We inspected Dalkeith on the 11 and 12 May 2017. Dalkeith provides accommodation and personal care to older people; some of these people were living with dementia. The home offers a service for up to 20 people. At the time of our visit 17 people were using the service. This was an unannounced inspection.

We last inspected the home in April 2016 and found that the provider was not meeting all of the regulations. We found that people’s capacity to consent to their care had not always been recorded. Additionally people could not be assured that the service was safe as fire safety routes were not always clear and equipment had not been serviced in accordance with manufacturer’s guidelines. During this inspection we found improvements had been made by the registered manager and care staff.

There was a registered manager in post. The registered manager was also the provider of 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 is run.

People enjoyed living in Dalkeith. People told us they felt safe at the service and enjoyed active and social lives. People had access to activities which were tailored to their individual needs and preferences. People felt cared for and happy.

People were supported with their on-going healthcare needs. Care staff supported people to access the healthcare support they required. People received their medicines as prescribed.

People had access to plenty of food and drink. People told us they enjoyed the food they received within the home, and had access to all the food and fluids they needed. Where people needed support to meet their nutritional needs, these needs were met.

People were supported by staff who were supported and trained to meet people’s individual needs. Staff were supported to develop and access additional training to further improve their skills.

Staff benefitted from effective leadership from a committed management team. There were enough staff with appropriate skills deployed to meet the needs of people living at the service. Staff spoke positively about the support they received from the registered manager, deputy manager and team leaders.

People and their relatives spoke positively about the management of the service. The registered manager ensured people, their relatives and external healthcare professionals’ views were listened to and acted upon. The registered manager had systems to assess, monitor and improve the quality of service people received at Dalkeith.

We inspected Dalkeith on the 20 and 22 April 2016. This was an unannounced inspection. Dalkeith is a residential home for up to 20 older people. 17 people were living at the home at the time of our inspection. Some of the people living at the home had been diagnosed with dementia.

We last inspected in July 2015. At the July 2015 inspection we found that the provider was not meeting all of the requirements of the regulations at that time. People were not always protected from the risks associated with their care as appropriate steps to mitigate these risks were not always taken. There was not always suitably skilled staffed deployed to meet people’s needs. People’s care plans were not always personalised and did not provide guidance for care staff to follow to meet people’s needs. The service’s quality assurance systems did not always enable them to identify and improve on concerns raised at the service. At the July 2015 we also made recommendations to the service regarding activities, ensuring people’s legal rights were protected, safeguarding and the management of people’s medicines. At this inspection we found the provider had made significant improvements to the service.

There wasn’t registered manager in post on the day of our inspection. The last registered manager deregistered from the service in August 2015. The two providers of the service had taken responsibilities for the day to day management of the service. They had submitted applications to become registered managers for Dalkeith. 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.

The provider did not always ensure the premises were safe. Fire drills were not carried out at the home. Fire extinguishers had not been checked by a relevant professional for over two years and fire exits were not always clear.

The provider had assessed people’s capacity to make specific decisions but had not always documented the outcome. The provider was working with external healthcare professionals to ensure people’s legal rights were being protected and staff knowledge in this area is improved.

People and their relatives were positive about the home, the staff and management. People told us they were safe and looked after well in the home. Staff managed the risks of people’s care and understood their responsibilities to protect people from harm. People received their medicines as prescribed, and the service had made improvements.

People had access to plenty of food and drink and received a diet which met their needs. Staff ensured their on-going healthcare needs were met. Where people stayed at the home for respite, staff ensured they had the emotional and physical support to promote their independence and move into alternative accommodation

People told us they enjoyed living at Dalkeith. There was a friendly, pleasant and lively atmosphere within the home. People enjoyed the time they spent with each other and staff. People were offered choices about their day. They told us they felt listened to and able to raise concerns or make suggestions.

Staff were supported by a committed management team and had access to training, supervision and professional development. They could request further training and development as required. There were enough staff with appropriate skills deployed to meet the needs of people living at the home. Staff spoke positively about the home, the managers and the improvements which had been made at the home.

People and their relatives spoke positively about the management and the service. The managers ensured people; their relatives and external healthcare professional’s views were listened to and acted upon. The managers involved staff were involved in decision

We undertook this inspection in response to information we received alleging theft of people’s monies and regarding possible unsafe administration of medication

Pre-admission assessments had not established if people had brought money with them when admitted to the home. There was an acknowledgement by the registered manager that for future admissions they would record the amount of money which people were planning to bring with them on admission. The allegation was referred to the police by the registered manager. Investigations by the police concluded it was not possible to confirm that the money was ever taken into the home. Investigations by the police concluded it was not possible to confirm that the money was ever taken into the home. They do not intend to continue with their investigation.

We received information about inappropriate administration of medication and the recording of it. No evidence to support this allegation was found following an investigation by the local funding authority. This inspection, and investigation by the local funding authority, found no evidence of falsification of records or failure to administer medication.

Following the allegations the registered manager had responded by reviewing how the home conducted pre-admission assessments and the procedure to seek medical advice regarding the management of medication.

The inspection took place on 21, 22 and 23 July 2015 and was unannounced.

The last inspection of the service was in July 2013 when it was found compliant in protecting people from abuse and safe management of medicines.

The service predominantly cared for older people who lived with dementia, had physical disabilities and mental health needs. It could accommodate up to 22 people and at the time of the inspection 16 people in total were living there.

The registered manager had left in June 2015. A new manager was in position and had started four weeks prior to our inspection. 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.

Some information of concern was received by us prior to the inspection. We had asked the provider to investigate the issues raised, which they did. They reported that none of the concerns reported were correct. The issues raised were also explored during this inspection.   

We found people’s needs and risks were not always met because of poor staffing numbers, a lack of staff knowledge and in places inadequate care planning. The manager was aware staff required more resources and support to ensure people’s needs were met. The manager was also aware that personalised care needed to be promoted and implemented. Appropriate checks were carried out before staff started work in order to protect people against those who may be unsuitable to care for them. People had access to activities but these were limited and not always provided in a way that met people’s needs or preferences. The arrangements in place to ensure people were properly protected under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards were being reviewed.

People’s privacy and dignity was maintained most of the time, but compromised when, for example, eye drops, were administered in front of other people at the dining room table. People’s medicines were managed safely, although some situations discussed with the staff, demonstrated they needed further training to ensure they understood and followed best practice guidelines at all times.

People’s care plans were not always maintained accurately and were read infrequently by some staff. This put people at risk of inappropriate and unsafe care because, care plans were not always kept relevant and some staff did not update themselves with the contents. People had access to health and social care professionals and to specialists when required. People were supported to have a balanced diet and to receive enough drinks. People who mattered to those who lived at Dalkeith were able to visit when they chose and were made welcome.

People lived in an environment which was being cleaned but where improvements to the cleaning arrangements were needed.  Arrangements were in place to avoid the spread of infection. Other regulators’ recommendations were followed and requirements were met, for example, the Fire Officer's recommendations. Improvements to the kitchen were planned for the latter part of 2015. Accidents and incidents were monitored and appropriate actions were taken to avoid reoccurrences.

Representatives of the provider were actively involved in the running of the service, A quality monitoring system was in place but had not effectively measured the service's performance and levels of compliance against their regulatory responsibilities. The manager was aware of the challenges the service faced in moving forward and in becoming compliant with the required regulations. People were responding well to the manager’s open approach and they and their relatives felt listened to. People felt confident that they could find a member of staff to speak to if they had a concern or wanted to raise a complaint. They told us the manager was very approachable.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in the following areas: the management of some risks which have an impact on people's health, the planning of people's care, training and support for staff and systems for quality monitoring and governance purposes. You can see what action we told the provider to take at the back of the full version of the report.

We also made four recommendations; that the service ensure that all appropriate deprivation of liberty safeguards have been correctly applied for, that staff receive further training and guidance in relation to medicine administration, that action be taken to improve people's and their representatives' awareness of safeguarding people from abuse and that advice be sought with regard to the provision of varied and meaningful activities.