We carried out our unannounced inspection visit on 25 July 2017. We returned announced on 1 August 2017.

Balmore Country House provides nursing and personal care for up to 46 older people and people with dementia and physical disabilities. On the day of our inspection there were 38 people using the service. At our last inspection we rated the service requires improvement overall. The provider had made the necessary improvements to the service people received.

The service had a registered manager. 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.

Action had been taken following accidents or incidents to prevent further occurrences. Risks associated with people’s care needs and the environment had been assessed and measures put in place to prevent avoidable harm.

People were supported by staff who understood how to keep them safe and could raise concerns if they needed to. There were enough staff to meet people’s needs. The provider followed safe recruitment practice.

People received their medicines as prescribed by their doctor. People were supported to maintain their health and had access to health professionals.

People were supported by staff who had received training and support to meet their needs. Staff felt supported and their competency in their role was checked.

People were supported to have enough to eat and drink. Where people had dietary requirements, these were met and staff understood how to provide these.

People were supported in line with the requirements of the Mental Capacity Act. People’s mental capacity to consent to their care had been assessed where there was a reasonable belief that they may not be able to make a specific decision.

Staff at all levels treated people with kindness and compassion. Dignity and respect for people was promoted. People were supported to maintain their independence.

The care needs of people had been assessed and were regularly reviewed to ensure they continued to be met. Staff had a clear understanding of their role and how to support people who used the service.

People had access to activities so that they could follow their interests and remain active if they wanted to.

The registered manager had sought feedback from people and their relatives about the service that they received. We saw that they had taken action based on this feedback.

Staff felt supported. Where necessary the provider’s disciplinary procedures had been implemented.

People and their relatives felt the service was well led. They felt the registered manager was approachable and that they would deal with any concerns they may have. The registered manager had a good over sight of the service.

Systems were in place to monitor the quality of the service being provided and to drive improvement. Where systems had identified areas of concern action had been taken to address these in a timely manner.

The registered manager was aware of their responsibility to report events that occurred within the service to CQC and external agencies.

We carried out an unannounced inspection of the service on 9 March 2016.

Balmore Country Home provides nursing and accommodation for up to 46 older people. It is registered for a maximum of 46 people. There were 34 people living at the home at the time of our visit.

On the day of our inspection there was 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.

People told us they felt safe at the service. They were supported by staff who understood how to report allegations of abuse. The provider took a protective approach to respect the people’s human rights when necessary. Risk assessments were in place, but did not always identify or reduce the risk to people’s safety. There were enough staff to keep people safe and medicines were stored and handled safely.

People were supported by trained and knowledgeable staff. People received effective suitable care that met their individual needs, preferences and choices.

People’s rights were protected under the Mental Capacity Act 2005. People received sufficient to eat and drink, but did not always have a good experience at meal times. Some people were not fully supported when eating their meal. People had access to other healthcare professionals and received care that was relevant to their needs.

People were encouraged and supported to keep positive caring relationships with each other, staff as well as their family and friends. People were treated with kindness and compassion and spoke highly of the staff. Staff interacted with people in a friendly and caring way. People’s privacy and dignity was protected and they felt able to contribute to decisions made about their care. Arrangements were in place for people to receive support from an independent advocate if they needed one.

People’s care records focused on people’s wishes and respected their views. Staff responded to people’s needs promptly. They encouraged people to participate in activities that were available in the home which reflected their needs. A complaints process was in place and staff knew how to respond to complaints.

People, relatives, staff, and healthcare professionals all complimented the registered manager. The registered manager actively sought people’s views and acted on them. There were systems in place to monitor and improve the quality of the service provided. The service was led by a registered manager who had a clear understanding of their role and how to improve the lives of some of the people at the service. They had a robust auditing process in place that identified the risks to people and the service as a whole and any issues were dealt with quickly and effectively.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found-

Is the service safe?

We observed staff speaking to people in a polite and respectful manner. The manager told us they had been working with staff to ensure they used appropriate language when supporting people with personal care, eating and drinking.

We found the provider had commenced reviews and was in the process of updating all care plans to ensure people were safe and their individual needs were met.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff understood when an application should be made, and how to submit one.

We saw staff had attended training and refresher courses. The manager told us they were in the process of booking for further training such as medication, infection control, health and safety, dementia and the mental capacity act.

Is the service effective?

Equality and diversity was acknowledged and understood. We saw people’s specific needs were recorded in their care plan.

We looked at five care files and found three files had been reviewed and updated. The plans of care were detailed and included appropriate information to ensure staff was able to care for people’s individual needs.

People told us they were happy with the care they received. It was clear from our observations and speaking with staff that they had good knowledge and understanding of people’s individual needs and knew how to support them. One person told us it was their choice to come and live at the home. Another person said, “The staff are lovely. I am pleased with everything.”

We spoke with the activities coordinator who told us they provided a variety of activities and encouraged people to get involved, if they wished to do so.

Is the service caring?

Staff had good knowledge of how people who use the service should be treated. We saw dignity and care training was completed in April 2013. One staff member told us they assisted people when required to help to meet their needs.

People were supported by kind an attentive staff. We observed staff used appropriate equipment to support people, we saw the staff were patient and gave encouragement where needed. We observed staff interacted with people who used the service and gave them choices with day to day activities, such as where they would like to sit. Staff were proactive to gain consent before they provided any care such as assisting people to the toilet. One person who used the service said, “They [the staff] spend time with me.”

Is the service responsive?

People’s needs were assessed before they came to live at the home. We found records confirmed that people’s preferences and experiences were taken into consideration. Staff we spoke with told us they acquired information on how to meet people’s needs and preferences from their care plan. People were encouraged to have contact with family and friends. We observed staff responding to people’s needs in a timely manner.

Is the service well-led?

The managers named in this report were not the managers at the home at the time of our visit.

Staff told us there had been a lot of improvements to the service since the new manager had been employed. People who used the service and their family gave positive comments about the staff and the service they received. We found the quality of the service was monitored on a monthly basis by the provider and outside professionals visited the home. We saw staff meetings along with resident and relative meetings were taking place regularly. The staff told us management consulted with them before implementing changes to the management of the home and they felt their views were taken into consideration.

The person in charge told us there had been a lot of changes in the home and different ways of working. We saw improvements had been made since our visit in September 2013.

Prior to our visit we reviewed all the information we had received from the provider. During the visit we spoke with five people who used the service and a relative and asked them for their views. We also spoke with four care workers, the deputy manager and the registered manager. We also looked at some of the records held in the service including the care files for five people. We observed the support people who used the service received from staff and carried out a brief tour of the building.

We found people gave consent to their care and treatment and received care and support that met their needs. A person told us, “Everyone is very well looked after, I would say first class.”

We found the premises were safe and suitable and repairs that were needed were planned to take place. A relative told us the home was, “Very clean and well maintained.”

We found the provider had taken steps to ensure there were sufficient and suitable staff available and people’s comments and complaints were acted upon. One person told us, “If I say there is something I don’t like they (staff) will sort it.”

We carried out a responsive review inspection because we had concerns that we had not visited since April 2010.

People who used the services told us overall the care seems fine.

Four people told us they felt safe with staff at the home.

Four people told us they thought staff knew what to do to meet their daily needs.

People told us there were sufficient staff to meet their needs and that staff were helpful.

One person said, “If I had any concerns I would talk with the staff and I would ask my family to help sort the problem out.”

One relative said, “Staff are not bad at respecting my relative’s views and wishes.” However during our inspection, we observed that staff did not always use appropriate language which respected the dignity of people who used the service.

The service had not always completed Mental Capacity Act 2005 (MCA) assessments or associated Best Interest Decision forms for people who may lack the capacity to make individual decisions.

We spoke with a person who used the service who told us, “I’ve got no problems with anything.”

We found that care plans and associated risk assessments had not always been completed.

We saw evidence in people’s care plans that external health care professionals were involved in the planning and delivery of care to meet people’s identified needs.

One staff member told us, “We contact GPs for people and they visit the home every Thursday to see some of the people here.”

During our inspection, we observed that effective systems were not in place to reduce the risk and spread of infection which meant that people may not always be cared for in a clean, hygienic environment.

Appropriate arrangements were not in place in relation to the storing, recording and safe handling and administration of medicines.