

We have made a recommendation about models to assess sufficient staffing levels.

We discussed safeguarding individuals from abuse or harm and found staff were knowledgeable about related principles. People told us they felt safe whilst living at Balmoral and the registered manager had risk assessments to maintain their safety and welfare.

The registered manager had a programme of training to underpin staff skills and knowledge. Staff confirmed training provision was sufficient. One staff member told us, “There is training given here.” Additionally, they had followed safe recruitment and induction procedures to protect people from unsuitable personnel.

We observed staff administered medicines safely by concentrating on one person at a time. They recorded in each person’s records afterwards to evidence they had taken their medication. The management team completed audits to assure safe procedures were maintained.

We observed staff supported people to eat their meals where they chose and provided condiments. They and their relatives told us they enjoyed their meals and were offered choice of what to eat and drink. One person said, “The food is good, we get a choice.”

Staff received training in the Mental Capacity Act (MCA) and associated Deprivation of Liberty Safeguards (DoLS). We found care records contained people or relatives’ consent prior to care and support. Throughout our inspection, we observed staff did not limit people in any way and they were able to move about Balmoral freely.

People and their relatives told us staff were kind and courteous. One person commented, “I’m cared for very well. The staff are very nice. They are a nice crowd and they look after us.” Care records we reviewed held evidence people were involved in their support and assisted to maintain their independence.

When we discussed the level of activities provided by the home with people and their relatives, we were given mixed comments. One person said, “We sometimes do dominos or throw a ball.” However, another individual added, “There are no activities.” Although we observed staff had short, meaningful conversations with individuals, people also sat for long periods asleep in communal areas.

We have made a recommendation about the provision of activities.

Staff updated care plans on a monthly basis to check support continued to meet people’s changing needs. The registered manager completed detailed life histories of each person and checked their wishes in relation to, for

We carried out an unannounced comprehensive inspection of Balmoral on 06 & 07 April 2016. At which a breach of legal requirements were found. This was because the provider had not consistently maintained people's environmental safety. They had failed to ensure the home's electrical safety certification was up-to-date. Not all window restrictors were effective in preventing potential harm and a step in one person’s en suite facility posed a falls risk. The provider had not always fully completed risk assessments to maintain people's safety and welfare.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on 30 November 2016 to check they had followed their plan and to confirm they now met legal requirements.

This report only covers our findings in relation to the latest inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Balmoral Rest Home’ on our website at www.cqc.org.uk.

Balmoral provides care and support for a maximum of 27 older people who may be living with dementia or a mental health condition. At the time of our inspection, there were 25 people who lived at the home. Balmoral is situated in a residential area of Thornton close to local amenities. All bedrooms offer single room accommodation and there are two lounges and a dining area. There are gardens available so people can choose where to relax.

A registered manager was in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

During this inspection, we found the provider had attended to the environmental issues we identified. This included the placement of new window restrictors and ensuring the home’s electrical safety certificate was renewed. One person who lived at Balmoral told us, “Yes, I’m safe here. It’s important for this place to be secure because we are all vulnerable.”

The management team and staff had enhanced people’s personal risk assessments to protect them from unsafe care. For instance, a document was introduced to give current, new and agency staff quick oversight of each person’s needs and any associated risks.

We could not improve the rating for safe from requires improvement because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

The inspection visit at Balmoral was undertaken on 06 and 07 April 2016 and was unannounced.

Balmoral provides care and support for a maximum of 24 older people. At the time of our inspection there were 23 people living at the home. Balmoral is situated in a residential area of Thornton close to local amenities. All bedrooms offer single room accommodation and there are two lounges and a dining area. There are gardens available so people can choose where to relax.

A registered manager was not in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 previous registered manager had left and we found the provider was registering a new manager.

At the last inspection on 21 May 2014, we asked the provider to take action to make improvements to people’s environmental safety. We requested they reviewed care planning to ensure people were fully involved and their support was updated, including nutritional assistance. We also asked the provider to enhance infection control procedures, other policies and quality assurance auditing. At the follow-up inspection on 28 July 2014, the provider completed improvements and had met the requirements of the regulations.

During this inspection, people told us they felt safe and comfortable whilst living at Balmoral. Staff were clear and confident about safeguarding people from abuse or harm. The management team had completed risk assessments documents. However, we found these did not always provide clear guidance and had missing information. Additionally, we noticed concerns with people’s environmental safety. The provider had not ensured the electrical safety certification was up-to-date. Not all window restrictors were effective in protecting people from potential harm or injury. This is a breach of Regulation 12 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe Care and Treatment.

You can see what action we told the provider to take at the back of the full version of the report.

During the management transition phase, we saw staff training had not been updated. The provider acknowledged training was not effective because staff had not received updated guidance to underpin their skills. We found the new manager was introducing a new training system.

We noted the provider had sufficient staffing levels and skill mixes to meet people’s requirements in a timely manner. They had followed safe recruitment procedures to protect people from unsuitable personnel.

Staff used a caring and courteous approach when they engaged with people. A staff member said, “I want to go home knowing the residents are happy.” The management team had guided staff about the importance of maintaining people’s privacy and confidentiality. We found they had involved people and their representatives in their care planning.

We observed people’s medicines were managed in a safe and discrete manner and staff concentrated on one person at a time. The new manager had carried out checks to ensure staff completed related processes safely.

We observed staff assisted individuals with their nutritional needs with a caring approach. People said they liked their meals. One person said, “The food is fine. I do enjoy my meals.” Staff monitored and documented people’s diet to protect them from the risk of malnutrition.

Staff demonstrated a good understanding of the principles of the Mental Capacity Act (MCA) and associated Deprivation of Liberty Safeguards (DoLS). Care files contained evidence of people’s consent to care and we observed staff consistently checked their agreement prior to supporting them.

We noted staff regularly completed assessments of people’s needs to check care met their ongoing re

This inspection was undertaken to review improvements the provider and registered manager had made following the previous inspection undertaken on 21st May 2014. During that inspection we found people were not involved in their care planning and review. Reviews were not always taking place. People’s weight was not always recorded due to the facilities for monitoring weight being inappropriate. There was no guidance for staff to follow in respect of responding to people’s mental capacity needs.

By not providing suitable hand wash facilities in two toilets meant there was potential for the spread of infection. The quality monitoring systems in place within the home had failed to identify these.

Some maintenance issues required attention to ensure the home was a safe place to live.

Some records we looked at were disorganised and had the potential for staff to miss essential information relating to peoples health and safety.

We asked the service to provide us with an action plan demonstrating what they had done to address the issue of non-compliance. We received an action plan from the registered manager. This detailed the procedures put in place to address the concerns. We used this inspection to see what actions had been taken.

We observed the home was clean and tidy on the day our visit and actions had been taken to protect people from the risk of infection.

We found new procedures and paperwork had been introduced. This was to ensure there was an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service.

Maintenance work was being carried out to ensure the homes environment was safe and suitable to meet the needs of people living at Balmoral Care Home.

The inspection was led by one inspector. Information we gathered during the inspection helped answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

During this inspection we looked at how well people were cared for, how the service managed cleanliness and infection control. Medication procedures were viewed in order to ensure they were safe and effective. We looked at the homes environment to see if it met the needs of people living at The Balmoral Rest Home. Also, how the home was staffed to meet the needs of people living there. We also looked at what quality monitoring systems were in place.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, staff supporting them, and from looking at records. We also had responses from external agencies including social services .This helped us to gain a balanced overview of what people experienced living at Balmoral Rest Home.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us that they felt safe. We were told staff were kind and caring. People also told us they felt respected by the people who supported them and their dignity was protected. Comments included, “The staff are so kind and caring, couldn’t ask for more”. Also, “The girls have a lot of patience and they always have time for a chat”.

The home did not have policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. The manager told us this was an area which needed to be developed and intended to attend training so that they would have the knowledge and skills to understand when an application should be made and how to submit one.

We saw the home had guidance in place for the management of infection control procedures, to ensure people were protected from the risks of poor hygiene practices. Protective clothing and gloves were made available to staff as well as a designated clinical waste management system. Staff we spoke with and observations we made confirmed they understood the principles of good hygiene practice. Most staff had attended Infection control training recently. We did find two toilets in the home did not have hand wash basin facilities in place. This meant that people were not provided with hand hygiene facilities in these areas. The manager was made aware of this and agreed the facilities required hand wash basins.

Medication practices had been reviewed recently to ensure the storage and administration was safe. We observed the morning administration of drugs. The manager and senior staff were responsible for the administration of drugs. Records we looked at showed they were accurate and up to date. We looked at the management of medication management for two people. The records we looked at and the level of stock was accurate in both instances. This meant the service managed medication safely.

Maintenance service certificates were in place and up to date to ensure systems in the home were safe. However, in one room we found access to the en suite facility was unsafe. In that there was a small step into the area. The resident using the room had fallen on one occasion due to tripping over the step. The door for this area did not close therefore the area remained a risk to the person using this facility.

Accidents and incidents were being recorded in daily log diaries for the individual resident. This meant it was difficult to identify any pattern occurring for people who may be at risk of falls.

Peoples weights were not being recorded as some people were unable to use the weighing facility available. In other instances peoples weight was not being recorded regularly therefore having the potential of putting them at risk due to being unable to monitor their weight effectively which can be an early indicator of ill health.

Is the service effective?

We were told that each person’s health and care needs had been assessed prior to the service commencing. This was to make sure that the home could provide the level of care and support required. Records were available to support this. However in some of the records we looked at there was limited evidence of regular reviews taking place. This meant the management of peoples care planning may not be effective and up to date.

People’s assessed needs were included in their care records. However, the records we looked at were disorganised so that it was difficult to follow any pattern of care. This included historic information being distributed throughout the file. A recent review had been placed in the centre of the file. This meant staff would have difficulty knowing what the current needs of the resident were.

Is the service caring?

People were seen to be supported by attentive and respectful staff. We saw that care workers showed patience and gave encouragement when supporting people.

Staff we spoke with told us it was a role they were proud to work in. “I have done this work for some time now and really enjoy it” Another told us, “I came here as a cleaner but now I work as a carer, it’s really rewarding”.

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with their wishes. Personal profiles had been developed by staff. Staff we spoke with told us this had helped them to understand things that were important with individual residents.

Is the service Responsive?

By not recording incidents that had occurred on individual records meant that it was not possible to confirm they had been reviewed and responsive action taken. Also although some of the detail of incidents were recorded, the outcome was missing from the records. We were told by the registered manager that outcomes would have been verbally discussed and action taken as required. However because of incomplete record keeping, we could not confirm this.

The service had a range of activities in place to support people to undertake chosen interests, There was evidence of organised parties and events throughout the year which people told us they enjoyed. A resident we spoke with said, “There are things going on if you want to join in but it’s up to you whether or not you choose to”.

People using the home and their relatives or advocates had completed six monthly satisfaction surveys. The results were used to inform the development and quality of the service. Any issues highlighted were looked at and responded to in order to ensure the home was responding to the needs of people.

Is the service Well Led?

The service had some quality assurance systems in place, however records seen by us showed not all the necessary documentation was completed, or that record keeping was robust and routinely applied. There was limited evidence of audits taking place for medication and care planning records. This meant there was a potential for constraints in the development of the service.

People we spoke with told us they felt supported by the manager and that they felt comfortable sharing any issues or concerns with them They felt confident they would be listened to and action taken where necessary.

We spoke individually with three staff, two people living at the Balmoral and two relatives. We observed staff interactions with people in their care. We reviewed care and staff records, safeguarding practices, policies and procedures and various audit processes.

We observed staff interacting with people in a supportive and respectful manner. This matched their related care plans. Care records were person-centred and reviewed regularly. A relative told us “I’m so glad she’s here. The staff care for my auntie very well”.

The home provided ample nutritious meals, snacks and drinks for people using the service. People were monitored to ensure their nutritional needs were maintained. Additionally, the Balmoral protected its service users from potential abuse by having an effective safeguarding protocol in place.

Staff felt supported and were provided with training that underpinned their work. The provider ensured the quality of service provision was maintained by undertaking a variety of audits. A relative told us, “The home’s managed and organised extremely well. They consult me on any changes. I would recommend the Balmoral to anyone”.

We spoke with eight people who used the service, they told us they were happy with the care and support they received. One person said “staff do anything for you they are family" and another said "all I have to do is ask, the staff are very good"

We observed good interaction between people who use the service and staff who were on duty on the day of our visit. We saw staff were respectful in their approach, treating people with dignity and courtesy

People told us the staff team provided flexible personal care support around the needs of people. “Staff attend when I need them with no delay and I have care when I need help".

People told us they could choose how they spent their day and were free to leave the home at their will. "I visit my sister or she visits me. I like to go out and see my friend or buy something I want". "I like to spend time in my room by myself, my choice as I feel safe and secure".

People told us they had access to health care when needed and could see their doctor when needed. "When I chose to live here I was registered with the doctor across the road". "I changed my doctor when I moved here".

A family member told us that they were happy with the care their relative was receiving. They said staff was caring and sociable and their relative liked the staff. The family member said that the staff were "encouraging and caring, they have got him walking with a frame, that's better than the two NHS rehabilitation services did. This place is a credit. He is happy and I'm happy".

A family member told us that her relative was eating well and liked the meals. People told us they enjoyed the meals. “ I don't know what lunch is until it’s put in front of me, but I’m not fussy”. "I really enjoyed that, up to the usual standard”. “I left a bit of the vegetables but I’m full, I don’t always eat all my vegetables but that was lovely”.