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 requires improvement. At this assessment the rating has changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At our last assessment the provider was in breach of the legal regulation relating to good governance. At this assessment improvements had been made, and the provider was no longer in breach of this regulation.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders demonstrated a clear understanding of the service and were actively involved in its day-to-day operation. The registered manager and provider maintained a visible presence and demonstrated a strong commitment to delivering high-quality, person-centred care.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had made improvements and implemented new systems and processes to strengthen governance, accountability and oversight. Further time was needed to ensure these arrangements became fully embedded and consistently supported effective monitoring of performance, risks and outcomes.

Governance arrangements had been strengthened through the introduction of improved monitoring systems, enhanced risk management processes, improved record keeping, regular audits and quality assurance checks. To support oversight, the provider had introduced a RAG-rated service improvement tracker, which monitored progress against actions and identified risks. The tracker recorded completed and ongoing actions, and progress was reviewed regularly. Following the last assessment, fortnightly governance meetings had also been established between the provider and registered manager to review audit findings, monitor progress against improvement actions and maintain oversight of service performance.

Care plans had improved and contained accurate, person-centred information which reflected people's current needs. Records demonstrated that risks to people's health, safety and welfare had been assessed and managed appropriately, with action taken to reduce or mitigate identified risks. Repositioning records were completed contemporaneously and evidenced people received support in line with their assessed needs and care plans. Guidance from healthcare professionals had been followed, and care records were updated to reflect current interventions and support needs.

The provider had strengthened incident management processes to address previous gaps in oversight and learning. Falls incidents, which had not always been consistently reviewed or analysed, were now subject to regular review, trend analysis and action planning. This enabled the provider to identify patterns, evidence actions taken to mitigate risks, embed learning into practice and implement preventative measures to reduce the likelihood of recurrence.

Additional systems had been introduced to strengthen oversight and support regulatory compliance. An improved Deprivation of Liberty Safeguards (DoLS) tracker provided effective oversight of authorised applications, pending decisions and upcoming expiry dates, helping to ensure applications, reviews and renewals were submitted in a timely manner. An improved safeguarding log supported monitoring of safeguarding concerns, actions taken, outcomes and lessons learned.

While significant improvements had been made, further time was needed to ensure governance systems and processes were fully embedded and consistently applied in day-to-day practice.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.