Shona Care Ltd
Recorded Key Question grade range: 3–4 — Adequate View on Care Inspectorate
Key Question scores
Requirements & recommendations
1. By 26 June 2026, the provider must, in line with legislation and guidance, ensure a consistent and effective approach to identifying and reporting adult protection concerns to protect adults from harm. To do this the provider must at a minimum: a) ensure that all events that require to be reported as an adult protection concern are appropriately identified and escalated to the appropriate agencies in a timely manner. b) ensure staff understand their responsibilities in relation to adult protection concern reporting. c) ensure that information contained within notifications to the Care Inspectorate is sufficiently detailed to support effective regulatory oversight. 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
1. To support people’s wellbeing, the provider should ensure the service continue to promote accurate time keeping and transparent recording of this. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: “I am supported and cared for by people I know so that I experience consistency and continuity.”(HSCS 4.16).
1. Observations of practice should include more detailed descriptions of staff actions, with opportunities for reflective input from managers, staff, and people experiencing care. 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 26 September 2025, the provider must ensure that people experience a service which is responsive to their health and wellbeing and promotes best practice. To do this the provider must, at a minimum. a. Improve the consistency of staff and timings of visits. b. Ensure daily notes are detailed and an accurate reflection of the care and support provided. c. Staff are knowledgeable and follow the service’s health and safety, and infection prevention and control policies. This is to comply with Regulation 3 and 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: ‘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. By 26 September 2025, the provider must ensure the service is well-led and promotes best practice by: a. Implementing a quality assurance system to monitor key service areas. b. Conducting and recording regular staff observations with appropriate follow-up. c. Using feedback from people, families, staff, and external agencies to inform the improvement plan. d. Ensuring all notifiable events are reported to the relevant statutory bodies and stakeholders. This is to comply with Regulation 3 and 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 which state that: “I benefit from a culture of continuous improvement, with the organisation having robust and transparent quality assurance processes”. (4.19)
1. By 26 September 2025, the provider must ensure that they have a clear oversite of staffing arrangements. To achieve this, the provider must, at a minimum:
Develop an improved staff rota system and process to monitor staffing arrangements. This is to comply with Regulation 7 of the Health and Care (Staffing) (Scotland) Act 2019 (HCSSA). This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state: “My needs are met by the right number of people.” (HSCS 3.15)
1. By 26 September 2025, the provider must ensure that each service user has a detailed personal plan outlining how their health, safety and welfare needs will be met. Plans must be reviewed at least every six months or following any significant change. To achieve this, the provider must ensure: a. Relevant risk assessments are in place to inform personal planning. b. Actions from reviews are clearly documented and any changes reflected in personal plans. Review records must include who has been part of the review. c. Audits are undertaken to ensure the quality and consistency of personal plans. This is to comply with Regulation 5 (1) and (2) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210). This is also 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)
1. To support people’s wellbeing, the provider should ensure staff have opportunity to keep up-to-date with training which should include refresher training relevant to their role. 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).