All staff use PASS to record visit notes including the health and wellbeing of SU.  In addition any issues outwith the norm are reported to the office who log this in the Daily Log. The log is audited daily and actions identified to redress any concerns.  Where a concern is notifiable then the Care inspectorate, Social Care Direct or Next of Kin are informed.

Additionally, monthly audits apply a weighting to SU needs which can predict whether needs are increasing, decreasing or remain unchanged despite interventions. The weighting is used to evidence change, evaluate interventions, plan support, review packages of care and raise awareness of potential future concerns with all parties in advance.

Stephen continues to collate, analyse and and share the findings of the monthly data analysis with the team.  In turn they use this to adjust support plans and to request changes from Social Care Direct.

Stephen continues to collate, analyse and and share the findings of the monthly data analysis with the team. In turn they use this to adjust support plans and to request changes from Social Care Direct. Stephen has raised his concerns over the delays experienced by service users in EHSCP responding to package of change requests.

Stephen continues to collate, analyse and and share the findings of the monthly data analysis with the team. In turn they use this to adjust support plans and to request changes from Social Care Direct. Stephen has raised his concerns over the delays experienced by service users in EHSCP responding to package of change requests. This Goal is marked Completed, although the analysis will continue monthly hereafter.

Social Care Alba (SCA) refers any concerns about a SU’s wellbeing to the appropriate healthcare professional immediately. Within this extended multi-disciplinary team we can share and access training, knowledge and best practise.

Using the analysis of the data collected we are better able to support our requests to other professionals.  For example, the data has been used to request pressure relieving equipment, referrals to the falls clinic, medication reviews  and more.

Using the analysis of the data collected we are better able to support our requests to other professionals. For example, 159 requests over the past 90 days have been triggered. This included requests for pressure relieving equipment, referrals to the falls clinic, medication reviews, increases to packages of care, adult protection concerns, housekeeping, deep cleaning of properties, security concerns, fire safety, nutritional concerns, physiotherapy referrals, CAS equipment, moving & assisting equipment and more.

Using the analysis of the data collected we are better able to support our requests to other professionals. Requests for pressure relieving equipment, referrals to the falls clinic, medication reviews, increases to packages of care, adult protection concerns, housekeeping, deep cleaning of properties, security concerns, fire safety, nutritional concerns, physiotherapy referrals, CAS equipment, moving & assisting equipment and more continue to be made on behalf of those we support.

Stephen provided Edinburgh Council with an analysis of the data collected in the first 2 quarters of 2025. In September he raised concerns about the response time to referrals such to professionals such as OT, Physio and the falls team. In addtion he made suggestions for improvements which would positively impact all service users across the city. Edinburgh is due to expand their trial of new assessment paperwork across the city, with the aim of providing better information on new referrals.

Going forward we will also record the time taken with this additional support as it is not currently reflected in the time spend during visits.

SCA conducts an environmental assessment for all new SU where any trip hazards are identified. Where a fall has occurred an accident form is completed and a notification made to the Care Inspectorate and/or Social Care Direct and the next of kin.

Where this is deemed to be progressive a falls risk assessment is completed and a referral made to the falls clinic for advice. We continue to monitor the occurrence of falls and if interventions from SCA or others help reduce the frequency.

SCA recommends SU and families use CAS alarms, fall detectors and PIR lighting.

New falls assessments have been created for all those we support.  Where indicated a referral has been made to either to investigate ways to prevent or reduce future falls.  

Falls outside of visit times remains a significant event. The percentage of alerts due to falls remains unchanged over the preceding quarter at around 16%. Whilst referrals to Social Care Direct have been made by SCA immediately, delays in processing the referrals by EHSCP has meant that no changes to people’s packages of support have been made. Stephen has raised his concerns over these delays to senior management within EHSCP.

Falls outside of visit times remains a significant event., with alerts due to falls in Q1 being 18.2 %, rising to 20.7% in Q2. The reasons for falls can include, social work reduction in the size of people’s packages or care. Incorrect or lack of mobility equipment. Discharges from hospital without a home assessment. A general deterioration in people’s overall health. Whilst referrals to Social Care Direct have been made by SCA immediately, delays in processing the referrals by EHSCP has meant that no changes to people’s packages of support have been made. Stephen has raised his concerns over these delays to senior management within EHSCP and continues to pursue these referrals.

From 11th August 25, requests for falls alarms are now to be submitted via THIS LINK.  The change to an online form by Edinburgh Council was made to speed up the process, with the form going directly to ATEC24.

ATEC24 says: In terms of a standard alarm unit and pendant – there are no criteria. We look to improve independence, improve confidence, offer reassurance, reduce isolation, support hospital discharge and reduce hospital admissions and therefore if someone asks for the alarm unit, we can provide it. The criteria only really starts to apply when referrers are asking for additional technologies such as door alarms or pressure mats.

Going forward we will also record the time taken with this additional support as it is not currently reflected in the time spend during visits.

SCA refers any concerns about a SU’s wellbeing to the appropriate healthcare professional immediately. Within this extended multi-disciplinary team we can share and access training, knowledge and best practise. Most commonly these are due to breathlessness, skin or urinary tract infections.

Preventative measures include promotion of regular vaccinations and good infection control procedures for staff, SU and their families.  Advice on these can be found on our SU/Family and staff websites.

As predicted the winter brought with it an increase in viral infections across Scotland.  SCA ensured those exhibiting early signs of breathlessness were referred to their GP or NHS 24 immediately.

Breathing difficulties remain unchanged at around 3.5% of alerts during the past quarter.  SCA continues to ensure those exhibiting early signs of breathlessness were referred to their GP or NHS 24 immediately.  Smoking has been identified as a  contributing factor in some of these cases.  NHS Lothian provides support for those wishing to stop smoking via this link.

As winter approaches SCA has published guidance on Winter Flu and Covid 19 Vaccinations. we have offered support to all those we support to access vaccinations should they wish. To date 85% have had or plan to have a vaccination with 15% opting out this year. Going forward we will also record the time taken with this additional support as it is not currently reflected in the time spend during visits.

SCA refers any concerns about a SU’s wellbeing to the appropriate healthcare professional immediately e.g. District Nurse or GP. A Waterlow and MUST assessment is made for those where skin integrity is a concern.

This may result in requests for equipment such as pressure cushions and mattresses. Regular training is offered to staff, SU and their families. Advice on this can be found on our SU/Family and staff websites.

New Tissue Viability and Nutritional assessments have been created for all those we support.  Where indicated a referral has been made to prevent the development of pressure sores through the provision of pressure relieving equipment.  SCA has worked closely with the District Nursing and G.P. service to support those most at risk.

Events related to skin care have reduced from 8.4% to 7.7% in the past quarter. New Skin Care and Nutrition Tasks have been created which mirror the best practise statements with the Tissue Viability and Nutritional Assessment. SCA has worked closely with the District Nursing and G.P. service to support those most at risk. Referrals continue to be made to prevent the development of pressure sores through the provision of pressure relieving equipment.

Events related to skin care have reduced from 10.9%in Q1 to 8.5% in Q2. New Skin Care and Nutrition Tasks which mirror the best practise statements with the Tissue Viability and Nutritional Assessment have made an impact. SCA has worked closely with the District Nursing and G.P. service to support those most at risk. Referrals continue to be made to prevent the development of pressure sores through the provision of pressure relieving equipment. Although skin conditions continue to arise, these figures include, redness and cuts from falls, trips or bumps. Service users and families ultimately have the right to refuse pressure relieving equipment, and take risks within their own home or outside.

Stephen shared the data of events related to skin care with Edinburgh Council, which have remained static over the last quarter. SCA continues to work closely with the District Nursing and G.P. service to support those most at risk. Referrals continue to be made to prevent the development of pressure sores through the provision of pressure relieving equipment. Figures include, redness and cuts from falls, trips or bumps. Service users and families ultimately have the right to refuse pressure relieving equipment, and take risks within their own home or outside.

Going forward we will also record the time taken with this additional support as it is not currently reflected in the time spend during visits.

SCA refers any mobility concerns to the appropriate healthcare professional such as a GP, Physio or Occupational Therapist. This may result in exercises to build strength, flexibility and coordination being prescribed.

Where SCA is requested to deliver these exercises then a review of the support package will be required. Often aids can be used to maintain independence, which are the responsibility of occupational therapy. Details on support groups for people with Arthritis can be found on our website.

SCA continues to make referral to occupational and physiotherapy with the permission of those we support.  This has helped improve peoples’ mobility, providing much needed equipment such as walking aids.  In some cases packages of support have needed to increase for 1 carer to 2 to safely support peoples’ needs.  In all cases SCA has accommodated these changes.   When support changes, it may impact others visiting times, as changes to runs are often required, we appreciate your understanding.

Events related to mobility have risen from 4.9% to 7.1% over the past quarter, reflecting the increasing complexity of people’s needs.  SCA continues to make referrals to Social Care Direct, occupational and physiotherapy with the permission of those we support.  However, delays in assessments and requested increases in packages of care have significantly impacted service users.  EHSCP is aware of this and we hope to have feedback from them shortly.

When support changes are required, it may impact others visiting times, as changes to runs are often required, we appreciate your understanding.

Events related to mobility have risen from 5.5% in Q1 to 12.2% in Q2, reflecting the increasing complexity of people’s needs.  SCA continues to make referrals to Social Care Direct, occupational and physiotherapy with the permission of those we support.  However, delays in assessments and requested increases in packages of care have significantly impacted service users.  EHSCP is aware of this and we hope to have feedback from them shortly.

As we support people to live in their own homes, mobility is often an ongoing concern. When support changes are required, it may impact others visiting times, as changes to runs are often required, we appreciate your understanding.

Stephen shared the data of events related to mobility with Edinburgh Council, which have remained static over the last quarter. This reflects the increasing complexity of people’s needs.  SCA continues to make referrals to Social Care Direct, occupational and physiotherapy with the permission of those we support.  Delays in assessments and requested increases in packages of care have reduced over the past 2 months, although some remain outstanding for several weeks. EHSCP is aware of this and are working to reduce the backlog.

As we support people to live in their own homes, mobility is often an ongoing concern. When support changes are required, it may impact others visiting times, as changes to runs are often required, we appreciate your understanding.

Going forward we will also record the time taken with this additional support as it is not currently reflected in the time spend during visits.

SCA has taken the following actions to promote continence.  

Training

We deliver continence promotion training to staff which is open to SU and their families on a regular basis. Training workshops dates are posted on our website in advance.

Continence Assessment

We conduct thorough, person-centred assessments to identify underlying issues such as medication side effects, dietary factors, or mobility challenges.

Hydration and Diet

Educate staff, service users and families about the importance of hydration and a fibre-rich diet to support bladder and bowel health.

Timed Voiding Schedules

We aim to maintain visit times to promote toilet routines to support users in re-establishing predictable patterns.

Access to Specialist Equipment

We assist in requesting raised toilet seats, commodes, or grab rails to make toileting safer and more accessible.

Professional Support

Work with continence advisors or physiotherapists to tailor interventions.

SCA continues to post open training workshops which families or those supporting you can attend.  If you require any special adjustments to facilitate this please let the office know.

Events related to continence have risen from 2.2% to 3.9% over the past quarter. This may be due to the need for additional support visits, a change in continence aids or equipment within the home. Often those with progressive health conditions such as dementia require simple solutions such as night lights within their toilet.  Where a change to a package of care is required SCA has quickly requested this.

We continue to post open continence training workshops which families or those supporting you can attend.  If you require any special adjustments to facilitate attending these workshops please let the office know.

Events related to continence remained stable at 7.3 in Q1 and Q2. We continue to post open continence training workshops which families or those supporting you can attend.  If you require any special adjustments to facilitate attending these workshops please let the office know.

SCA continues to support people with referrals to the Bladder and Bowel Nurse Team in Edinburgh. Going forward we will also record the time taken with this additional support as it is not currently reflected in the time spend during visits.

SCA makes feedback easy through Spot Checks, Visit Feedback, Service Reviews, Open Training Days, Open social events, OpenPASS, phone, email or online feedback amongst others. This allows us to work together to tailor the support plan and package to better meet peoples needs.

EHSCP has cut package sizes and it is important to be aware that whilst we may wish to provide more support, this may not be possible if EHSCP does not agree to support this.

SCA conducted 82 reviews in the previous 90 days where we sought feedback from those we support and their families.

SCA conducted 128 reviews or spot checks in the previous 90 days where we sought feedback from those we support and their families.

In Q1, SCA received 237 positive comments feedback from service users and families.  This included reviews at week 1, week 6 and 6 monthly, as well as Spot Checks.  78 requests were made of which only 5 were unable to be fulfilled immediately.

In Q2 we received 275 positive comments. 11 General Requests were made, all of which were fulfilled.  32 Requests for visit time changes were submitted, of which we were able to fullfill the vast majority.  25 Other Actions were recorded relating to continence, medication, tissue viability, etc which would improve the lives of those we support.  

In Q3 we received significant numbers of Visit Change Requests (VCR) the majority of which we were able to accommodate. We continue to undertake week 1, week 6, 6 monthly reviews as well as Spot Checks and eMAR Audits to name just a few. Going forward we will also record the time taken with this additional support as it is not currently reflected in the time spend during visits.

SCA runs several types of training workshops on a monthly basis, including but not limited to Stress & Distress, Medication Management, Convenience Promotion and Dementia Awareness. In addition online courses are available in over 50 different areas.

Courses are open to SU and their families and we regularly post online resources for those wishing to improve their understanding of particular conditions such as through the SSSC Learning Zone.

By Aug 2025, all staff and service users have been involved in the Risk Analysis which we publish monthly. Additionally, service users and their families have this recorded at review, with details of what has triggered the Risk Score. For clarity, predictive Support is:

PREDICTIVE SUPPORT

SCA records all events outside of normal support delivery in the Daily Log.  We review and categorise these monthly to identify those areas where additional intervention has been required.  

Examples of these includes, access issues, breathing difficulties, behaviour outwith the norm such as confusion, continence, falls, hospitalisation, medication, reduced mobility and skin conditions. 

RiSK SCORE:  This is numerical value based upon the total number of events recorded during the course of the month.  Together we can use this information to identify:

• If additional support is required
• If a review of medication levels is appropriate
• A pattern of improvement or decline
• A referral to another professional would be beneficial

Staff are trained in recognising the signs of pain, particularly in those who may be unable to voice their distress through cognitive impairment or communication difficulties. Any changes in a person’s wellbeing are reported to the GP whose responsibility it is to assess and manage pain. SCA will follow the GP’s or other professionals guidance, which may include medication or gentle exercises.

SCA will monitor the effectiveness of these interventions and report the outcome back to the SU family or medical professional. Occupation aids, pressure reliving equipment, medication assessments may form part of the pain management plan.  Ongoing pain may result in referral to a pain management clinic via the GP.

A review of all prescribed medications ensured that all service users who experience acute or chronic pain have a suitable pain management in place. Where breakthrough pain exists, SCA has ensured the service user’s G.P. is aware of this and remedial action is taken. As pain management is an individual and ongoing need, we have marked this Goal as Ongoing. SCA shall continue to monitor this at spot checks, reviews and medication audits.

A review of all prescribed medications ensured that all service users who experience acute or chronic pain have a suitable pain management in place. Where breakthrough pain exists, SCA has ensured the service user’s G.P. is aware of this and remedial action is taken. As pain management is an individual and ongoing need, we have marked this Goal as Ongoing. SCA shall continue to monitor this at spot checks, reviews and medication audits.

Going forward we will also record the time taken with this additional support as it is not currently reflected in the time spend during visits.