Letham Park Care Home
Recorded Key Question grade range: 3 — Adequate View on Care Inspectorate
Key Question scores
Requirements & recommendations
1. The service should ensure sufficient housekeeping staff are in place to maintain high standards of cleanliness and to carry out regular deep cleaning activities to ensure that people experience a clean and welcoming environment . This is to ensure that 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 experience an environment that is well looked after with clean, tidy and well maintained premises, furnishings and equipment' (HSCS 5.22).
2. The service should ensure there are adequate numbers of staff to improve the quality and consistency of meaningful engagement and activity provision. This is to ensure that people experience stimulation, social interaction, and opportunities that reflect their individual interests and preferences. This is to ensure care and support were consistent with the Health and Social Care Standards (HSCS), which state that; I can maintain and develop my interests, activities and what matters to me in a way that I like (HSCS 2.22).
3. The service should improve mealtime experiences by ensuring that sufficient staff are available and effectively deployed to provide timely, well organised, and supportive dining routines. The provider should continue to use people's feedback about the quality of the meals to improve their dining experience. This is to ensure that care and support were consistent with the Health and Social Care Standards (HSCS) which state that; 'I can enjoy unhurried snack and meal times in as relaxed an atmosphere as possible (HSCS 1.35) and 'I can choose suitably presented and healthy meals and snacks, including fresh fruit and vegetables, and participate in menu planning. (HSCS 1.33)
1. By 11 February 2026, to ensure that people’s care and support needs are met effectively, the provider must ensure staffing arrangements are safe. To do this, the provider must, at a minimum: (a) ensure staff have sufficient time to complete daily documentation accurately and promptly, ensuring records are up to date, person-centred, and reflective of the care provided (b)enable staff to have time to engage meaningfully with people they support, promoting wellbeing and ensuring interactions are not rushed or task-focussed (c) ensure there are sufficient staff to enable the person in charge to respond promptly to the needs of people using the service and support staff. This includes having the capacity and skills to review and accurately report accidents, incidents and protection issues in a timely manner (d) ensure there are enough skilled, knowledgeable staff available at all times to support people with t
1. To enhance the safety and wellbeing of people experiencing care, the provider should ensure that staff have access to an appropriate on-call system and are trained in how to use it to obtain managerial support. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which states that: ‘My care and support is provided in a planned and safe way, including if there is an emergency or unexpected event’ (HSCS 4.14). and ‘I experience high quality care and support because people have the necessary information and resources’ (4.27).
1. By 3 November 2025, the provider must ensure that people who are at risk of pressure damage to their skin receive appropriate care to reduce the risk of damage and that care intervention documentation evidences that people are getting the required level of support to meet their assessed needs. In order to do this the provider must: (a) ensure people are supported to reposition in accordance with their pressure damage prevention plans and ensure that care intervention documentation evidences that people are receiving the required support to meet their assessed needs. (b) ensure that classification of pressure wounds is accurate and that staff receive further training to support them in carrying out pressure damage assessments. (c) ensure that people’s continence care needs are being met and that continence care interventions are documented to evidence that they are receiving the required levels of support to promote their healt1. By 3 November 2025, to ensure the health, welfare and safety of people using the service the provider must notify the Care Inspectorate of all reportable events as detailed in the Care Inspectorate's 'Adult care services: Guidance on records you must keep and notifications you must make' (March 2025). In order to do this the provider must: (a) Ensure that all notifiable events are reported to the Care Inspectorate in the line with the guidance for providers of adult care services as detailed above. (b) ensure local authority adult protection teams and the Care Inspectorate are informed of all adult protection concerns/adverse incidents and actions taken to safeguard people using the service. (c) Ensure that incident records contain accurate details including correct dates, and an accurate account of adverse events and communications w2. By 3 November 2025, to ensure the safety and protection of people using the service the provider must regularly audit the security of the premises and ensure that staff are following best practice infection control guidance when disposing of clinical waste. In order to do this the provider must: (a) With immediate effect ensure that the premises are safe and secure to protect people from potential harm. (b) Ensure that staff are at all times promoting the safety and protection of people using the service by securing areas which pose any risks to people. (c) Ensure that clinical waste bins are locked and any spillage of clinical waste is disposed of promptly. This is in order to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210), regulation 4(1)(a) and regulation 4(1)(d). This is also to ensure tha
1. To promote people's health, wellbeing and comfort, the provider should ensure that staff are recording pain management checks and following 'as required' guidance for prescribed pain relief consistently. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: My care and support meets my needs and is right for me (HSCS 1.19).
2. To promote effective communications about people's health and wellbeing needs including opportunities for meaningful engagement and daily activity, the provider should review and make improvements to internal and external communications. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: 'I experience high quality care and support because people have the necessary information and resources' (HSCS 4.27).
3. To ensure that people's safety and wellbeing needs are consistently promoted the provider should check that all staff are following the guidance set out in people's individual falls risk assessments. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: Any treatment or intervention that I experience is safe and effective (HSCS 1.24).
1. To promote sustained improvements to people's care experience the provider should look at how actions identified from service audits are being implemented across the home. More frequent checks following audits should be carried out to confirm that improvements made have been sustained. This is also to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: I benefit from a culture of continuous improvement, with the organisation having robust and transparent quality assurance processes. (HSCS 4.19)
2. To promote people's rights to know how any complaint/concerns they have raised have been actioned and provide them with reassurance, the provider should check that people have been informed of the outcome of their complaint. All formal complaints and outcomes should be recorded in the service's complaint log. This is also to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: If I have a concern or complaint, this will be discussed with me and acted on without negative consequences for me. (HSCS 4.21)
1. To improve people living with dementia's care experience, the provider should carry out further observations of staff practice, provide increased mentoring for staff with limited care experience and more in depth dementia and positive behaviour support training. The provider should also provide some staff with more training to ensure that each person supported experiences respectful and dignified communications at all times. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: I have confidence in people because they are trained, competent and skilled, are able to reflect on their practice and follow their professional and organisational codes. (HSCS) 3.14. 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.
2. In order to evidence that there are sufficient levels of staff to meet people's needs and evidence that people experience responsive care in a timely manner, the provider should review staffing levels and reduce the call bell response times for attending to people's needs. This is to ensure that 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 confident that people respond promptly, including when I ask for help' (HSCS) 3.17.
1. To promote people's wellbeing, dignity and self worth the provider should ensure that people are supported to personalise their rooms and to ensure that people experience a consistently clean environment, including changes of linen/bedding when required. Cleaning records should evidence that people's rooms are cleaned and checked daily and deep cleaning checks should be carried out consistently. 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.
2. To promote people's dignity and respect, the provider should regularly check that only items belonging to people are placed in their rooms and all laundry returned belongs to them. Regular checks should be carried out to monitor that improvements have been made and are sustained. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: 'I benefit from a culture of continuous improvement, with the organisation having robust and transparent quality assurance processes' (HSCS) 4.19.
1. To support people to lead meaningful lives and prevent isolation, the provider should review the outcome and meaningful engagement sections of people's personal plans evidencing that all people supported have their choices, interests and preferences promoted and planned for. This is to included ide