Threshold Support Services - Residential
Recorded Key Question grade range: 3–4 — Adequate View on Care Inspectorate
Key Question scores
Requirements & recommendations
1. By 14 December 2025, to promote the safety and wellbeing of people, the provider must ensure that staff receive essential training and that training records are accurate and up to date. To do this, the provider must, at a minimum: a) Implement a cohesive and well-monitored system for recording all staff training, including mandatory and service-specific courses. b) Ensure all staff complete overdue refresher training, including first aid, within appropriate timescales. c) Maintain a centralised and accessible training matrix that clearly identifies training status for all staff. d) Introduce quality assurance processes to regularly review training compliance and take action where gaps are identified. This is in order to comply with section 8 (1)(a)(b) of the Health and Care (Staffing) (Scotland) Act 2019. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state: "I have
1. To reduce risk and improve safety for people and staff, the provider should strengthen its medication support systems by ensuring body maps are consistently used for topical creams and that a returns book is maintained to record medicines sent back to the pharmacy. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS), which state that: "I experience high quality care and support based on relevant evidence, guidance and best practice." (HSCS 4.11)
1. To support staff development and accountability, the provider should implement a reliable and well-monitored system to ensure staff receive timely and recorded supervision, observations of practice, and appraisal in line with the service’s own policy. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS), which state that: "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. To promote safety and ensure compliance with fire safety guidance, the provider should improve oversight of fire safety checks, staff participation in fire drills, and completion of actions from the Scottish Fire and Rescue Service report. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS), which state: "My environment is secure and safe." (HSCS 5.17)
2. To support people to live in a safe, comfortable, and dignified environment, the provider should strengthen oversight of environmental needs through a Specific, Measurable, Achievable, Realistic, and Timely (SMART) environmental plan. This should include, but not be limited to, identifying required actions, setting clear timescales, and ensuring environmental needs are addressed promptly. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS), which state: "I experience an environment that is well looked after with clean, tidy and well-maintained premises, furnishings and equipment." (HSCS 5.22)
1. To promote consistent and person-centred responses to stress and distress, the provider should ensure personal plans include clear information about individual potential triggers, presentation, and strategies that support a person during times of stress or distress. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS), which state: "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) and "I am supported to be emotionally resilient, have a strong sense of my own identity and wellbeing, and address any experiences of trauma or neglect." (HSCS 1.29)