Balmoral Court

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

The service was not always safe and has moved to requires improvement in this key question We identified 2 breaches of regulation. We found the service was unclean and there were infection control risks and unclean equipment such as hoists. We saw people using equipment which was faulty. High risk items such as hot kettles and thickener for drinks had been left in communal areas. The building was undergoing a full refurbishment. Medicines were not always administered safely. Systems were not effective in ensuring staff were recruited safely. There were shortfalls and issues with each of the 4 recruitment files reviewed. Risk assessments were in place and regularly reviewed but these did not always contain specific information on what people’s behaviour may look like. The service carried out investigations when things went wrong in the service and lessons were learnt from accidents and incidents. We reviewed the gas, electrical installations, emergency lighting, lifting equipment and Legionella certificates which all were in date and had no concerns were identified within them. People were protected from the risk of harm and staff told us they knew how to report a concern regarding potential abuse. Staffing was provided at safe levels.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Documentation was not available to show us what actions had been taken in response to notifiable safety incidents. The provider's policy did not clearly set out the actions the service needed to take. Accidents and incidents were recorded and analysis undertaken at unit level. Debriefs and lessons learnt were shared with staff following accidents and incidents including with night staff. The registered manager told us, "I have worked nights to try and include night staff more." This included learnings from interventions and when providing emergency first aid. This information was also discussed during handover meetings. The registered manager had also introduced an initiative called "Flamingo" to help staff communicate to each other or a leader if they felt overwhelmed and needed assistance to keep someone safe.

Staff worked in ways to involve people in their care to minimise the risks people were exposed to. For example, during any transition to or move from the service staff worked with people and their family or health professionals to identify a transition plan to support and reassure the person during the period of change.

Staff were aware of the needs and risks of the people they care for following a pre-assessment and this was recorded in their care plans which they knew how to access. One staff nurse we spoke to told us that "We will try to work with individuals to take positive risks where we can as there are some [people with] complex needs. "

Professionals we spoke with felt they received a good response from the team to any input they make, and their views and opinions were listened to. One social worker said, "I was impressed with the workplace culture and my observations of staff being readily available to engage and spend time with people."

Systems were in place to ensure information was shared between the multi-disciplinary team of professionals who involved with people's care. These meetings were felt to be productive where valuable information was shared.

People we spoke with said they felt safe. Feedback from relatives was mixed. Some people felt their relatives were safe. Some relatives said staffing had not been consistent recently which meant they did not always get knowledgeable updates on their relative’s condition. The manager told us, "Staffing has remained consistent with teams of the same staff working on the same units. Staff turnover is high but same individuals have remained in place." One relative we spoke with said they were informed about the safeguarding process when their relation was involved in an incident.

Staff were aware of how to raise a safeguarding concern. The registered manager understood how to escalate safeguarding concerns and was proactive in having discussions with people and their next of kin or care managers regarding behaviour that may be seen as a risk.

Observations were carried out by the management team to review staff relationships and interactions with people.

Systems were in place to ensure incidents were appropriately reported to safeguarding. Accident and incident records documented where an incident had been reported to safeguarding. Lessons learnt were also clearly recorded and shared with the staff team for learning.

Staff were trained in PMVA (Prevention and Management of Violence and Aggression) following their dementia training. This was completed by domestic, maintenance and care staff so that everyone was trained to the same level. Staff worked with external professionals to find best outcomes for people who used the service. The registered manager told us, "We have individual challenging behaviour support plans that involve the older people or learning disability teams, they're written simple and easy to understand. They're kept as paper copies on the units."

Feedback from relatives was positive regarding how staff managed difficult situations. One relative said, "There are people who are in worst case scenario situations so have quite challenging behaviour and are hard to handle but the staff seemed to handle this well." We spoke with a social worker who told us, "The nurse within the home when I visited was extremely knowledgeable and appeared to have a very good understanding of the service user after only five days of residing there ... and the staff team were using de-escalation techniques to manage behaviours, leading to a noticeable positive change in the service users presentation.”

Whilst risk assessments were in place and regularly reviewed, Positive Behaviour Support (PBS) plans did not always contain specific information on what people’s behaviour may look like. For example, one person's care plan stated they had epilepsy. There was no information in the plan to support staff should they suspect a seizure had taken place. We asked a nurse about this. They told us they were not aware of what the seizure activity would look like. This meant staff did not have all the required information to support this person safely. The manager did inform us after the inspection that the person in question had no seizures and this was part of his long past history.

A person we spoke with was using a broken wheelchair with no footplates, the staff member on-site explained that a new wheelchair had been ordered however we observed they were still using this defective equipment. We received consistent feedback from people in relation to the noisy environment in the home. This was from loud music and noise from other people. People told us about the upkeep and maintenance of the building and equipment, including timeliness of repairs. This included a person whose en-suite bathroom toilet had been broken for 4 weeks and therefore remained locked to prevent access. A relative told us that their family member’s bedroom was adjacent to the outside smoking area which meant opening the window allowed smoke to come in which was unpleasant.

Staff spoke positively about access to fire safety training and drills, and the registered manager told us that each unit has a maintenance diary in place as well as health and safety being an agenda item in bi-monthly meetings. There were currently 2 maintenance staff supporting the service whilst it underwent refurbishment. A maintenance staff member we spoke to told us they were recruiting additional maintenance staff.

People were using equipment which was faulty. For example, one person had sellotape applied to the brake on their wheelchair, foam had broken off the stand-aid which supported their legs and another person was sat in a wheelchair where the armrests had broken off. There were numerous examples where people were in wheelchairs without any footrests. We saw hot kettles were left out in dining areas where people had access to these and could injure themselves. A written procedure did state these should not be left out.

Audits were in place but did not identify all the issues we found on site with the environment and equipment. We reviewed documents submitted as evidence of refurbishment plans. We reviewed the gas, electrical installations, emergency lighting, lifting equipment, Legionella certificates and found all were in date and no concerns were identified within them.

People told us that they felt generally there was enough staff to meet their care needs. Relatives told us that there were sufficient staffing levels in the home, they were able to respond to call bells quickly and that the staff understood the needs of the people who used the service with challenging behaviours. Most relatives were happy with the care provided. One relative told us, "I think most of the time they are quite well staffed and when you walk in it feels quite easy and there's not a lot of rushing around. I have noticed that the call bells are usually answered quickly."

The registered manager acknowledged that staff turnover had been a challenge and that recruitment was ongoing. They said, "The service is never short staffed. We saw dependency levels for people were adhered to.

During the course of our inspection visits to the service, we saw staffing was provided at safe levels to meet the needs of people.

Systems were not effective in ensuring staff were recruited safely. There were shortfalls and issues with each of the 4 recruitment files reviewed. There were gaps in recruitment records and some records were not present. The manager provided evidence of supervision and risk assessments being in place for all staff. Care staff were allocated to work on each unit and minimum staffing levels were identified.

Several relatives raised with us they found the building smelt and feedback from visiting professionals we spoke with also described the building as "rough and ready”. The registered manager told us any smells were dealt with immediately. Some people we spoke with however did acknowledge the refurbishment was beginning to have a positive effect on the relevant areas of the home.

Staff told us they had received training in IPC during their induction, online training and face to face. They also explained they had good access to PPE and felt comfortable in how to use it safely and there were posters up reminding them how to do this. The registered manager was aware of what steps to carry out in the event of an outbreak in the home and told us they carried out walk arounds which was reflected in comments from staff. A care assistant we spoke to told us, "We have had infection training including how to store food properly. Managers also carry out spot checks and make sure we have changed it. There is a good supply of PPE on every wall".

Cleanliness issues were identified across multiple area of the home. There were numerous examples of this. This included kitchen areas in dining rooms which were unclean, chipped paint, dirty windows, unclean areas in communal rooms, bathrooms and people’s bedrooms. We saw equipment in bathrooms that was rusty meaning it could also be defective as well as unclean. Some bins were not foot operated.

Checks and audits did not identify the issues relating to infection prevention and control found on our visits. The registered manager told us they did a twice daily walk around to check the building but this nor the cleaning logs identified risk areas for infection control and whether the building had been cleaned appropriately. We found the building was extremely unclean and there were infection control risks such as unpainted wood, defective seals and unclean equipment such as hoists.

Staff we spoke to were aware of what to do if someone did not wish to take their medicines and also the process for giving as required medicines. The registered manager told us, "Medication audits are every month for each unit. We also have the Quality Assurance manager empty every cupboard. The deputy also carries out daily controlled drugs checks. Temperature checks are our usual failing, I have reminded them of the code of conduct and carried out extra training. They are starting to get it now but sometimes make mistakes."

Medicines were not always administered safely. Topical records did not always show they were being applied as prescribed. Temperature monitoring was taking place; however this was not in line with the provider’s policy. Medicine care plans were not always followed and did not always contain person specific information. Medicine care plans were not always easily accessible for staff administering medicines. Records relating to medicines given covertly were not completed consistently although we observed processes were in place for supporting people that needed their medicines given covertly, hidden in food or drink. Audits were taking place; however, they had not identified all issues we found whilst on inspection. Records of regular medicines were generally well maintained and followed national guidance including recording people’s allergies.