Caledonia Care Home
Recorded Key Question grade range: 3–4 — Adequate View on Care Inspectorate
Key Question scores
Requirements & recommendations
1. By 29 June 2026, the provider must ensure that people's health and wellbeing needs are met effectively. To achieve this, the provider must, as a minimum: a) Ensure the wider staff team, including, but not limited to trained members of staff, have appropriate oversight and understanding of all aspects of people’s health and welfare needs, so that emerging concerns can be identified and responded to promptly. b) Ensure the management team have effective oversight of all aspects of people’s health and wellbeing needs, to ensure appropriate monitoring of any concerns. c) Ensure improved monitoring and review systems are implemented, to evaluate the effectiveness of interventions and the outcomes achieved for people. d) Ensure all supporting documentation is completed in full, to reflect the care and support provided. This is to comply with Regulation 4(1)(a) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulatio2. By 29 June 2026, the provider must ensure that all records relating to personal care are fully completed. To achieve this, the provider must, as a minimum: a) Ensure all health charts and medication records are kept up to date. b) Ensure these records contain sufficient information to demonstrate and support good practice. This is to comply with Regulation 4(1)(a) 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: “My care and support meets my needs and is right for me.” (HSCS 1.19).
1. By 29 June 2026, the provider must ensure that quality assurance processes are used to inform continuous improvement of the service. In order to do this, the provider must, at a minimum: a) Ensure that identified audits are carried out across the whole service including, but not limited to, medication, environmental cleaning and care planning, in line with providers quality assurance policy. b) Ensure clear, measurable actions plans are in place and progress tracked to ensure ongoing improvement. c) Ensure improvements are communicated to people and staff and these become embedded in practice. This is to comply with Regulation 4(1)(a) 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 benefit from a culture of continuous improvement, with the organisation having robu1. By 29 June 2026, the provider must ensure that people's personal plans and risk assessments contain up to date and essential information, to give staff clear instruction on how to meet their needs safely. In order to do this, the provider must, at a minimum: a) Ensure all personal plans are accurate, detailed and reflect the current assessed needs of people. b) Ensure all risk assessments are accurate, detailed and reflect the current assessed needs of people. c) Ensure appropriate action is taken in response to the needs and concerns identified during the six-monthly review. This is to comply with Regulation 5(1) 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: "My personal plan is right for me because it sets out how my needs are to be met, as well as my wishes and c
1. To ensure people continue to experience activities that are meaningful to them and meet their individual needs, the provider should: a) Ensure activities are offered regularly and frequently to all people living in the service, including those who prefer to spend more time in their bedrooms. b) Ensure personal activity and engagement plans are developed in greater detail, taking account of each person’s abilities, preferences and interests. c) Ensure the impact and benefits of people’s participation are clearly reflected in activity evaluations and six-month reviews. 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 meets my needs and is right for me." (HSCS 1.19).
1. To support people experiencing care to get the most out of life and to offer a sense of purpose and fulfilment, the activities programme should offer increased opportunities for functional and occupational activities, as well as more outdoor and community based options. Positive risk taking that enhances people's quality of life by helping them to maintain skills, abilities and reach their full potential should be promoted. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: 'I get the most out of life because the people and organisation who support and care for me have an enabling attitude and believe in my potential' (HSCS 1.6); and 'I make informed choices and decisions about the risks I take in my daily life and am encouraged to take positive risks which enhance the quality of my life' (HSCS 2.24).
2. Care plans for meaningful activity and engagement should be developed in more detail, taking account of individual abilities and interests with the impact and benefits of participation being clearly reflected in evaluations and six-month reviews. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: 'I can choose to have an active life and participate in a range of recreational, social, creative, physical and learning activities every day, both outdoors and indoors' (HSCS 1.25).
3. Menus should be reviewed in consultation with residents and their families, and should more fully reflect the nutritionally balanced options available daily. Regular mealtime audits should be reintroduced to inform and support consistently positive mealtime experiences for residents. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: 'I can enjoy unhurried snack and mealtimes in as relaxed an atmosphere as possible.' (HSCS 1.35).
1. To enable people to feel empowered and valued, a participation and involvement policy should be devised and implemented in consultation people experiencing care and their families. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: 'I can be meaningfully involved in how the organisations that support and care for me work and develop' (HSCS 4.6); and 'I am actively encouraged to be involved in improving the service I use, in a spirit of genuine partnership' (HSCS 4.7).
2. So that people experiencing care and their families benefit from a culture of continuous improvement, including robust and transparent quality assurance processes, the management team should ensure that the quality assurance framework becomes well established. It should be clear how the systems and processes in place underpin and drive change and improvements that deliver positive outcomes for people using the service and their families. This is to ensure that care and support is consistent 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).
1. In addition to the monthly dependency assessments, the management team should implement the staffing method framework to consider and link the various aspects of workforce and workload planning that deliver positive outcomes for people as well as supporting the wellbeing of staff. Staffing assessments should be shared with residents, families and staff in an open and transparent way. 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 ensure that people are safe and to offer security and safety from avoidable harm, m aintenance checks should be closely monitored as part of the quality assurance framework. This includes the equipment used to meet the needs of residents. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: 'My environment is secure and safe' (HSCS 5.17).
1. To ensure that people using care services benefit from dynamic, innovative and aspirational care and support planning which consistently informs all aspects of the care and support they experience, personal plans should be reviewed to improve recording, including meaningful involvement, anticipatory care planning and outcome focussed evaluations. This is to ensure that care and support is consistent with the 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).