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Inspection on 06/12/06 for Victoria Nursing Home

Also see our care home review for Victoria Nursing Home for more information

This inspection was carried out on 6th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff provide appropriate care for a specific type of resident who have very specific social needs. The provider has put in place a number of systems that when working would provide a good safety system for those resident. These include some really good record keeping systems for medication. These systems can show if medicines are given properly to residents and they could help the provider/manager to make sure that medication is handled safely. Of the four people spoken to all made positive comments about the service. This included phrases such as " staff are nice" and, " the home is full of nice people". One relative said that the staff at the home made them feel very welcome.

What has improved since the last inspection?

Full risk assessments of residents had been completed. Copies were in each resident`s file examined. Recruitment processes were good and this good practice helps protect residents. Regular supervision of staff was well established. The records for this were maintained appropriately. New furniture for some areas had been purchased. This included blinds for the windows of the public areas. The provider/ manager has undertaken a complete audit of the home and was in the process of developing a realistic improvement plan.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Victoria Nursing Home 9 Anson Road Victoria Park Manchester M14 5BY Lead Inspector Nick Allen Unannounced Inspection 6th December 2006 10:00 X10015.doc Version 1.40 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 Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 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 Older People. 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. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Nursing Home Address 9 Anson Road Victoria Park Manchester M14 5BY 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) 0161 224 0302 Homesend Limited Mr Adrian Webb Care Home 21 Category(ies) of Dementia - over 65 years of age (19), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Mental Disorder, excluding learning disability or dementia - over 65 years of age (19) Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users accommodated shall be 21 all of whom require nursing care. Service users shall be above pensionable age and require care by reason of mental disorder or dementia. 2 named service users currently accommodated require care by reason of mental disorder but are below 65 years of age. If either of these service users reaches the age of 65 or no longer resides at the home, the category will revert to MD(E). 12th July 2006 Date of last inspection Brief Description of the Service: Victoria Nursing Home registered in July 2002 to provide accommodation with nursing care for a maximum of 21 older people. All of the residents had been assessed as having mental health needs. The home is operated by Homesend Limited with Mr Adrian Webb, the manager and the responsible individual. The home is situated in the Victoria Park area of Central Manchester close to local shops, public houses, Manchester Royal Infirmary and other social areas and amenities. The home is close to public transport routes to the City Centre and South Manchester. The home consisted of a large converted semi-detached building, adjoining Surrey Lodge Health Centre and set within its own grounds. The home offered accommodation on three floors with all communal spaces being on the ground floor. The accommodation comprised of 5 single and 8 double bedrooms. There were four communal areas, which included a smokers lounge, a radio lounge, lounge/dining room and a quiet sitting area next to the office/medication room. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Victoria included an unannounced site visit as part of the inspection process. Two inspectors carried out the inspection one being the specialist pharmacist inspector. The inspection was completed over a period of four hours. The inspection also included time spent talking to the provider/manager, staff and several residents. Documents including staff files, records and other relevant documentation were also examined. Information was also obtained from documentation held on file at the offices of the Commission. A tour of the building was conducted to make sure the building was safe and that the people who use the service are provided with a homely place to live. A large number of requirements made at the last inspection had still not been completed. Those that are still to be done are identified at the end of this report. Since the last inspection the Commission for Social Care Inspection (CSCI) has not received any complaints about the service. Since the last inspection officers from the Commission for Social Care Inspection (CSCI) has met with the provider to discuss outstanding issues Each section of this report contains a judgement about the quality of the service provided. In making the judgements the inspectors have considered all the information made available; the unannounced site visit, information from the people who use the service. There was also a themed part of the inspection which was part of a National Study, which is taking place by the Commission for Social Care Inspection. This Themed part of the inspection focused on information given to people on admission having a contract which records the terms and conditions of a residents stay, whether people had their needs assessed before admission and residents awareness of how to make a complaint Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: At the last inspection, requirements were made for the improvement of the environment. It was disappointing to note during this inspection, that only some of these had been addressed. The provider/ manager advised that the work that had commenced on improving the bathrooms was due for completion “very soon”. One bathroom was not used and was awaiting upgrading whilst another was waiting completion. However this did not affect the resident’s ability to bathe. The home was required to have in place good systems for handling medication and a requirement was made at the last inspection for arrangements to be made concerning the safekeeping, recording and handling and administration of medication. However, this remains outstanding and a number of concerns regarding the management of medication were identified. The provider /manager must make sure that all residents receive their medication as prescribed and that their medication does not run out. The provider/ manager Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 7 must also make sure that the nurses complete all records concerning medication accurately so that evidence can be provided that residents receive all their medicines properly. Requirements made about medication can be found at the end of this report. During the tour of the building it was noted that not all areas of the home provided residents with a comfortable, homely environment nor ensure their safety. Fixtures and fittings together with the décor were in a ‘poor state of repair’ and carpets in some parts of the home required attention and repair. One external fire door had rotted at the bottom and light could be seen coming through the gap. It would be possible for water or vermin to gain access to the building in the same way. 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. The summary of this inspection report can be made available in other formats on request. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using the available evidence including a site visit to the home. Victoria Nursing Home provides adequate information to enable potential residents to make an informed choice about moving into the home. The home ensured that residents have their health needs identified through completion of comprehensive need assessments. EVIDENCE: The home’s Service User Guide was examined and was found to contain information about staff qualifications and experience, the philosophy of care provision, a brief description of the home and a copy of the home’s complaints procedure. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 10 The files of four residents were chosen at random for examination. One file was of a recent admission to the home. All of the files examined had signed contracts detailing the terms and conditions of residency. During discussion with the provider/manager it was confirmed that residents and their representatives were encouraged to visit the home prior to admission. Detailed assessments completed by the home were seen in all care files examined. These included information about the psychological well-being, food preferences, health and social needs and expectations of the residents. Details of weight gain and loss were also recorded. The home did not provide intermediate care. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,and 10 Quality in this outcome poor. This judgement has been made using the available evidence including a site visit to the home. The health care needs of residents were well-documented and known to staff, however, the home handled medication procedures poorly. EVIDENCE: Care plans were examined and instructions about meeting health needs were clearly identified. All staff spoken to were aware of these plans ensuring that they provided the best possible care to the residents. Records and daily reports for residents confirmed that all routine and specialist health care including pressure area care was provided. Results and prescriptions confirmed that health care checks including opticians, dentist, Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 12 influenza injection, podiatry as well as out patient appointments, nursing care and other specialist input was appropriate. The staff interaction with residents was also observed and monitored, it was noted that on this site visit there was an improvement in the interaction and that the staff appeared much more relaxed. For the most part staff supported the residents in line with the written care plans. As found on previous inspections there were privacy screens or curtains in shared bedrooms. Locks were provided to all rooms and most were in use. However, where locks were not in use, it was possible for the residents to enter each other’s bedrooms whenever they wished and this issue was discussed with the staff . They said that those rooms that remained open were to assist residents. The need to leave the room open had been identified after full risk assessments/ care planning had been carried out. Of the staff spoken to all were aware of this. However, on the files examined no recorded evidence of this was available. The home should therefore ensure that this is properly evidenced within its files. Since the last inspection the provider/manager had installed roller blinds. These were used instead of curtains. The provider/ manager said these were working well. The provider/manager provided details of all Nursing staffs’ PIN numbers. Since the last inspection the provider/ manager has met with the Commission for Social Care Inspection. At that meeting he stated that he had removed himself from the nursing rota until the issue of his registration with the Nursing Midwifery Council could be resolved. The residents were not protected by the medication policies in the home because they are very poor and do not give the staff proper guidance to help them look after residents and their medicines safely. The home has some really good record keeping systems which could show if medicines are being given properly. By using these systems the pharmacist inspector found that medicines were not being given properly. If these records were used properly they could help the manager to make sure that medication is handled safely. The pharmacist inspector noted during the inspection that nurses did not make a record of the medication they had administered at the time they had administered it. Due to this poor practice, last month, one person had received a double dose of their medication. On some occasions nurses failed to fill in the records properly making it difficult to tell if the residents have received their Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 13 medicines properly. Residents’ health is potentially at risk from these poor practices. Some residents did not have their medicines administered in the way that the doctor had intended. Residents sometimes got the wrong doses of their medicines. Sometimes residents did not get their medicine either because nurses signed that they had given it but did not administer it or because the home had run out of the residents’ medicine. On some occasions the nurses decided to change the dose of medicine without discussing it with the doctor. When residents are not given their medicines as the doctor has prescribed to them then the health of residents could be put at risk. The nurses’ failure to administer medication as prescribed and failure to accurately record what medication they administer to residents shows they are not following their professional code of conduct as set out by the Nursing and Midwifery Councils (NMC) guidelines. Failure to follow the NMC guidelines could put residents’ health at risk. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using the available evidence including a site visit to the home. Residents were supported to maintain some choices and preferences of lifestyle including choice of meals, but the range of available activities was limited. EVIDENCE: Evidence was available to show that activities that residents enjoyed participating in were noted in individual records. It was evident from those records that the frequency of activities taking place had improved. The provider/manager said that the people who lived at the home remain disinterested in a lot of group social interaction. However, there was evidence of increased individual activities. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 15 Staff spoken to said that they had seen an improvement in the interaction between those residents who joined in with activities. This was also observed during the site visit. For those resident who had visitors, visiting times were open and flexible ensuring that they maintain good contact with family and friends. On the day of the site visit, one visitor said that they were very happy with the staff and manager of the home. The manager/ provider said that they were trying to arrange for this person to be able to spend more time at the home by turning one of the double bedrooms into a small “bedsit”, thereby allowing the relative to spend the occasional night there. Residents’ meetings were not established and the registered provider/ manager said that it was unlikely that those who lived at the home would be able to attend a meeting. However, he had sought the views of relatives and visiting professionals. The information obtained was seen and on the whole it provided positive outcomes. The nutritional value of meals provided in the home was in keeping with current guidelines and the choice offered to those residents on special diets was varied. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. The home had relevant policies, procedures and systems in place to enable concerns to be raised and to protect residents from neglect and/or abuse. EVIDENCE: The home’s complaints procedure was robust, clearly written and staff, visitors and residents spoken to said that they understood who they should go to and that they were entitled to voice any complaints and be listened to if they had any concerns. The complaints procedure was examined and assessed as offering those resident and their relatives a robust clearly written procedure to follow. Complaints were recorded and a note made of the outcome and actions taken. All of the residents’ spoken to confirmed that they were confident that staff would treat any concerns seriously. Of the staff spoken to on the day of the site visit, all confirmed that they were aware of the complaints process and that training had been provided. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 17 Those staff currently employed had been provided with updated training on Adult Protection. The service had its own policy on Adult Protection. This policy was based on the local authority’s “No Secrets” guidance information. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. The home is poorly maintained and some furnishings were inadequate to meet residents’ needs EVIDENCE: During the course of the inspection various concerns were noted. The home had a cellar area where the laundry room and kitchen were located. The laundry room was clean and tidy; the washing machines had programmes for disinfecting and sluicing laundry and the systems for laundering residents’ clothing was found to be hygienic. Staff had been employed specifically to work in the laundry. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 19 The kitchen was found to be clean and hygienic. Appropriate temperature recordings were being maintained for ‘fridges and freezers. There was no fly screen at the door of the kitchen leading to the outside, nor was there a sign to indicate that the top of the door sloped dramatically downwards. This was a serious health and safety concern for people using this door. There was a strong odour of urine in some areas of the home (bedrooms) and staff were observed steam cleaning these rooms which had the effect of reducing the presence of malodour. One lounge was a dedicated smoking room and contained a number of large ashtrays. During the inspection all lounge and corridor doors were propped open, by either furniture or fire extinguishers. The registered provider/ mangers wife spent a lot of time removing these but residents put them back. She said that self-closing door guards were on order. Until they arrive this meant that any fire prevention/protection procedures would be rendered ineffective. The provider/ manager was considering fire retardant paint for a number of areas. The stairs leading to the upper floors had loose and ill-fitting carpet on the first floor landing. This needed to be addressed to prevent it becoming a trip/fall hazard. During the inspection one of the ground floor toilets was locked. There was a notice on the door saying the room was being refurbished. Since the last inspection work had commenced but was not yet completed. However, toilet facilities were still sufficient in number to meet the residents’ needs. Bedrooms had generally been personalised. New furniture had, where necessary, been purchased. In order to improve the living environment for the majority residents all remaining bedroom furniture needed to be replaced as part of the overall refurbishment of the home. Bedroom doors had locks fitted but not all were in use/operational. The provider/ manager felt that residents did not want their rooms locked, however there was no written information to support this opinion. There was evidence at the time of the inspection to demonstrate that work had commenced on various parts of the home. However, a lot of the work remained incomplete. The provider/manager was asked about this and he said that some of the work was incomplete because they were awaiting delivery of “parts”. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,and30 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service Effective recruitment and training processes competent staff members were employed. EVIDENCE: During the inspection the home was accommodating 20 residents. There were sufficient staff on duty to meet the assessed needs of those resident. The provider/manager said that the problems recruiting care staff had now been resolved. Additional domestic staff had been employed. There were details of training programmes available to staff with allocated places, in the office. This included training on revised policies and National Vocational Qualification (NVQ) training. Staff commented positively about training. Files and records for three staff members were examined. Each file contained the necessary paper work to show that the home operated good recruitment procedures. There was evidence of induction, supervision and training. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 21 ensured that skilled and Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is poor. This judgement has been made using the available evidence including a site visit to the home. Some health and safety arrangements are in place but improvement is needed in this area to ensure the environment is safe for the residents, staff and visitors. EVIDENCE: The registered provider/manager had put some very good systems in place with regard to the recording of medication handling. These systems could provide information, which would show how well medication was handled in the home. They could also show if the residents all received their medicines as the Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 22 doctor prescribed them. However, the provider/manager has failed to use these systems to find out if medicines were being handled safely or to check that nurses were giving the residents their medicines as prescribed. The provider/manager’s failure to monitor if medicines are handled appropriately could put residents health at risk. There were records of monies held on site for individual residents. Details of monies spent were recorded individually. A development plan for the home had been written, but this did not address all the requirements identified at previous inspections Appropriate records for fire, electrical installation, equipment and risk assessments were in place and up-to-date. There are a number issues surrounding health and safety that have been identified in other areas of this report. These include; the propping open of fire doors by residents. Staff were observed removing these wedges, however residents immediately used fire extinguishers or chairs to re prop open the doors. Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 x 3 X X 1 Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes B 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 OP9 Regulation 13(2) Requirement The registered person must ensure that medication policies are updated to reflect current legislation and ensure safe practice. A copy of the revised policies must be sent to the Commission. (Previous time scale of 16/03/06 and 30/08/06 not met) 2. OP9 13(2) The registered person must ensure that all records relating to medication are accurate and up to date. (Previous time scale of 16/03/06 and 30/08/06 not met) 4. OP9 13(2) & 18 (1) (c) (i) The registered person must ensure that all nurses administering medication must access training and have their competency to administer medication assessed. (Previous time scale of 01/04/06 and 30/08/06 not met) 30/01/07 12/01/07 Timescale for action 30/01/07 Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 25 5. OP25 13 The provider must install appropriate door guards on any door that has been risk assessed as needing to be kept open. (Previous time scale of 30/08/06 not met) 30/01/07 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. Refer to Standard OP31 Good Practice Recommendations It is recommended that the home manager complete the Registered Managers Award. Advice should be sought from the health and safety executive in order to prioritise maintenance work. 2. OP19 Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Victoria Nursing Home DS0000021660.V324345.R02.S.doc Version 5.2 Page 27 - 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. 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