Dalkeith

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Despite the concerns we identified during the assessment, the leadership team responded positively during the assessment and demonstrated their willingness to improve their governance processes to ensure people consistently received good quality care and improved outcomes.

Staff generally described the service as having a positive culture, ensuring that people’s equality, diversity and human rights were met.

While staff spoke positively about feeling supported by managers and we observed kind and compassionate care, not all leaders consistently demonstrated a clear understanding of the context in which care, treatment and support were delivered. This meant they did not always fully reflect the organisation’s values in their oversight of the service. Leaders did not consistently apply their skills, knowledge and experience to ensure effective leadership, and they did not always demonstrate openness, transparency and accountability in their approach.

Leaders did not consistently have effective oversight arrangements or systems to identify, recognise, and appropriately escalate concerns within the service. Gaps in internal processes meant risks were not always identified or addressed in a timely way. While leaders promoted an inclusive culture, gaps in their understanding of day‑to‑day service delivery limited the effectiveness of governance and assurance arrangements, reducing their ability to maintain safe and effective oversight.

The registered manager and provider were in the process of developing a more robust and effective governance process, including the introduction of an action tracker to monitor and address any concerns. In addition, the registered manager was looking at ways to strengthen the management team to provide improved oversight of the service.

Staff told us they felt supported by managers. Feedback on their skills and knowledge was positive, and we observed the managers of the service providing kind and compassionate care to people.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff confirmed they felt there was an open and honest culture. Staff knew and understood how to raise concerns and had knowledge of whistleblowing processes and the freedom to speak up.

The service had a whistleblowing policy and procedure. Staff demonstrated an understanding of whistleblowing and could explain what they would do if they needed to escalate concerns about poor practice. A staff member told us, “The management promotes one on one supervisions, and each time I raise concerns, the management listens”. Another staff member told us, “If I have ever spoken up, I have been listened to, and my concerns were taken seriously.” Leaders acted on the information appropriately, which reinforced a culture of transparency and trust within the service.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service had an equality, diversity and inclusion policy, and staff received relevant training. The staff team was diverse, and we found no evidence of bullying or discriminatory behaviour. Staff reported feeling valued and respected by both their colleagues and the management team. One staff member said, “I have no concerns about how the service treats me or other staff as we are all treated equally and with fairness.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider's systems were not effective in assessing, monitoring and improving the quality and safety of the service. Audits were incomplete, lacked depth and failed to identify concerns found during the assessment. Records relating to people’s care, were not accurate, complete or contemporaneous. Risks to people’s health, safety and welfare were not effectively assessed or mitigated. Where risks were identified, measures to reduce or remove those risks were not always implemented within a timescale that reflected the level of risk and impact on people using the service.

Repositioning records had not been completed in accordance with people’s care plans and District Nurse instruction, and documentation was not updated effectively. This meant there was a risk people were not being repositioned as required, which could increase the risk of skin damage, pressure ulcers, and unnecessary discomfort. In addition, inaccurate or incomplete records limited staff oversight and continuity of care, particularly for staff unfamiliar with the person’s needs. This reduced assurance that people were receiving safe and responsive care in line with professional guidance.

The provider did not have processes to learn from incidents to improve outcomes for people using the service. Incident reports, specifically in relation to falls had not been consistently analysed or reviewed. This meant the provider could not be clear whether measures had been taken to reduce risks and minimise the potential for reoccurrence.

The provider had not identified concerns relating to maintaining safe environments.

Staff meeting minutes, provider and registered manager meetings lacked agendas, structure and documented outcomes. Minutes did not record actions, responsible person, or deadlines. There was no evidence that issues raised were reviewed at future meetings. This meant leaders did not demonstrate effective oversight or accountability.

The provider did not have clear roles, responsibilities, systems of accountability and good governance. This had impacted on their ability to provide good quality, sustainable care, treatment and support.

Leaders were open and honest throughout the assessment and had a desire to make improvements, but time was needed to make and embed these changes. Leaders showed integrity, openness and honesty throughout the assessment process.

More time was needed to ensure effective governance of the service was embedded into day-to-day practice.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Most professionals were complimentary about how the service worked in partnership to achieve the best possible outcomes for people.

Staff and leaders understood their duty to collaborate and work in partnership with people, other organisations and communities to achieve the best possible outcomes for people. They worked in partnership with a range of stakeholders within the local community, including health professionals and the local authority, to support people’s care and wellbeing. We received positive comments regarding the support provided by leaders. Staff and external partners' views and concerns were encouraged, heard and acted on to shape the service and culture.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

There was a lack of accurate and effective auditing and quality assurance of the service. Many audits were tally charts and did not evidence any gaps, errors or actions taken as a result of findings. This meant there was limited oversight of the service provision and no actions taken to make improvements.

Following our assessment, the provider was looking to introduce new electronic care planning systems, to improve oversight and monitoring of the care planning process. Time was needed to ensure improvements would be made and embedded within the service.