Capability Scotland - Community Living Services South West
Recorded Key Question grade range: 3–5 — Adequate View on Care Inspectorate
Key Question scores
Requirements & recommendations
1. By 20th July 2026, the provider must ensure that quality assurance processes are carried out effectively, and in a manner which achieves improvements in the service. The provider must ensure, at a minimum: a) Development of effective quality assurance systems. b) Ensure routine and regular management audits are being completed across all areas of the service being provided. c) Ensure internal quality assurance systems identify any issue which may have a negative impact on the health and welfare of people supported. d) Clear action plans with timescales are devised where deficits and/or areas for improvement have been identified.
e) Action plans are regularly reviewed and signed off by an appropriate person in the organisation when improvements are achieved. This is to comply with Regulation 4(1)(a) (Welfare of users) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210).
This is to
1. To ensure oversight of key areas for improvement, managers should develop a service improvement plan incorporating all aspects of the service. This should include, but is not limited to: detailed outcomes for service improvements which are informed by self-evaluation and feedback from people using the service, identified staff and managers with responsibility for specific actions in meeting the outcomes for the service and regular review of outcomes, updated to reflect progress. This is to ensure that care and support is consistent with 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); and 'I benefit from a culture of continuous improvement, with the organisation having robust and transparent quality assurance processes'. (HSCS 4.19)
1. To ensure continued oversight of staff training, the provider should develop a structured training plan to address gaps, with priority given to PBS and epilepsy training. The provider should produce a clear, comprehensive overview of all training and compliance across both services. 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) and 'I experience high quality care and support because people have the necessary information and resources'. ( HSCS 4.27)
2. To ensure consistency in people's care and support, the provider should ensure that there are sufficient numbers of staff deployed with the right skills and knowledge, to support people at all times and demonstrate how the outcome of people’s assessments are used to inform staffing numbers and arrangements. T his is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: 'My needs are met by the right number of people'. (HSCS 3.15) and 'I experience stability in my care and support from people who know my needs, choices and wishes, even if there are changes in the service or organisation'. (HSCS 4.15)
1. To support people's health and wellbeing and the effectiveness of any support they receive, the provider should improve the documentation of 'as required' medication. This should include, but is not limited to, ensuring that the reason for the administration of the medication and the effectiveness of the medication is documented in sufficient detail. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which states that: 'Any treatment or intervention that I experience is safe and effective'. (HSCS 1.24)