Threshold Edinburgh
Recorded Key Question grade range: 4 — Good View on Care Inspectorate
Key Question scores
Requirements & recommendations
1. To support positive outcomes for people the provider should undertake a self-assessment and produce a formal improvement plan with the involvement of people, their families and staff. This should include but is not limited to, ensuring the improvement plan is regularly reviewed and updated. 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); and 'I can be meaningfully involved in how the organisations that support and care for me work and develop' (HSCS 4.6).1. To support people’s health and wellbeing, the provider should review and improve their system of collating and monitoring staff training compliance. This should include, but is not limited to, ensuring records clearly identify training required for individual staff roles. 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 support people’s health and wellbeing, the provider should develop and improve the quality and detail contained within documentation. This should include, but is not limited to incident reporting, risk assessments and positive behaviour support plan. 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 because people have the necessary information and resources' (HSCS 4.27).
1. By 20 May 2026, to ensure that people's receive effective support with their health and wellbeing needs, the provider must at a minimum: (a) ensure that health monitoring charts have a clear purpose and guidance for staff to follow as to when action is required and reported to management. (b) ensure that risk assessments are in place to guide staff effectively when providing support to people. This is to include minimising potential risks to people who are risk of choking, those with stoma support needs and those at risk of skin damage. This is to comply with Regulation 4(1)(a) Welfare of Users of the Public Services Reform (Scotland) Act 2010. This is to comply with the Health and Social Care Standards (HSCS) which state that: 'My care and support meets my needs and is right for me' (HSCS 1.19)
1. By 20 May 2026 to ensure that staff have the right skills and knowledge to meet people's assessed needs the provider must at minimum: (a) ensure that all staff have an understanding of promoting people's skin health and factors which contribute to skin damage. (b) ensure that all staff have practical first aid training including choking. This is in order to comply with section 8 (1)(a) 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 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. By 23 February 2026, to ensure people receive safe and effective care and support with their medication, the provider must, at a minimum: (a) ensure that people's medication is stored safely. (b) ensure that people receive their medication as prescribed with medication administration records being completed consistently and accurately. (c) ensure that any discrepancies in recording of people's prescribed medication, including 'when required' medication are picked up promptly and addressed through a system of regular planned quality assurance and monitoring. This is to comply with Regulation 4(1)(a) Welfare of Users of the Public Services Reform (Scotland) Act 2010. This is to comply with the Health and Social Care Standards (HSCS) which state that: 'Any treatment or intervention that I experience is safe and effective' (HSCS 1.24)
2. By 23 February 2026, to ensure that people's receive effective support with their health and wellbeing needs, the provider must at a minimum: (a) ensure that seizure monitoring charts are being completed effectively and detail of the type and length of seizure activity is recorded. (b) ensure that oral care, bowel monitoring, stoma care and continence care records are completed consistently. (c) ensure that health monitoring charts have a clear purpose and guidance for staff to follow as to when action is required and reported to management. (d) Ensured standards are maintained through regular quality and monitoring. This is to comply with Regulation 4(1)(a) Welfare of Users of the Public Services Reform (Scotland) Act 2010. This is to comply with the Health and Social Care Standards (HSCS) which state that: 'My care and support meets my3. By 23 February 2026, to ensure that people's personal plans are right for them, the provider must at minimum: a) ensure that personal plans accurately reflect all health and wellbeing needs with detailed and clear information about how people are to be supported. b) Undertake reviews of personal plans every six months and when people's needs or circumstances change. The service should ensure that supported people are meaningfully involved in developing and reviewing their personal plans and involve people who are important to them. (c) ensure that risk assessments are in place to guide staff effectively when providing support to people. This is to include minimising potential risks to people who are risk of choking, those with continence and stoma support needs and those at risk of skin damage. (d) ensure that all equipment in use to promote people's skin health is detailed in their plans. This is in order1. By February 23 2026 order to ensure that people’s who require support with manage their finances are being supported effectively, the provider must at a minimum: (a) Ensure that all transactions are clearly documented with an explanation of the reason for monies being paid out of people’s funds. (b) Ensure that a full audit of people’s financial support plans is carried out and people's arrangements for accessing their monies are clear. (c) Ensure that all shared living financial arrangements are reviewed. This is to comply with Regulation 4(1)(a) Welfare of Users of the Public Services Reform (Scotland) Act 2010. This is to comply 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. By February 23 2026 to ensure that staff have the right skills and knowledge to meet people's assessed needs the provider must at minimum: (a) ensure that stoma and continence care training is organised for staff supporting people with their stoma and continence needs. (b) ensure that all staff are following best practice guidance when using hair pull release techniques. (c) ensure that all staff have an understanding of promoting people's skin health and factors which contribute to skin damage. (d) ensure that staff are trained in safe wheelchair practice. This is in order to comply with section 8 (1)(a) 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 that: 'I have confidence in people because they are trained, competent and2. By February 23 2026, to ensure that people's staffing arrangements are right for them, the provider must: (a) ensure that all staff providing support to people living with epilepsy have the required training to support them safely. (b) ensure that staffing arrangements are regularly checked so that all people supported have staff with the right skills and knowledge to promote their wellbeing. This is in order to comply with section 8 (1)(a) 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 that: 'My care and support is provided in a planned and safe way, including if there is an emergency or unexpected event' (HSCS 4.14).
1. To promote people's safety and wellbeing staff should consistently follow safe food storage practice. The provider should ensure that all staff have had appropriate training and instruction in food hygiene and safe storage of food and that staff practice is regularly monitored. This is to ensure care and support is consistent with Health and Social Care Standards (HSCS) which state that: 1.24 Any treatment or intervention that I experience is safe and effective.
1. To promote people's safety and wellbeing and minimise stressed behaviours the provider should ensure that incidents are analysed. This is so that factors which may have contributed to people experiencing stress are identified and used to improve the quality of people's support. This is to comply with the Health and Social Care Standards (HSCS) which state that: 'My care and support is provided in a planned and safe way, including if there is an emergency or unexpected event' (HSCS 4.14).
2. To improve the quality of support people experience, the provider should complete recorded observations of staff practice. This is to include observations of how people are supported with their mobility equipment. This is to comply with the Health and Social Care Standards (HSCS) which state that: 'I benefit from a culture of continuous improvement, with the organisation having robust and transparent quality assurance processes' (HSCS 4.19).
3. To promote positive outcomes for people experiencing care the provider should develop a comprehensive service improvement plan which includes learning from adverse events and details actions to be completed with timescales for review. This is to ensure care and support is consistent with Health and Social Care Standards (HSCS) which state that: ‘I benefit from a culture of continuous improvement, with the organisation having robust and transparent quality assurance processes’ (HSCS 4.19).
1. To promote staff learning and development the provider should review the quality of staff supervision and support leaders in further developing their skills in this area. 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. In order to ensure positive outcomes for people, the provider should ensure that care plans reflect how to support people to manage their pain effectively. This should include, but is not limited to, clearly identifying as required medication, what advice may be required, and supporting the person to identify the level of pain they are experiencing. This is to ensure care and support is consistent with Health and Social Care Standards (HSCS) which state that: ‘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).