PAK Health Care Solutions

1. To be support service developments and changing needs, the service should strengthen its quality assurance arrangements to promote a culture of continuous quality improvement. This should include, but is not limited to: a) reviewing current quality assurance systems and processes to ensure they are effective and responsive. b) maintaining a clear quality assurance plan that sets out audit activity, actions and outcomes c) ensure the manager to have oversight of improvement actions and can demonstrate that these have been completed and reviewed This is to ensure that care and support is consistent with the Health and Social Care Standards which state "I benefit from a culture of continuous improvement, with the organisation having robust and transparent quality assurance processes. (HSCS 4.19)

1. To ensure people receive safe, consistent, and well-coordinated care and support, the provider should ensure that staff rotas are planned sufficiently in advance and are informed by people’s assessed needs. This should include, but is not limited to: a) Planning rotas further in advance to promote continuity of care and reduce last-minute changes b) Keep people informed of any changes to planned rota schedules. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS), which state: “I have confidence that there are enough people with the right mix of skills to support me safely and effectively” (HSCS 3.15). “If I am supported by a team, this is well coordinated so that I experience continuity” (HSCS 4.17) spa

1. By the 31st March 2026, the provider should ensure a more consistent outcome focused review process be developed that is reflective of the person receiving the support. Details of outcomes and actions agreed through six monthly reviews of personal plans must be evidenced. This would enhance the quality and consistency of support provided. This is to ensure care and support is consistent with the Health and Social Care Standards which state that: 'I am fully involved in assessing my emotional, psychological, social and physical needs at an early stage regularly and when my needs change.' (HSCS 1.12) 'I am assessed by a qualified person, who involves other people and professionals as required.' (HSCS 1.13) 'My personal plan is right for me because it sets out how my needs will be met as well as my choices and wishes.' (HSCS 1.15)

2. By the 31st March 2026, the provider should ensure people are confident they will receive safe, high quality medication support that is provided in line with each person's assessed level of need and that staff adhere to best practice guidance. This should include clear and consistent information about people's assessed support needs in terms of medication, throughout all relevant documentation including care plans, risk assessments and medication administration records (MARs) and by ensuring support with medication (including topical medication) is appropriately and accurately recorded and effectively audited. 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 organ3. By the 31st March 2026, to ensure the service remains responsive to accidents and incidents within the service which may result in significant deterioration in people's health and wellbeing they should review and enact the current guidance regarding statutory notifications to the Care Inspectorate. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which states that: 3.21 'I am protected from harm because people are alert and respond to signs of significant deterioration in my health and wellbeing, that I may be unhappy or may be at risk of harm.'