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Conduct an immediate medicines audit across all residents

Review all MAR charts for the past 30 days, remove any expired stock, reconcile discrepancies, and produce a written report for the registered manager.

Implement weekly MAR chart checks by a senior member of staff

Introduce a rolling weekly medicines check completed by a registered nurse or senior carer. Document each check on a standard audit form and retain in the governance file.

Ensure all outstanding safeguarding referrals are submitted to the local authority

Identify any incidents in the past 6 months that may have required a safeguarding referral. Complete and submit outstanding referrals and document the decision-making process for each.

Deliver mandatory safeguarding refresher training to all staff

Book and complete a CQC-recognised safeguarding training course for every member of staff. Ensure training records are updated and retained. Agency staff must be included.

Introduce a medicines competency assessment for all staff who administer medicines

Assess every medicines-trained member of staff against a written competency framework. Those who do not meet the standard should be suspended from administering medicines until reassessed.

Review and update all care plans to reflect current assessed needs

Conduct a structured care plan review for every resident. Ensure each plan includes a current risk assessment, communication preferences, and is signed off by the key worker and resident or their representative.

Complete MCA assessments for all residents who lack or may lack capacity

Identify every resident for whom capacity may be in question. Complete a formal MCA assessment for each, document the outcome, and ensure best interest decisions are recorded in line with the MCA Code of Practice.

Introduce a monthly care plan review cycle

Implement a structured monthly review process for all care plans. Assign each resident a named key worker responsible for initiating the review and updating the plan.

Deliver MCA and DoLS training to all staff

Ensure all staff complete up-to-date MCA and DoLS training. Include practical scenario-based elements. Retain certificates and update the training matrix.

Audit care plan quality on a quarterly basis

Introduce a quarterly care plan quality audit completed by the registered manager or deputy. Results to be discussed at governance meetings and documented.

Deliver dignity and respect training to all care staff

Implement mandatory dignity in care training for every care worker. Include scenarios specific to personal care routines. Evidence completion on the training matrix.

Establish a structured process for involving relatives in care planning

Introduce a six-monthly care review meeting for each resident that includes the resident, a family member or representative where appropriate, and the key worker. Document each meeting.

Introduce a dignity champion role within the staff team

Identify and appoint a member of staff as Dignity Champion. Provide additional training and create a role description. The Dignity Champion should lead monthly reflective practice sessions with the team.

Conduct quarterly resident and relative satisfaction surveys

Implement a structured quarterly survey for residents and relatives. Analyse results, share findings with residents at house meetings, and document any actions taken in response.

Acknowledge and investigate all outstanding complaints immediately

Contact all complainants whose complaints have not been acknowledged. Issue written acknowledgements within 48 hours. Appoint an investigator for each complaint and set a response deadline of no more than 28 days.

Implement a compliant complaints policy and procedure

Review and update the complaints policy in line with CQC guidance. Ensure it includes timescales, who to contact, the right to refer to the Local Government and Social Care Ombudsman, and is accessible to residents and relatives.

Introduce a formal incident reporting and learning system

Implement a written incident reporting form and log. All incidents must be reported within 24 hours, investigated by a senior member of staff, and discussed at the next team meeting.

Create a monthly complaints and compliments log for governance review

Record all complaints, concerns, and compliments received each month. Present a summary at the monthly governance meeting. Identify themes and document improvement actions.

Introduce quarterly learning from incidents reports

Produce a quarterly report summarising all incidents, complaints, and near misses. Identify patterns, document learning, and share outcomes with staff at team meetings.

Establish a monthly governance meeting with a formal agenda and action log

Schedule and hold a monthly governance meeting attended by the registered manager, deputy, and senior staff. The agenda must include: complaints, incidents, audits, staffing, training, and CQC compliance. Produce written minutes with named action owners.

Implement a rolling audit schedule covering all key risk areas

Create a 12-month audit calendar covering: medicines, care plans, infection control, H&S, fire safety, and MCA. Assign each audit to a named member of staff. Ensure audit outcomes are recorded and acted upon.

Produce and submit a written improvement plan to CQC

Draft a formal improvement plan addressing each concern raised in the inspection report. The plan must include named action owners, timescales, and measurable outcomes. Submit to CQC within 28 days of the inspection report date.

Conduct a full staffing review and address identified gaps

Review current staffing levels against dependency tool scores and minimum safe staffing guidance. Identify gaps and implement a recruitment or agency cover plan immediately. Document the review and any actions taken.

Introduce an annual staff survey and respond to findings

Design and distribute an anonymous staff survey covering: workload, management support, training, communication, and morale. Analyse results, share a summary with staff, and produce an action plan in response.

Establish a quality assurance dashboard reviewed at each governance meeting

Create a single-page dashboard summarising: audit completion rates, complaint numbers, incident rates, training compliance, and staffing fill rate. Review at every governance meeting and retain as evidence of oversight.