Dalkeith

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment at the service.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always report safety events to enable investigations to take place. Lessons were not always learnt to continually identify and embed good practice.

We saw a monthly report of accidents and incidents. The document did not provide evidence of any analysis, action or outcome following accidents or incidents. The reports did not provide any evidence of lessons learnt or learning being shared with the wider staff teams. We identified that incidents and safety events were not consistently reported to the registered manager in a timely way. Although incident reports were being completed, staff did not always ensure the manager was made aware of events that had occurred. There was limited evidence that learning from incidents was identified, shared, or used to improve practice. This meant opportunities to reduce risks were missed and increased the likelihood of similar incidents reoccurring.

While management had processes in place to promote a culture where reporting concerns was encouraged, this was not consistently embedded. Some staff were aware of how to escalate incidents both internally and externally, and knew how and when to add to the accident and incident log.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different service.

A referral process was in place, with individual records demonstrating timely and appropriate referrals to relevant professionals. Policies and procedures relating to referrals and transitions were effective.

Pre-admission assessments were undertaken prior to admission, with information obtained from people, their relatives, and relevant healthcare professionals. This ensured the provider had sufficient information to assess and safely meet people’s individual needs. The assessment process supported informed decision-making and contributed to a safe and well‑managed transition into the service. People and relatives told us they had no concerns regarding the transfer of care into the service.

Communication systems, including daily handovers and communication books, supported the sharing of information about people’s needs. However, we saw that some information shared as part of the handover process had not always been updated and reflected in individual’s care plans. We raised concerns with the provider and the registered manager. Actions were being taken to strengthen systems and processes to improve the consistency and accuracy of information being recorded.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider had arrangements in place that were intended to support working with people and healthcare partners to understand what being safe meant to them and how this should be achieved. Staff demonstrated a focus on supporting people to live safer lives and to uphold their right to be protected from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. However, these arrangements were not always effective in practice, and concerns were identified in relation to the provider’s oversight of the Deprivation of Liberty Safeguards (DoLS).

We assessed whether the service was operating in line with the principles of the MCA and how DoLS were managed. People may only be deprived of their liberty to receive care and treatment where there is appropriate legal authority. In care home settings, this is usually authorised through the Deprivation of Liberty Safeguards (DoLS), which form part of the Mental Capacity Act 2005 (MCA).

The provider had systems to record DoLS applications and associated conditions; however, these systems were not sufficiently robust and did not provide assurance that applications and conditions were routinely reviewed. We also identified inconsistencies within one person’s care records regarding whether they were subject to a deprivation of liberty. Although we found no evidence that people were being deprived of their liberty unlawfully, the lack of a clear and effective process meant the provider could not be assured people’s arrangements were reviewed and updated as their needs changed. This increased the risk that people could be deprived of their liberty unlawfully.

Safeguarding concerns were promptly and appropriately shared with relevant agencies. Staff received role-specific safeguarding training and were equipped to identify individuals at risk. They understood the systems, processes and procedures in place to protect people from abuse and felt confident raising any concerns. A staff member who provided feedback told us, “I would feel confident speaking up because safeguarding is a priority, and concerns should always be taken seriously”. Everyone knew who the safeguarding lead was and how to access them.

We observed the service had developed a policy reflecting strong partnerships with external agencies and local safeguarding teams. The policy had been reviewed in February 2026; however, there was no evidence to indicate a time frame of when the policy was next due to be reviewed. This meant the absence of a clear review date; did not provide assurances the policy would be kept up to date. This increased the risk that guidance could become outdated and not reflect changes in practice, learning from incidents, or current best practice.

Safeguarding concerns were taken seriously and acted upon promptly by the registered manager and senior staff. A safeguarding log was shared by the service following the assessment. The log documented safeguarding concerns from June 2025 to March 2026, the log demonstrated actions taken and outcomes, including a matrix that provided risk levels for each person in relation to previous safeguarding concerns and risks identified. Staff completed safeguarding training and knew how to recognise concerns.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Individual risk assessments relating to falls were reviewed, including the control measures in place, as well as the assessed likelihood and severity of associated risks. However, for one person who was a falls risk, the information was inconsistent as records showed no history of falls in the past 12 months but then stated the person had recently had a fall. The care plan had not been updated to reflect this. We observed another person’s repositioning records had not been routinely completed in accordance with their care plan and District Nurse instructions. Staff assured us they were completing repositioning in accordance with the care plan but had not documented the information correctly. This meant the provider could not be assured that all reasonable steps were being taken to minimise the risk of developing pressure areas.

One person had not been weighed daily as specified within their care plan. The absence of an accurate record or review meant the provider could not be assured this person was being supported in accordance with their care plan.

People were exposed to risks because the provider did not always operate an effective system or process to record, recognise or act on risks and professionals’ instructions. This included environmental risks. People were put at risk of harm as the home’s environment had not been maintained.

We reviewed people’s Personal Emergency Evacuation Plans (PEEPs). These were recorded within individual care plans, with copies also held centrally for staff access in the event of an emergency. However, records showed that PEEPs had not been consistently reviewed to ensure they reflected people’s current needs.

Although documentation did not always reflect peoples identified risks staff felt they had a good understanding of how to mitigate the risks people faced. One staff member told us, “Care plans and risk assessments give me clear guidance on how to support individuals safely. They explain a person’s needs, any risks involved, and the steps I should take to reduce those risks. For example, they may include information about mobility support, medication, behaviours, or health conditions, along with instructions on what to do to keep the person safe while still promoting their independence”.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Food temperatures were not being routinely checked before serving food. The Food Standards Agency (FSA) emphasise the importance of checking food temperatures to ensure harmful bacteria are killed and that food is safe to eat.

The home was located in an older building which appeared tired and dated. In bedrooms, we identified environmental risks, including a trailing electrical lead, exposed wiring to an electric reclining chair, and items left on the floor, which increased the risk of trips and injury. We found trailing cables, damage to flooring and exposed nails on carpet grippers which posed a potential risk to people’s safety. These concerns were shared with the registered manager and provider, who advised actions would be taken as a matter of urgency.

We observed an overgrown section of the garden which contained a piece of wood with exposed nails. Following the site visit, the provider and registered manager advised the wood had been removed and action was being taken to address the overgrown garden area.

We reviewed external fire and health and safety assessments, including asbestos management. The fire risk assessment action plan had been completed, but the most recent assessment (November 2024) was not in line with HSE guidance for annual review. The provider arranged a new assessment and a fire door inspection (December 2025), which identified issues. While the provider stated risks were mitigated, there was no clear risk assessment, action plan or updated PEEPs. Following inspection, these were completed to manage risks during remedial works.
 

The October 2023 asbestos survey identified low-risk chrysotile asbestos in Artex ceilings, with annual visual checks carried out. However, there was no documented asbestos risk assessment or management plan, which was not in line with HSE guidance.

Policies and procedures relating to health and safety were current and supported good practice. Records evidenced up-to-date certification for health safety checks. Equipment, including hoists and slings, had been serviced and inspected. Fire safety arrangements were robust, with systems for testing alarms, maintaining fire equipment and supporting safe evacuation where required.

The service had an emergency evacuation and fire contingency plan.

Staff had received appropriate training in the event of a fire and Fire Marshall training; that was reviewed and updated every 12 months. Staff members told us they knew how to respond in the event of a fire. A staff member told us, “I have completed fire safety training, take part in regular drills, and know how to use evacuation equipment. There is a fire warden on each shift”

The provider had not consistently evidenced fully robust arrangements for staffing and oversight of training. Although systems were in place to support safe and effective care, these were not always applied consistently. Improvements were required to strengthen processes and ensure greater clarity and consistency.

Recruitment checks had been completed for all newly appointed staff prior to commencing in their roles.

Staff had completed mandatory and role-specific training. However, a review of the training matrix identified that some refresher training was out of date. It was not always clear how frequently refresher training should be completed to ensure it remained in line with current guidance. Non‑care staff had not received training in areas such as dementia, learning disabilities and first aid. The provider informed us they were in the process of reviewing the training policy and training arrangements. This was to ensure staff had protected time to complete training, training did not expire, and staff were paid for any training completed outside of their contracted hours. The provider told us they would take action to update their training policy in a timely manner.

Staff feedback was mostly positive regarding staffing levels. One staff member told us “Staffing levels are good. I don’t feel overworked or don’t witness staff feeling overworked just shift patterns are long which is normal for the industry. There are always enough staff on shift and if someone calls in sick in the carers team, usually sufficient cover is provided via agency work”. Another told us, “Staffing levels are good, the way the rota is done has a good skill mix. But sometimes we are under a lot of pressure on the floor, as we need to do the laundry as well as sometimes the cleaning at weekends.”

Feedback from professionals was mostly positive. However, we received some feedback raising concerns. One professional told us they felt the registered manager could spend more time away from direct care duties. However, they acknowledged the manager was included in staffing numbers to support meeting people’s needs and to enable activities and outings to take place. Another professional told us they had, at times, concerns about staffing levels and the potential impact on standards of care. They highlighted issues relating to the cleanliness of rooms and bedding, and the availability of basic facilities such as soap, paper towels and working sinks. They also recognised the service was based in an older building and acknowledged this would require ongoing maintenance.

There were sufficient staff on duty to meet people’s needs during the week. However, there was increased pressure on staff at weekends as the housekeeper did not work during this time. This resulted in care staff having to undertake additional cleaning duties alongside their care responsibilities. People living at the service, provided positive feedback.

A dependency tool was used to provide a structured method to assess the care needs of people and ensure the right number of staff with the right skills were available at the right time, to meet people’s needs. The provider had an electronic system (Medicare online) for monitoring call bell response times in the service. This included a monthly call bell audit for monitoring the length of time people waited to receive care. With regards to the length of response time, one person commented “Quickly, if they are not busy. There are 20 in here [to look after in Dalkeith]”.

Staff told us they received a suitable induction to the service. One staff member told us “When I started, I received an induction that introduced me to the service, policies, and procedures. This included training in areas such as safeguarding, health and safety, and infection control. I found the induction helpful as it gave me a good understanding of my role and what was expected of me.” Staff received regular supervision. A supervision matrix was used to monitor the frequency of supervision sessions and included details of the next planned meeting. Staff we spoke with told us they felt well supported by managers and senior leaders. One staff member said “I receive regular supervision sessions with my manager or senior staff member. These sessions give me the opportunity to discuss my performance, any concerns, and my development. I find them helpful as they provide support and guidance. I feel supported by the leadership team. They are approachable and available if I need advice or support. Good leadership helps create a positive working environment and ensures that staff feel valued”

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found the kitchen was not clean. There was dirt and debris present in the gaps between freestanding appliances and cupboards. Kitchen items were stored in a cluttered manner, and some items were visibly dirty, with food residue present. These items were not fit for purpose.

The provider and registered manager told us they were not aware of these concerns and said they would arrange for the affected items to be replaced.

We found some cooker functions were not operating as intended. The provider told us the cooker was in the process of being replaced and said this had not impacted the food service provided to people using the service. Following the on-site visit, the cooker and kitchen utensils had been replaced. We requested a follow-up visit by the Food Standards Agency (FSA).

We observed people’s bedrooms were not consistently clean. This included the presence of food debris under a bed and soiling to a chair cushion in one bedroom. In some bedrooms, toilet bowls were soiled, and faecal matter was present on toilet seats. The disabled toilet on the ground floor was not clean. There was an odour, and the toilet bowl was visibly dirty.

Staff meeting minutes from August 2024 and March 2026, documented where cleanliness within the home was discussed with staff. However, there was no evidence of actions taken following these meetings to address the concerns raised or to improve standards of cleanliness.

Infection prevention and control audits were completed but did not identify the concerns we found during assessment. The audit lacked structure and did not include an action plan where areas of non-compliance were identified. The audit did not cover all of the areas required which meant the provider could not be assured people were being supported safely to minimise and mitigate infection control and health and safety risks.

Staff had received appropriate Infection Prevention and Control (IPC) training and demonstrated good understanding of infection control practices. Personal protective equipment (PPE) was regularly available and used appropriately by staff. Staff were aware of how and when to use personal protective equipment and dispose of it safely.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

A medicine for one person was out of date and was stored in the fridge. There was no evidence to indicate this had been quarantined ready for disposal or that a system was used to ensure the correct disposal of medicines that required refrigeration. This placed people at risk of receiving out of date medicines. The fridge that stored vaccines and other medicines that require refrigeration was not visibly clean.

Medicines audits did not provide full oversight of all areas including Medicines administration records, storage, fridge temperature monitoring, expired medicines, and PRN/Covert Protocols or a detailed action plan when concerns were identified. This placed people at risk of harm. However, Medicines were ordered, received and stored securely.

Staff who administered medicines were trained and had their competencies assessed. Medicines administration records were appropriately completed, and there were clear protocols for ‘as required’ (PRN) medicines. Covert medication protocols were available for people who required medicines to be administered covertly. These individuals had been appropriately assessed by the GP and pharmacist, in line with the Mental Capacity Act 2005, and decisions were made in the person’s best interests.