Governance pack
Preview built from the live record — export arrives in the production stage
Pack configuration
Scope, period and sections
Northstar Care Group
Safety, quality and risk report · 01–30 September 2026 · compared with August 2026
Prepared from the records held in SiteIQ Safe. Demonstration data.
Executive summary
Northstar Care Group recorded three serious incidents during September, with one investigation remaining open at period end. Overall inspection completion improved, although Riverside Campus remains below target.
High-priority action backlog increased from 12 to 17, driven primarily by facilities actions at Riverside Campus. Two risks increased in residual rating during the period and require management attention.
Complaint handling remained within response timescales apart from one overdue response. Learning recorded in period is concentrated on communication with families and on housekeeping standards in shared circulation areas.
Management attention
- OverdueACT-2026-0415 — Review cleaning schedule and wet-floor protocol6 days overdue
- OverdueACT-2026-0418 — Add rear entrance to weekly premises checkOverdue
- OverdueACT-2026-0421 — Replace medication fridge thermometer10 days overdue
- OverdueACT-2026-0431 — Clear East Wing corridor and add to weekly housekeeping check1 days overdue
- Review requiredINC-2026-0148 — Slip at rear entranceHSA review due in 3 days
- Review requiredINC-2026-0148 — Slip at rear entranceHIQA review overdue
- Review requiredINC-2026-0153 — Restricted record — detail withheldHIQA review overdue
- Review requiredINC-2026-0147 — Medication storage issueHIQA review overdue
Incident summary
- Incidents recorded7
- Serious incidents open4
- Awaiting investigation0
- Closed in period1
- INC-2026-0153 — Restricted record — detail withheld · Meadow House · High
- INC-2026-0147 — Medication storage issue · Oakview Residential · High
- INC-2026-0145 — Service user fall in day room · Harbour Day Services · High
- INC-2026-0139 — Safeguarding concern raised by family · Greenfield Centre · Critical
Inspection performance
- Inspections in period5
- Completed2
- Overdue3
- Sites affected by overdue3
Findings
- Findings raised4
- Open3
- Awaiting verification1
- Closed1
Actions / CAPA
- Actions open10
- Overdue high priority4
- Completed, awaiting verification2
- Verified effective2
- 0–7 days since completion: 2
- 8–14 days since completion: 0
- 15+ days since completion: 0
Risk
- Risks on register5
- High or extreme residual2
- Reviews overdue1
- Review recommended1
- RISK-0074 — Legionella in low-use water outlets · residual High · next review 05 Nov 2026
- RISK-0088 — Medication administration errors during shift handover · residual High · next review 12 Sep 2026
Complaints and feedback
- Records in period5
- Open4
- Responses overdue0
- Closed1
Regulatory reviews
- INC-2026-0148 — Slip at rear entrance · HSA · due 10 working days · by 18 September 2026
- INC-2026-0148 — Slip at rear entrance · HIQA · due Assessed 04 September 2026
- INC-2026-0153 — Restricted record — detail withheld · HIQA · due 3 working days · by 08 September 2026
- INC-2026-0147 — Medication storage issue · HIQA · due Assess by 09 September 2026
- INC-2026-0145 — Service user fall in day room · HIQA · due 3 working days · by 07 September 2026
Advisory only. Reportability decisions remain with the responsible manager.
Recurring themes
- Communication — 5 records across 5 sites (1 incidents, 0 findings, 4 complaints)
- Slip / trip — 3 records across 2 sites (2 incidents, 1 findings, 0 complaints)
- Equipment — 2 records across 1 site (0 incidents, 2 findings, 0 complaints)
- Housekeeping — 2 records across 2 sites (2 incidents, 0 findings, 0 complaints)
Site comparison
| Site | Incidents | High risks | Overdue actions | Completion | Status |
|---|---|---|---|---|---|
| Riverside Campus | 1 | 0 | 4 | 100% | Attention required |
| Oakview Residential | 1 | 0 | 2 | 100% | Monitor |
| Meadow House | 2 | 1 | 0 | 0% | Attention required |
| Harbour Day Services | 1 | 0 | 0 | 0% | Attention required |
| Greenfield Centre | 1 | 0 | 0 | 0% | Attention required |
| Cedar Lodge | 0 | 1 | 0 | 100% | Monitor |
Governance decisions
- GOV-DEC-012 — Request facilities resourcing review · Request Further Review · James Wilson, 29 Aug 2026 (GOV-2026-008)
- GOV-DEC-013 — Accept residual rating for vehicle and pedestrian risk · Accept · James Wilson, 29 Aug 2026 (GOV-2026-008)
Actions arising from governance
- ACT-2026-0405 — Refresh safeguarding briefing for the governance review · Emma Clarke · due 30 Sep · In Progress · verification Pending
Learning
- Communication — Proactive family updates during an overnight transfer removed the need for the family to chase for information. (CMP-2026-0061)
- Procedure — Agency induction did not cover personal clothing labelling. (CMP-2026-0052)