Stobhill Nursing Home

1. By 28 June 2026 , people must be supported to experience care and support that is safe and right for them. To do this the provider must ensure that; a) Accurate assessment of individuals’ physical and mental health needs are regularly completed. This must include, but is not limited to - risk of falls, nutritional needs, continence/ skin care needs, covert medication and stress and distress b) Records used to evaluate people’s health and wellbeing are improved. This should include but is not limited to food an fluid intake records. This information must be used to evaluate the effectiveness of interventions at regular intervals throughout the day and direct staff on how to support people. This is to comply with Regulation 4(1)(a) and Regulation 5(b) (i)(ii) and (iii) of The Social Care and Social Work Improvement Scotland( Requirements for Care Services) Regulations 2011. This is to ensure that people's health benefits from their care and support and takes account of1. By 23 January 2026 the provider must ensure people are safe, risk is reduced and people receive quality care and support that meets their needs. To do this, the provider must, at a minimum: a) Ensure audits are consistently completed b) Ensure audit tools in use are robust to more fully identify improvement and reduce risk c) Ensure plans are in place to action and complete issues identified in the audit process d) Ensure strong management oversight of the quality assurance processes. 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. 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 systems". (HSCS 4.19). Th2. By 6 August 2026 you, the provider must ensure people are kept safe and their health and wellbeing are promoted, by the service having robust communication and reporting systems. This must include, but is not limited to: a) Ensure all staff recognise and escalate incidences of harm or potential harm to ensure appropriate follow up; b) Submit timely notifications to the Care Inspectorate in accordance with guidance entitled: 'Adult Care Services: Guidance on records you must keep and notifications you must make’. This is in order to comply with regulations 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 use a service and organisation that are well led and managed' (HSCS 4.23).

1. By 6 August 2026, the provider must ensure service users’ holistic needs are accurately assessed, documented and effectively communicated between all relevant staff and met. To do this the provider must, at a minimum ensure that: a) Personal plans are implemented, and care is delivered in accordance with the assessed needs and preferences of each individual service user b) Improved evaluation of the effectiveness of care interventions and the outcomes used to direct staff on how to support people c) Daily recordings fully reflect individuals experiences over the 24-hour period. This is to comply with Regulations 4(1)(a) (Welfare of Users) and 5 (Personal Plans) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210). This is to ensure 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. By 23 January 2026 to promote the safety, health and wellbeing of people the provider must ensure staff receive essential training for their role and responsibilities. To do this the provider must at a minimum: a) Ensure all staff receive IDDSI training and have their competency assessed. b) Ensure improved presentation of modified meals. c) Have robust auditing processes in place to ensure people are receiving the correct diet. d) Ensure all records relating to nutrition and hydration are consistently and timeously completed and take swift corrective action where needed. e) Ensure all records relating to personal care are accurate and take swift corrective action when needed This is to comply with Regulation 4(1)(a) and (b) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 and Section 8 (a) of the Health and Care (Staffing) (Scotland) Act 2019. As a minimum the provider must: a) Establish written procedures for identifying, documenting, and returning unused, expired, or discontinued medications to the pharmacy. b) Through monitoring processes ensure staff competency in understanding and implementation of best practice guidance for returns medications. This is to comply with Regulation 4(1)(a) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011. 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) and "I have confidence in people because they are trained, competent and skilled, are able to reflect on their practic3. By 23 January 2026 to promote people’s rights and ensure positive outcomes for people in line with their choices and wishes, the provider must clearly demonstrate collaborative decision-making. To do this, the provider must, at a minimum: a) Have in place a locked door policy aligned to Mental Welfare Commission (2021) best practice guidance "Rights, risks and limits to freedom" b) Ensure robust risk assessments are in place in relation to people’s rights to protection from potential restraint. c) Evidence collaborative decision making with relevant stakeholders, or people's representatives when legal powers are in place. This is to comply with Regulation 4(1)(a)(b)(c) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: "I experien1. By 23 January 2026 the provider must ensure people are safe, risk is reduced and people receive quality care and support that meets their needs. To do this, the provider must, at a minimum : a) Ensure audits are consistently completed. b) Ensure audit tools in use are robust to more fully identify improvement and reduce risk. c) Ensure plans are in place to action and complete issues identified in the audit process. d) Ensure strong management oversight of the quality assurance processes. 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 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 systems".1. By 23 January 2026 the provider must ensure that information in personal plans is up-to-date and sets out the health, welfare and safety to meet people's needs. To do this, the provider must, at a minimum: a) Ensure personal plans are updated when a person’s needs change and this is consistently evidenced throughout the plan. b) Ensure all appropriate care plans are in place and reviewed regularly. c) Ensure information which no longer reflects people’s needs is removed and archived. d) Ensure the auditing of personal plans is robust and objective. e) Ensure personal plans six monthly reviews include focused future outcomes for people. This is to comply with Regulation 5(2)(a) (b) (c) of the Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011. This is to ensure that care and support is consistent with the Health and Social Care Standar

1. By 2 December 2025 to promote people's wellbeing and reduce the risk of choking while respecting peoples’ right to food choice, the provider must, as a minimum: a) Serve food and drink in line with individual assessments, as outlined by the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. b) Ensure all staff involved in food preparation and food serving receive training in IDDSI framework levels of modification and choking risks. c) Regularly audit meals to confirm texture matches prescriptions and adjust practices as needed. d) Provide at least two options per meal, including for those on modified diets. This is to comply with Regulation 4(1)(a) and (b) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 and Section 8 (a) of the Health and Care (Staffing) (Scotland) Act 2019. This is to ensure that care and support is consistent with th2. By 2 December 2025 to ensure people’s wellbeing and comply with best practice for managing returned medication the provider must, as a minimum: a) Ensure appropriate oversight of medication ordering and maintain adequate stock for people living in the service. b) Develop and follow written protocols for ordering, reordering, and checking stock levels. c) Establish written procedures for identifying, documenting, and returning unused, expired, or discontinued medications to the pharmacy. d) To support audit trails and accountability, log all returned medications with details including but not limited to, the person’s name, medication name, reason for return, and date. e) Store returned medications in a locked, clearly labelled container separate from active stock until collection or disposal. f) Provide training for all staff involved in medication handling on the returns medication protoc1. By 2 December 2025 the provider must ensure people are safe, risk is reduced and people receive quality care and support that meets their needs. To do this, the provider must, at a minimum: a) Develop a dynamic service improvement plan that is informed through quality assurance activities and feedback from people. b) Ensure that systems of quality assurance and audits are consistently completed. c) Ensure detailed actions are addressed timeously through action plans. d) Develop an overview of all significant events and a comprehensive analysis of all accident, incidents and such events. e) Include an evaluation of progress made. 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 . This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state tha1. By 2 December 2025 the provider must ensure people’s preferences are respected and staff are supported to confidently deliver care. To do this, the provider must, at a minimum: a) Routinely assess rotas to ensure a mix of male and female staff is present, reflecting the preferences and needs of the people receiving care. b) Provide regular supervision in line with the provider's policy. c) Ensure all staff are provided with appropriate training, regular competency assessments and personal development opportunities. d) Ensure there is a comprehensive overview of staff training attendance. This is to comply with Regulation 4 (1)(a) and (b) of the Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 and Section 7(1) and 8(1)(a) of Health and Care (Staffing) (Scotland) Act 2019. This is to ensure that care and support is consistent with the Health and Social Care Sta1. By 2 December 2025 the provider to ensure the safety of people, visitors, and staff. To do this, the provider must, at a minimum: a) Develop and maintain a documented timetable for daily, weekly, monthly, and annual checks covering all areas of the premises. b) Conduct regular and timely environmental safety checks. c) Log all checks with dates, findings, and actions taken. d) Address identified risks promptly and record actions taken. This is to comply with Regulation 4 (1)(a) and Regulation 10(2)(b) of the Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011. 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. By 2 December 2025 the provider must ensure that information in care plans is up-to-date and accessible and sets out the health, welfare and safety to meet people's needs. To do this, the provider must, at a minimum: a) Identify where information can be streamlined and take action to carry this out. b) Ensure a review of the care plan is carried out at least every six months, or if there is a significant change. This is to comply with Regulation 5(2)(a) (b) (c) of the Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011. 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).