This inspection took place on 23 and 24 October 2018 and the first day was unannounced. This meant no-one at the service knew when we were initially planning to visit.

Balmoral care home was last inspected on 18 July 2016 and was rated as 'good' overall.

Balmoral is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Balmoral is a purpose built care home, which is registered to provide nursing and personal care for up to 85 adults. Accommodation is provided over three floors. There were three separate units at Balmoral care home. The Hampton unit was on the ground floor and could support up to 20 people with residential needs. The Chatsworth unit was on the first floor and could support up to 29 people with nursing needs. The Windsor unit was on the first and second floor and could support up to 26 people living with dementia. There were 66 people living at Balmoral care home across all three units at the time of this inspection.

There was a registered manager employed at the service. 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.

The registered manager had failed to ensure staff received appropriate training, support, supervision and appraisals to enable them to carry out their role effectively.

People’s life histories and preferences weren’t fully recorded to enable staff to provide person-centred care. People told us they would like more things to do and more opportunities to go outside.

Not all the quality assurance and audits systems in place to monitor and improve service delivery were effective.

Not all people had an accurate, complete and up to date care record.

From our observations we saw there were enough staff employed to meet people’s care and support needs in a timely way. However, we recommend the registered provider consider people’s comments about staffing levels as not everyone we spoke with thought there enough staff available to ensure people’s care and support needs were met.

Not all the home was in a good state of repair. There was a comprehensive refurbishment plan in place to address this.

Safe recruitment procedures made sure staff were of suitable character and background.

Medicines were stored safely and securely, and procedures were in place to ensure people received their medicines as prescribed.

There were systems in place to recognise and respond to any allegations of abuse. Staff had received training in this area.

Most people told us they enjoyed the food served at Balmoral Care Home, which we saw took into account their dietary needs and preferences.

We saw the signage and decoration of the premises were suitable to meet the needs of people living with dementia.

Positive and supportive relationships had been developed between people, their relatives, and staff. People told us they were treated with dignity and respect.

There was an up to date complaints policy and procedure and this was displayed in the reception area.

There were systems in place for people, visitors and staff to regularly give their views of the service. This feedback was analysed and action was taken in response to the comments made.

The service had up to date policies and procedures which reflected current legislation and good practice guidance.

Safety and maintenance checks for the premises and equipment were in place and up to date.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were a breach of Regulation 9, Person-centred care, Regulation 18, Staffing and Regulation 17

This inspection took place on 18 July 2016 and was unannounced. This meant prior to the inspection people were not aware we were inspecting the service on that day.

Balmoral is a purpose built home, which provides nursing and personal care to older people. Balmoral is a large home (85 places) and accommodation is provided over two floors. There is a separate unit on the first floor where people living with dementia are provided with residential care. On the day of our inspection there were 75 people living in the home.

There was a manager at the service who had applied to be registered with CQC. 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.

Our last inspection at Balmoral took place on 14 July 2014. The home was found to be meeting the requirements of the regulations we inspected at that time.

People felt safe living in the home and said they had no concerns about their safety.

Staffing numbers were reviewed and assessed to make sure sufficient numbers of staff were available to provide quality care and support to people.

Medicines were managed safely. Staff were trained in medicines administration and had their competency checked annually which helped to prevent mistakes being made.

Staff were required to complete an induction and programme of learning so they had the knowledge and skills required to carry out their role.

The service followed the requirements of the Mental Capacity Act 2005 (MCA) Code of practice and Deprivation of Liberty Safeguards (DoLS). This helped to protect the rights of people who lacked capacity to make important decisions themselves.

Healthcare professionals were actively involved and included in making best interest decisions for people who used the service.

People who used the service and their relatives spoke highly of the staff. They told us staff were kind and caring and treated them with dignity.

A programme of activities and outings was available to people. People could choose if they wanted to be involved in activities. If people didn’t want to be involved then staff respected this.

The mealtime experience was pleasant. People were seen being offered choice and being supported to eat their meal in a dignified way. Food, snacks and drinks were readily available throughout the day and night.

There were systems in place to assess and monitor the quality of service provided and to make improvements to the service.

An adult social care inspector carried out this inspection. At the time of this inspection Balmoral was providing care and support to 67 people, some of whom had a diagnosis of dementia. We spoke with 17 people living at the home, and six visiting relatives to obtain their views of the support provided. In addition, we spoke with the home manager, the regional manager and eight members of staff about their roles and responsibilities.

We considered all the evidence against the outcomes we inspected to help answer our five key questions; is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People who used the service told us they were treated respectfully by staff members and said they felt safe living in the home.

Safeguarding procedures were robust and staff understood their role in safeguarding the people they supported.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

We found risk assessments had been undertaken to identify any potential risk and the actions required to manage the risk. This meant that people were not put at unnecessary risk but also had access to choice and remained in control of decisions about their lives.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. Three applications had been submitted which confirmed to us that relevant staff had been trained to understand when an application should be made and how to submit one. This meant that people would be safeguarded.

Our conversations with people who used the service, relatives and staff, together with observations on the day of our inspection evidenced there were enough staff on duty, however there was a significant number of vacant qualified staff hours being covered by agency nurses. People who used the service, their relatives and staff all said many agency nurses working did not know the needs of people, meaning that people who use the service did not receive consistency of care.

Is the service effective?

We found people were provided with nutritious food. Some people required specialised diets for health or personal reasons and these were provided.

People who used the service told us that food was very good and they enjoyed their meals.

During our visit, we found people were provided with the support they needed. We found staff knew people well and were aware of their individual preferences. We found staff treated people in a kind manner.

Care files we checked confirmed initial assessments had been carried out by the staff at the home before people moved into the home. This was to ensure the home was able to effectively meet the needs of the people. Specialist mobility and equipment needs had been identified in care plans where required. People who used the service and their relatives said they had been involved in writing their care plans and they reflected their current needs. Visitors confirmed they were able to see people in private and that visiting times were flexible.

Is the service caring?

We observed warm and respectful interactions between staff and people who used the service as well as some good humoured banter.

People who used the service were positive about the staff and felt they were known personally to them. Comments from people included, “Staff are wonderful,” “I like it here very much,” “Staff look after me alright. People come and help me (with personal care)” and “I get everything I need.”

One relative spoken with told us, “My family member is much calmer since they came here. I don’t worry about them now. I used to get phone calls from neighbours who found them wandering but I’m happier they are being well looked after. They are a lot better.

Is the service responsive?

Staff told us the care and support provided was flexible to the person’s needs and adjustments could be made where required. Staff said they informed the manager if they felt any change in needs was required and the support was reviewed. For example one relative told us, “My family member has a specific communication difficulty and requires sign language. They have one to one sessions weekly with somebody who can sign to them.” A person who used the service told us, “I’ve just been given a new wheelchair which I'm starting to get used to.”

On the day if the inspection people who used the service were going on a day trip to Bakewell. One person said, “I'm looking forward to going out. I like it here and I'm very hard to please because I'm very awkward.”

We observed staff making sure people had sun hats as it was a particularly hot day and that people had visited the toilet before leaving the building. The interaction between them was warm and very friendly.

There were no outstanding complaints about the service. People who used the service said if they had any worries they would take their concerns to a member of staff or to the managers’.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

People spoken with said they were invited to attend ‘resident and relative family night’ which was held every month. One person said, “It’s a good idea, we can talk about whatever we want”

Staff had regular meetings with the manager and were kept updated about any information they needed to know about the service. This helped to maintain consistency in the running of the service and to ensure staff were aware of relevant information.

The service carried out a yearly ‘Quality Assurance Survey’. Feedback was sought by way of customer satisfaction surveys sent to people who used the service, their relatives and friends, staff and healthcare professionals. This showed people had the opportunity to put their views across.

During our SOFI observation we found that staff had positive interactions with people, they spoke patiently and kindly whilst offering choices and involving people. People also had positive interactions and communication with each other.

People that we were able to communicate with told us that overall they were happy living at the home. Their comments included, "I can sum up this place in one word – great" and "I was told I could have six months to decide if I wanted to stay. I decided in six minutes."

Records checked showed that before people received any care or treatment they were asked for their consent and the staff acted in accordance with their wishes.

During the inspection we spent time sitting with people in the communal areas of the home and with people individually in their rooms. We found that care and support was offered appropriately to people.

We spoke with five relatives who were visiting the home and they confirmed that they were satisfied with the care provided.

Our conversations with people, relatives and staff, together with observations on the day of our inspection evidenced that there were enough staff on duty and staff working in the home were appropriately qualified to do their jobs.

The provider had an appropriate system in place for gathering and evaluating information about the quality of care the service provided.

We found that records were held securely and retained for an appropriate period of time.

People who we were able to verbally communicate with told us that they were happy living at the home and that they were satisfied with the care they received. People said, "The staff here are good and I get on well with them all," "I'm fine, I have everything I need," "I didn't think I would like it here but I'm settled" and "I would like to go home but I can't so I'm OK here."

We spoke with three relatives. They spoke fondly about the staff and the care that was provided. They told us "We are very happy with the care here, we have no issues or worries," "Staff are approachable and make sure I'm included in my relatives care" and "The staff are always around to carry out care tasks and have a chat."

We spoke to two visiting health professionals. They said "We have never had any concerns about the way people are treated. The staff know people well and assist us to do our job. The staff are very good at making sure people's healthcare needs are met."

Sheffield Local Authority Contracting and Commissioning had recently (March 2012) carried out a full monitoring visit. Their report showed that they believed that the service met all aspects of the Essential Standards of Quality and Safety.

A significant number of people who live at Balmoral have a diagnosis of dementia and therefore have varied methods of communication. Some people were able to express their views clearly, others were not able to verbally communicate with us. Due to people’s communication needs, during the site visit we sat with people who lived on the Dementia wing and observed them closely. This meant we were able to ascertain whether their needs were met.

During our observation we saw that people and staff communicated well. People were at ease chatting with the staff about everyday events. Staff listened to people and when people asked for assistance staff gave this in a friendly and supportive way. Staff were aware of people’s individual needs and preferences. People were shown respect and their dignity and privacy was maintained.

When we spoke to people who were able to communicate with us verbally, they told us:

“I’m very happy here. I feel safe and the staff are good”

“I’ve never complained about anything, because there’s nothing to complain about”

“I can’t grumble at all. They look after us very well”.

“The staff are all OK”.

“Although the staff have changed over, everyone who comes is good”.

“There’s always someone to talk to if you’re worried or upset about anything”.