Clannalba

1. The service should improve the consistency, accuracy and completeness of key daily records, including but not limited to bowel monitoring, restrictive practice logs, and kitchen daily checks. This is to ensure care and support is consistent with the Health and Social Care Standards (HSCS), which state: “My care and support meets my needs and is right for me“. (HSCS 1.19) and “I have confidence in people because they are trained, competent and skilled, are able to reflect on their practice, and follow their professional and organisational codes”. (HSCS 3.14)

2. The service should strengthen the consistency of medication recording and audit follow up. Ensuring that all actions from audits are clearly documented and completed will enhance oversight and reduce the risk of issues re emerging. This is to ensure care and support is consistent with the Health and Social Care Standards (HSCS), which state: “My care and support meets my needs and is right for me”. (HSCS 1.19) and “I have confidence in people because they are trained, competent and skilled, are able to reflect on their practice, and follow their professional and organisational codes”. (HSCS 3.14)

1. The service should strengthen the recording and completion of incident and protection concern documentation. This will improve accountability, transparency, and the accuracy of safeguarding records. This is to ensure care and support is consistent with the Health and Social Care Standards (HSCS), which state: “I experience high quality care and support based on relevant evidence, guidance and best practice”. (HSCS 4.11) and “I benefit from a culture of continuous improvement, with the organisation having robust and transparent quality assurance processes”. (HSCS 4.19)

1. The service should strengthen compliance with key training requirements, particularly in relation to epilepsy and medication administration. Ensuring that all staff complete and maintain up to date training in these core areas, will support safe practice, reinforce staff confidence, and reduce the risk of avoidable errors. This will also enhance the service’s ability to demonstrate consistent competence in medication support. This is to ensure care and support is consistent with the Health and Social Care Standards (HSCS), which state: “My care and support meets my needs and is right for me”. (HSCS 1.19) and “I have confidence in people because they are trained, competent and skilled, are able to reflect on their practice and follow their professional and organisational codes”. (HSCS 3.14)

1. The service should strengthen the recording, tracking and completion of actions identified through environmental audits. Repairs and environmental issues should include clear actions, timescales and review notes, to ensure they are followed through to completion. Improving the consistency and structure of audit follow up will support a safer, more comfortable and well maintained living environment. This is to ensure care and support are consistent with the Health and Social Care Standards (HSCS), which state: “I experience high quality care and support based on relevant evidence, guidance and best practice”. (HSCS 4.11) and “I benefit from a culture of continuous improvement, with the organisation having robust and transparent quality assurance processes”. (HSCS 4.19)

2. The service should strengthen the consistency, accuracy and tracking of environmental improvement actions. This includes ensuring that key refurbishments—such as bedroom upgrades, soft furnishings and carpet replacements—are recorded using SMART (Specific, Measurable, Achievable, Relevant and Time bound) criteria and supported by a clear tracking system. In addition, feedback from people and families should be routinely gathered and incorporated into environmental planning, to enhance relevance, transparency and accountability. This is to ensure care and support are consistent with the Health and Social Care Standards (HSCS), which state: “I experience high quality care and support based on relevant evidence, guidance and best practice”. (HSCS 4.11) and “I benefit from a culture of continuous improvement, with the organisation having robust and transparent quality assurance processes”. (HSCS 4.19)