153 Victoria Street

1. By 12 October 2026, the provider must ensure that people experience safe, timely and proactive care and support, that meets their health, safety, and wellbeing needs. To do this the provider must, at a minimum: a) Ensure people receive safe and timely care to meet all health and wellbeing needs, as directed by their care plans. This should include, but not limited to, continence, positive behaviour support and the mealtime experience. b) Ensure people have sufficient levels of supervision, as directed by their assessments and care plans. c) Ensure staff know, and follow, people’s care plans. d) Review staffing arrangements and deployment of staff and take any action that is necessary to ensure staff are available to meet people’s needs in a timely manner. e) Demonstrate how people’s needs and assessments influence staffing numbers. This is to comply with Regulation 4(1)(a) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations

22. By 12 October 2026, the provider must ensure people are protected from harm and experience safe care in a well maintained and clean service. This must include robust processes to ensure both effective infection prevention and control (IPC) and management of the property’s health and safety. To do this, you must, at a minimum:

a) Develop, and ensure staff are provided with, specific guidance on being outbreak ready including the safe and timely implementation of transmission-based precautions (TBPs). b) Ensure all necessary health and safety checks and services are complete, and evidence that any actions from these are acted upon promptly. c) Ensure people benefit from a consistently clean and safe service. d) Implement an effective quality management system to monitor health and safety, cleanliness, and the implementation of the service’s IPC policy and associated guidance.

This is to comply with Regulation 4(1)(a)(d) and 10 of The Social Care and Social Work Improvement Scotland (1. By 12 October 2026, the provider must ensure that people experience safe care as a result of effective quality assurance. To do this, the provider must, at a minimum: a) Review quality assurance systems, including audits and checks, to ensure they meet the needs of the service. b) Ensure leaders investigate all unplanned events in sufficient detail and take necessary actions to prevent reoccurrence. c) Ensure leaders and staff can demonstrate how actions taken following unplanned events have been embedded and sustained. d) Ensure that lessons learned from unplanned events are shared with the wider staff team. This is to comply with Regulation 4(1)(a) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210). This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: ‘I benefit from a culture of continuous improvement, with the organisation having robust

1. To support people’s health and wellbeing the provider should ensure that medication administration records and medication care plans are clear and reflect people’s needs. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: ‘My care and support meets my needs and is right for me.’ (HSCS1.19) And; ‘I experience high quality care and support because people have the necessary information and resources.’ (HSCS 4.27)

1. By 18 August 2025, the provider must ensure that people experience safe and effective support with medication. To do this the provider must, at a minimum: a) Review the medication policy and procedure, ensuring it reflects statutory requirements and best practice guidance. b) Ensure all people receiving support with medication have a clear care plan detailing the level of support they require. c) Ensure all “as required” medication has a clear care plan. d) Ensure people who are given medication covertly, have the required legal agreements and care plans in place. This is to comply with Regulation 4(1)(a) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210). This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which states: ‘My care and support meets my needs and is right for me’ (HSCS 1.19) a By 14 July 2025, the provider must ensure all people can be evacuated from the building safely. To do this the provider must, at a minimum: a) Ensure sufficient equipment is available to safely evacuate people who are unable to move themselves, as required in the Scottish Fire and Rescue audit. b) Review personal evacuation plans for all people, to include the use of equipment purchased to aid in evacuation. c) Ensure staff are adequately trained to use equipment purchased to aid in evacuation. This is to comply with Regulation 4(1)(a) and 14(b) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210). This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which states: ' My care and support is provided in a planned and safe way, including if there is an emergency or unexpected

1. To ensure that people experience a safe and enjoyable arrival to the service, the provider should review pre-admission procedures. This should include a review of pre-admission documentation and the arrival process. This should result in all necessary information being shared between families and staff. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which states: ' My care and support is consistent and stable because people work together well.' (HSCS 3.19) a nd; ' If I am supported and cared for by a team or more than one organisation, this is well coordinated so that I experience consistency and continuity.' (HSCS 4.17)

1. To ensure that people have consistently positive experiences, the provider should ensure staff have sufficient time to spend with people. To do this the provider should, at a minimum, review staffing arrangements. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which states: 'I experience people speaking and listening to me in a way that is courteous and respectful, with my care and support being the main focus of people’s attention.' (HSCS 3.1)2. To ensure that people have enough staff to meet their needs the provider should review staffing levels. To do this the provider should, at a minimum, develop a staffing tool. This should consider factors such as, group size, people’s physical health, mental wellbeing, level of independence, and personal preferences. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which states: ' If I experience care and support in a group, the overall size and composition of that group is right for me.' (HSCS 1.8) and ' My needs are met by the right number of people.' (HSCS 3.15)

1. To ensure that people benefit from a consistently clean and comfortable environment, the provider should review cleaning procedures in the service. This should result in thorough cleaning and infection control procedures in between different groups of people. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which states: 'I experience an environment that is well looked after with clean, tidy and well maintained premises, furnishings and equipment.' (HSCS 5.24)

1. To ensure that people are supported to get the most out of life, the provider should ensure that people are supported to work towards their goals. To do this the provider should ensure that care plans are outcome focussed and that records are kept to evidence people working towards their goals. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which states: 'My personal plan (sometimes referred to as a care plan) is right for me because it sets out how my needs will be met, as well as my wishes and choices.' (HSCS 1.15)