St. Davids Care Home

1. By 30 October 2025, in order to meet people's care and support outcomes; the provider must ensure that: a) Pre-admission assessments are carried out, and care and support plans are available for staff, which clearly set out people's care and support requirements. b) Protocols for the management of acute health concerns are available for staff. c) P eople’s health care recording charts and assessments are completed accurately, and that these are reviewed at appropriate intervals to support ongoing evaluation and assessment of people’s current and changing needs.

d) Ensure that all risk assessments, including consents for any equipment that could restrict people's movements are reviewed and kept up-to-date. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 SSI2. By 30 October 2025, in order to ensure the safety of people and the public, the provider must ensure that substances that could be hazardous are locked away or under supervision at all times. This includes, but is not limited to clinical waste and cleaning products. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations SSI 2011/210 Regulation 4.(1)(a) Welfare of service users. This is to ensure that care and support is consistent with Health and Social Care Standards (HSCS) which state that: 'My environment is safe and secure'. (HSCS 5.19)

1. By 30 October 2025, the provider must ensure that the service can meet people's identified needs and comply with its conditions of registration by developing a clear process to support appropriate admissions to the service which should include but is not limited to: a) Complete a full pre-admission assessment and support plan of new residents to ensure that the service can meet their stated outcomes. b) Submit a variation to the Care Inspectorate if people's support needs or age are out with the current conditions of registration, clearly stating how the service will meet the needs of the person/people, and which also considers the impact on people already living at the service. Variations must also be agreed prior to new admissions entering the service. c) Ensure that staff have appropriate training in place prior to admission, to ensure staff understand and are competent to support new or unfamiliar health and support needs.

2. By 30 October 2025, the provider must ensure that people benefit from a service that is well led by developing and implementing comprehensive and structured systems for assuring the quality of the service. To do this, the provider must as a minimum: a) Review and develop the quality assurance plan and procedural guidance. b) Include formal auditing and monitoring all areas of the service provided to evidence that the standards set out in the quality assurance plan are met. c) Ensure relevant staff receive training in the quality assurance procedures and be able to demonstrate an understanding of how these can be used to assure the quality of the service. d) Ensure that residents, staff and all stakeholders have opportunities to feedback about the service. e) Implement effective action planning to address areas of required improvement to include appropriate timescales for completion and review of actio1. By 30 October 2025, in order to ensure the safety of people, the provider must ensure that staff are recruited through robust and safe recruitment procedures. To achieve this, the provider must carry out checks before new employees start work with the service. This must include, but is not limited to: a) Maintain accurate and clear documentation of each stage of recruitment process. b) Carry out checks on identity, and right to work checks. c) Ensure that appropriate references have been sought, and concerns followed up and recorded. d) Carry out PVG/Disclosure checks. This is in order to comply with: SSI 2011/210 Regulation 4 (1)(a), 9(1)(2) 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 am confident that2. By 30 October 2025, in order to ensure that staff practice is supported by effective supervision and support, and that staff access suitable training to ensure that they can meet the needs of people and the conditions of their registering professional bodies; the provider must ensure: a) That the service has a staff supervision policy in place, which clarifies the frequencies of supervision for staff, and that staff are provided with copies of these meetings. b) All core and essential staff training requirements are planned, to ensure people receive responsive care, and are kept safe by a knowledgeable and competent staff team. c) Staff have access to, and complete training relevant to their role.

d) A staff training matrix is developed to ensure that the management team are able to monitor staff training. This is in order to comply with section 8 of th3.