Lisden
Recorded Key Question grade range: 2–3 — Weak View on Care Inspectorate
Key Question scores
Requirements & recommendations
1. By 15 June 2026, the provider must ensure that the care service is led and managed in a manner that results in people's health, safety, and wellbeing needs being met. In order to achieve this you must: a) Establish and clarify the roles and responsibilities of all staff providing leadership and/or care across the service and ensure this is shared and understood by all staff. b) Establish clear communication processes and systems to share information about people's current or changing needs on a daily basis. This should include, but is not limited to, wound care, falls, nutrition, infections, and medication. c) Establish clear clinical oversight in relation to care planning and delivery of treatment and care. This may include, but is not limited to, observation of people's care experiences, observation of staff practice and communication, and regular review/audit of care plans, daily notes, and records.
1. By 15 June 2026, the provider must ensure that quality assurance systems are robust and used consistently to ensure that the health, safety, and wellbeing requirements of people receiving care are met and that they experience positive outcomes. To do this, the provider must, at a minimum: a) Ensure that all staff understand their roles and responsibilities in relation to quality assurance. b) That audits and checks are used consistently which enable the quality of the service to be monitored and which impact directly on improving outcomes for people. c) Ensure any identified areas for improvement are addressed without delay. d) Ensure there is always appropriate and effective leadership of the service. e) Ensure that concerns and complaints are clearly recorded, actions identified and feedback provided to relevant people. This is in order to comply with Regulation 4(1)(a) (Welfare of users); and Regulation 10(2)(a), (b), and (d) (Fitness of premises) of The Social Care1. By 15 June 2026, the provider must ensure that, at all times, the number of staff working in the care service is appropriate to support the health, wellbeing, and safety of service users and the provision of safe and high-quality care. To do this, the provider must, at a minimum: a) Ensure their overall assessment of staffing takes account of the building layout and aggregated information of the physical, social, psychological and recreational needs and choices in relation to the delivery of care for all service users. b) Ensure that staff are following policies and procedures and that practice reflects the training provided to ensure people's needs are being met safely. c) Ensure staff are visible and available to ensure that people receive the care and support they need or wish timeously. This is to comply with: Section 7(1)(a)(b)(c) of the Health and Care (Staffing) (Scotland) Act 2019. This is to ensure that care and support is consistent with the Health and Soci1. By 15 June 2026, to ensure that people experience an environment that is safe and well maintained, and that meets their needs, the provider must ensure that people can access both showering and assisted bathing facilities. This should include the repair or replacement of the bath that is out of order. This is to comply with Regulation 10(2)(a) and (b) (Fitness of premises) of The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210). This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS), which state that: 'I experience an environment that is well looked after with clean, tidy, and well maintained premises, furnishings, and equipment' (HSCS 5.22) and; ‘As an adult living in a care home, I have ensuite facilities with a shower and can choose to use a bath if I want. If I live in a small care home that has not been purpose built, I might need to share a bathroom wi1. By 15 June 2026, in order to ensure people and any legal representatives are fully consulted and involved in the development and review of their care plan, the provider must: a) Ensure all care plans are reviewed in consultation with relevant people. b) Ensure there is an accurate record maintained of the discussion and any actions agreed. c) Ensure that there is a plan going forward to ensure the frequency of reviews meets the regulatory requirement of at least once every six months and when people's needs change. This is to comply with Regulation 5 (1)(b) of the The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011, SSI 2011/210. This is also to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: 'My views will always be sought and my choices respected, including when I have reduced capacity to fully make my own decisions' (HSCS 2.11) and 'I am fully involved in developi
1. In order to ensure that people are safe and their needs are met the Provider should; - review staffing arrangements throughout the day, identifying when and where additional staff may be required. - the manager should ensure they have regular oversight of how staff are delegated across the home to ensure that there is sufficient observation and supervision in all areas including corridors when this is necessary. This is to ensure care and support is consistent with the Health and Social Care Standards (HSCS), which state that: 'My needs are met by the right number of people' (HSCS 3.15) and 'I am supported and cared for sensitively by people who anticipate issues and are aware of and plan for any known vulnerability or frailty' (HSCS 3.18).
1. In order to ensure people are cared for in an environment that is designed and organised to meet their needs, the Provider should undertake further observation and consultation in relation to the space and layout of the environment to ensure that people's needs and outcomes can be consistently met. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS), which state that: ' I can use an appropriate mix of private and communal areas, including accessible outdoor space, because the premises have been designed or adapted for high quality care and support' (HSCS 5.11).
2. To ensure that facilities provided are easily accessible, fit for purpose and meet the health, wellbeing, dignity and privacy needs of service users, the Provider should produce an action plan that describes progress with plans to improve ensuite rooms where possible. This should include; - the outcome of their consultation - the evaluation of the feedback received - the actions planned to bring about improvements - feedback to stakeholders. This is to ensure care and support is consistent with the Health and Social Care Standards (HSCS), which state that: 'The premises have been adapted, equipped and furnished to meet my needs and wishes' (HSCS 5.16).
3. In order to ensure people are afforded for bathing or showering, the Provider should ensure that there are sufficient assisted baths available and that these are fully operational and well maintained. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS), which state that: ' The premises have been adapted, equipped and furnished to meet my needs and wishes' (HSCS 5.18).
1. In order to ensure people and any legal representatives are fully consulted and involved in the development and review of their care plan, the manager should ensure that there is an accurate record that describes how the care plan and relevant documentation has been reviewed. This should include confirmation of who has been consulted and any actions agreed. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS), which state that: 'My views will always be sought and my choices respected, including when I have reduced capacity to fully make my own decisions' (HSCS 2.11) and 'I am fully involved in developing and reviewing my personal plan, which is always available to me' (HSCS 2.17).