Inspection on 03/11/05 for Albert House

This inspection was carried out on 3rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Albert House 13/02/09

Albert House 07/04/08

Albert House 15/05/07

Albert House 09/05/06

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Albert House 167 High Street Clapham Bedfordshire MK41 6AH Lead Inspector Andrea James Unannounced Inspection 10:30 3 November 2005 rd Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Albert House Address 167 High Street Clapham Bedfordshire MK41 6AH 01707 652053 01707 662719 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CareTech Community Services (No.2) Ltd Donna Maria Lee Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of people that can be accommodated at the home is 8. The home shall only admit service users between the ages of 18 and 65 years. All persons who are admitted to the home must have learning disabilities as their primary assessed need. The home may admit service users who have physical disabilities in addition to their learning disabilities. Date of last inspection Brief Description of the Service: Albert House is located in the village of Clapham, a short car or bus ride away from Bedford, which has shops, leisure facilities and links with national bus and rail services. The home has been sympathetically converted from its original purpose as a domestic dwelling. The building is an extended bungalow which provides single room accommodation for 8 younger adults with learning difficulties and who may also have physical disabilities. The home has adequate bathing and toilet facilities. A communal lounge/diner and a room that can be used for activities are located to the rear of the property. A shared drive at the front of the property leads to a parking area for several vehicles. To the rear of the property is a large garden that leads directly to the river Ouse. Access to the garden for service users has been limited by the construction of a paved area immediately behind the home that has been fenced in for safety purposes. Access to the remainder of the garden is with staff escort only. The home provides care for people with learning disabilities, including those who have additional physical disabilities. Most service users at the home need considerable support with their personal care and communication. The home also provides day activities for most of the service users. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 3rd of November 2005. The registered manager was available for the duration of the inspection, which lasted for 5.5 hours. The inspection followed a case tracking methodology where samples of the service users were chosen to inspect. As a result only a selection of service users and staff files were inspected. The inspection report consists of the views of the care staff and manager because the service users were unable to communicate effectively and no visitors were available during the inspection. The home had recruited a large number of care staff in the past months and was hoping to improve their retention for the future. What the service does well: What has improved since the last inspection? The home had addressed the majority of their outstanding requirements from the last inspection and as a result improvements were made to several aspects of the home. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 6 The home had recruited an additional 8 carers to the home, which enabled the home to rely on less agency cover and created consistency for the service users. Improvements were made to the shower room creating better facilities for service users. Risk assessments were completed for service users to ensure they were safe in the environment. Records were stored in a secured place within the home. Medication procedures were improved to include satisfactory guidelines for administering diazepam. The Protection of Vulnerable Adults (POVA) procedures were developed and all suspected abuse or unexplained injuries were reported. The home had also ordered new dining room furniture’s which were due to arrive in a few days. The home ensured that care staff received satisfactory standards of training and the care staff had accessed several areas of training. What they could do better: The home was still using a large percent of agency staff to care for the service users. The home had not obtained satisfactory clearances for these staff and could not produce evidence to suggest they were qualified to do the job required of them. The home ensured that 4 staff were on shift at all times but care staff felt that this ratio was insufficient to meet the needs of the service users. The home had one ancillary staff who was employed for three times per week. The care staff were therefore expected to carry out all domestic duties for the other 4 days of the week which could result in service users needs not being satisfactorily met. The care plans in the home also needed further development to ensure they were recorded in a clear and comprehensive manner. The plans failed to identify service users specific needs and as a result it was not clear what care intervention was required to be carried out. They also failed to produce evidence that they were kept under review or updated on a regular basis. The home also needed to ensure that all service users received a comprehensive assessment of need that identifies their needs. The health and safety aspects on the home in regards to doors being wedges open, using correct clinical waste bins and ensuring medications are stored at the correct temperatures needed to be addressed. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 7 The home needed to ensure a minimum of 50 of the care staff receives their NVQ level 2 in care. The Commission would like to thank the service users, care staff and the manager for their co-operation in the inspection process. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3 Satisfactory processes were in place to ensure perspective service users have enough information to make an informed choice about living in the home, and their needs were adequately assessed. As a result service users living in the home appeared happy and were appropriately placed. The information provided in the service users plan needed further development to ensure service users are aware of all the resources the home has to offer. EVIDENCE: The home had a Statement of Purpose that was satisfactory in meeting with requirements of the National Care Standards regulations. The home also had a welcome pack that detailed the resources available. This document was accompanied by the Service User Guide, which had very limited information. The manager said the Service User Guide was to be developed corporately and as a result the current format was not complete. The home had developed new admission assessment tools that appeared satisfactory in meeting the needs of the service users but this was only completed for the two new admissions and those service users living in the home for a longer period had no assessment of need completed. This resulted in some care needs not satisfactorily identified. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 10 The home ensured service users were able to visit the home before admission and where necessary tea stays and over night stays were arranged. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. Satisfactory processes were not in place to ensure the health care needs of all the service users were identified and addressed in the care plan documentation as a result some service users needs were not being met. Where possible service users were able to make some decisions about their lives, take risks and participate in daily activities, as a result they were able to maximise their independence. EVIDENCE: The home had collated a lot of information for service users which resulted in detailed documents held on file, however, the care plans failed to show the care interventions required to be carried out by the care staff in meeting the needs of the service users. The care offered could not be measured. Their were no assessed needs of most of the service users which made it difficult to measure if the home was meeting the holistic needs of the service users. Some files inspected showed that the care plans had not been reviewed for over 1 year and the care plan were designed so that once implemented they Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 12 could not be changed. There was no evidence that service users were consulted about the care to be implemented. All the care plans had a minimum of 17 risk assessments for service users, which showed that the home had assessed all potential risks but this could be counterproductive if staff were overwhelmed with all the risk assessments and were not aware of those that were most important. On observation is was apparent that staff were not aware of all the guidelines set down in the care plan and relied on information from each other to meet the needs of the service users. Service users were encouraged to take risks in order to maximise their independence. One service user attended weekly horse riding, another two had day centre placements and most service users were encouraged to access community resources. Those service users able to understand expressed their pleasure in the chosen activities by showing their trophies to the inspector. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14 and 17. Satisfactory processes were in place to ensure service users were encouraged to engage in activities, have personal development, access community and have a balanced diet, as a result the service users lifestyles were in meeting with their required needs. EVIDENCE: The home had an activities programme that was rotated on a weekly basis. The service users were observed to take part in various activities including a snozeleoon area. The home also bought in therapists for some service users. Service users were observed to be participating in activities that were age appropriate. Two of the service users attended day centres three times per week. The care staff felt that the service users would benefit from more outdoor activities as it can become monotonous for those service users who do not have regular community involvement. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 14 The menus were planned with the involvement of the service users. The care staff explained that the service users were able to choose what they wanted to eat when they were shown pictures of their favourite foods. Service users were not able to access the kitchen independently because of the risk factors but staff were observed to offer regular beverages to service users. One service user was given liquidised meals to meet with her ability to eat and digest meals. Care staff said professional input was sought and as a result the current feeding method was beneficial for the service user. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 21. The home had good processes in place to ensure service users health care needs were met, along with satisfactory medication processes and procedures to deal with the wishes of the service users in the event of their death. As a result service users needs were being met. EVIDENCE: The records showed that service users had regular contact with external professionals. On the day of the inspection care staff were seen escorting service users to various appointments. The mid- day medication was observed and the care staff appeared competent to administer the medication. The home offered staff training on medication before they were allowed to administer medication. The stocks appeared satisfactory and records were satisfactorily maintained. The medication room, which also housed the boiler, had temperatures in excess of 18 degrees and as a result the room was too hot to store the medications used by the service users. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 16 The home had policies and procedures in place to ensure service users wishes in the event of their death were satisfactory. All care plans seen documented the wishes of the service users in the event of their death. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home had satisfactory processes to record and deal with complaints or any forms of abuse should they occur, as a result service users safety was not compromised EVIDENCE: The home has had no complaints since the last inspection. The complaints policy inspected was satisfactory with the exception of some information that needed to be changed. The home also produced a complaints form that was in a pictorial format suited for the service users. The home ensured that all care staff either had abuse awareness training or was due to complete the course. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26,27,28,29 and 30. The home provided comfortable and safe bedrooms, communal areas and bathing facilities that would ensure the service users comfort and as a result their needs were met by the environmental standards offered. EVIDENCE: The home appeared warm and welcoming and provided sufficient communal space to ensure service users comfort. The home had separate activities rooms that provided more space for service users. The service users bedrooms viewed suggested service users were able to have personal belongings and decorate the rooms to their choice. Service users spoken to were proud to show their rooms, which were cleaned to a high, standard. The bathing and toileting facilities seen appeared satisfactory and improvements were made to the shower room since the last inspection. They were also equipped with various lifting equipment to enable service users to maintain independence and dignity. The home ensured service users safety and had implemented risk assessments for some of the identified areas that may cause harm to service users. The manager said further work was due to Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 19 be carried out in the home for areas identified as potential risks to service users. These included the ramp leading from the activities areas to the lounge and some service users bedroom doors. The home appeared clean and no offensive odours were identified. The ancillary staff spoken to said she worked in the home three times per week and on the other days the care staff were expected to clean the home. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34 and 35. The home had made improvements to their staffing structures that provides a more competent, supported and effective staff team who were appropriately trained in meeting the needs of the service users. As a result service users were cared for in a safe hands. The home was still using a large percentage of agency staff, and the new team were still not familiar with all the needs of the service users, as a result service users could not benefit from an effective staff team The home needed to make further development to improve the number of care staff with their NVQ level 2 in care qualification to ensure service users receive good standards of care. EVIDENCE: Improvements have been made to the staffing structures in the home since the last inspection. The manager said 8 new care staff have been recruited and only had vacancies for another 5 staff. The current care staff were fairly new and agency staff were still being used in the home to cover a large percentage of the caring duties. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 21 The home had a new staff team that were also learning about the needs of the service users. The home had recently employed a new deputy manager and was hoping that the current staffing structures would benefit the service users in providing consistency. The staff team appeared competent and dedicated to meeting the needs of the service users. Staff spoken to said they received regular training and were confident that they could meet the needs of the service users. 5 of the 12 staff had obtained their NVQ level 2 in care, which was only 41 of the staff team. All had achieved mandatory training and the home had provided evidence to suggest other areas of training were also undertaken. The home had one ancillary staff that carried out the cooking and cleaning duties on a part-time basis, which required the care staff to perform all care and domestic duties. Staff spoken to said they would benefit from having more staff on duty to ensure they are able to meet the needs of the service users, as some service users required one to one care. The staff-training file seen suggested all care staff received satisfactory levels of training and future training was scheduled to be carried out for some care staff. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38,41 and 42. The home had satisfactory procedures in place to ensure good leadership was provided and the best interest of the service users were maintained, as a result service users were able to benefit from a well run home. Some aspects of the home’s health and safety procedures were poor and as a result service users welfare could be compromised. EVIDENCE: The manager have been in post for I year and had achieved her NVQ level 3 in care. She was working on her NVQ level 4 and her Registered Managers Award. The manager appeared competent in dealing with the management aspects of the home. She was also knowledgeable about the needs of the service users. The care staff spoken to said the manager was approachable and she operated an open door policy. They also commented that they received regular supervision and she offered a good level of support when required. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 23 The home had satisfactory recording procedures in place to safely manage and record service users finances. The organisation was the appointee for several of the service users and the manager only dealt with small amounts of service users finances, which were all satisfactorily recorded. The home had satisfactory health and safety policies but some aspects of the home’s health and safety needed to be addressed. The home had some of the service users bedroom doors wedged open. The manager said they were in the process of finding alternative door closures. The temperature in the medication room was also a health and safety risk to service users. Clinical waste was not disposed of using the correct equipments. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 2 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Albert House Score X 3 3 3 Standard No 37 38 39 40 41 42 43 Score X 3 X X 3 2 x DS0000065423.V258031.R03.S.doc Version 5.0 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 (1) Requirement Arrangements must be made to ensure all service users receive a full and comprehensive assessment of needs. All care plans must be kept under review and updated as required. Arrangements must be made to expand the service users care plans to incorporate all areas of assessed needs as listed in Standard 2 including health care needs. Previous timescale:30/09/05 Arrangements must be made to obtain full information about agency staff’s skills and suitability to meet the needs of the service users, including all information listed in Schedule 2 of the Care Homes regulations. Previous timescale: 31/1/05 and 31/7/05 Arrangements must be made to ensure all agency staff has satisfactory clearances before they are allowed to care for the service users. Arrangements must be made to ensure agency cover is kept to a DS0000065423.V258031.R03.S.doc Timescale for action 30/02/06 2 3 YA6 YA6 15 (2) (b) 15 30/02/06 30/01/06 4 YA32 18 (1) 30/02/06 5 YA32 19 (1) 30/02/06 6 YA33 18 (1) 30/02/06 Albert House Version 5.0 Page 26 minimum. 7 YA33 18 (1) Arrangements must be made to ensure ancillary staff is available in such numbers to cover the home 7 days per week. Arrangements must be made to ensure all bedroom doors are held open using appropriate measures that will not compromise service users safety in the event of fires. Arrangements must be made to ensure the medications are not exposed to excessive temperatures above 18 degrees. Arrangements must be made to ensure clinical waste is disposed of in secured disposable bins. 30/02/06 8 YA42 13 (4) (a) 30/02/06 9 YA42 13 (4) (a) 30/02/06 10 YA42 13 (4) 30/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard YA1 YA1 YA12 YA20 YA22 YA26 Good Practice Recommendations Arrangements should be made to develop the Service user Guide to ensure it includes all the areas as listed in the Regulations. Consider providing key information in meaningful formats example audio or video formats. Arrangements should be made to ensure more activities are provided for service users, which allows them to access the community on a regular basis. Arrangements should be made to ensure all staff administering medication provides a sample signature. The complaints procedure should be developed to ensure all information are correct to reflect current practices. Arrangements should be made to ensure all service users have adequate calling systems in their rooms to be able to alert staff if needed. This should include partially sighted service users. Arrangements should be made to consider increasing the number of staff per shift to ensure all the needs of the DS0000065423.V258031.R03.S.doc Version 5.0 Page 27 7 34 Albert House 8 9 35 39 service users are satisfactorily met. Arrangements should be made to ensure a minimum of 50 of the care staff obtain their NVQ level 2 in care. Ensure that there are effective systems to monitor and review the quality of care provided and outcomes for the service users. Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Albert House DS0000065423.V258031.R03.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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