Action plan

In consultant review
ClientConsultant

30-day plan

Critical and highest-impact actions

  • Create a clear safeguarding oversight record

    Sandra Whitfield · Due 10 Jul 2026

  • Complete and sign off the May medicines audit

    Priya Sharma (Senior) · Due 07 Jul 2026

  • Reinstate quarterly governance meetings

    David Okoye (NI) · Due 14 Jul 2026

  • Update the business continuity plan

    Sandra Whitfield · Due 21 Jul 2026

90-day plan

Follow-on improvements

  • Evidence lessons learned shared with staff

    Grace Adeyemi · Due 18 Jul 2026

  • Clear the overdue audit backlog

    Sandra Whitfield · Due 24 Jul 2026

  • Add learning outcomes to the complaints register

    Grace Adeyemi · Due 31 Jul 2026

  • Refresh MCA & consent training for six staff

    Sandra Whitfield · Due 04 Aug 2026

Critical

3

Create a clear safeguarding oversight record

Not started

Current evidence suggests safeguarding concerns may be recorded, but management oversight and lessons learned are not clearly evidenced. Create a monthly safeguarding oversight log showing concerns, actions, outcomes, themes and learning shared with staff.

Section
Section: Safe
Owner
Owner: Sandra Whitfield
Due
Due: 10 Jul 2026
Evidence
Evidence: Safeguarding oversight log

Consultant insight

This is the single highest-impact action before any inspection.

Complete and sign off the May medicines audit

In progress

The MAR audit lacks documented follow-up actions and manager sign-off. Complete the audit, record corrective actions and date the manager review.

Section
Section: Safe
Owner
Owner: Priya Sharma (Senior)
Due
Due: 07 Jul 2026
Evidence
Evidence: MAR audit with actions

Reinstate quarterly governance meetings

Not started

No governance minutes for Q1 or Q2 were provided. Schedule and minute a governance meeting covering audits, incidents, complaints and learning.

Section
Section: Well-led
Owner
Owner: David Okoye (NI)
Due
Due: 14 Jul 2026
Evidence
Evidence: Governance minutes

Consultant insight

Demonstrates provider oversight — reviewers will look for this.

High priority

3

Update the business continuity plan

In progress

Continuity plan is over 12 months old and does not reflect current staffing or systems.

Section
Section: Safe
Owner
Owner: Sandra Whitfield
Due
Due: 21 Jul 2026
Evidence
Evidence: Business continuity plan

Evidence lessons learned shared with staff

Not started

Show how learning from incidents and complaints is communicated to the team — e.g. team meeting minutes or learning bulletins.

Section
Section: Safe
Owner
Owner: Grace Adeyemi
Due
Due: 18 Jul 2026
Evidence
Evidence: Team meeting minutes

Clear the overdue audit backlog

Not started

Three scheduled audits are overdue (medicines, care plans, infection control). Complete and record outcomes.

Section
Section: Well-led
Owner
Owner: Sandra Whitfield
Due
Due: 24 Jul 2026
Evidence
Evidence: Completed audits

Medium priority

2

Add learning outcomes to the complaints register

Not started

Complaints themes are captured but outcomes and learning are not consistently recorded.

Section
Section: Responsive
Owner
Owner: Grace Adeyemi
Due
Due: 31 Jul 2026
Evidence
Evidence: Complaints register

Refresh MCA & consent training for six staff

Not started

Six staff are outside the 12-month refresher window for Mental Capacity training.

Section
Section: Effective
Owner
Owner: Sandra Whitfield
Due
Due: 04 Aug 2026
Evidence
Evidence: Training certificates

Low priority

1

Tidy policy version control

Not started

Several policies show inconsistent version numbers and review dates.

Section
Section: Policies
Owner
Owner: Grace Adeyemi
Due
Due: 12 Aug 2026
Evidence
Evidence: Policy index