Inspection on 12/12/05 for Stratford Court

This inspection was carried out on 12th December 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 but made no statutory requirements on the home.

Other inspections for this house

Stratford Court 12/03/09

Stratford Court 21/02/07

Stratford Court 21/06/05

Stratford Court 02/02/05

Stratford Court 10/06/04

Stratford Court 18/12/03

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Stratford Court Stratford Road Salisbury Wiltshire SP1 3JH Lead Inspector Ms Sally Walker Unannounced Inspection 9:35am 12 December 2005 th 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 Stratford Court DS0000028322.V268420.R01.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 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. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stratford Court Address Stratford Road Salisbury Wiltshire SP1 3JH 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) 01722 328855 01722 328494 The Orders Of St John Care Trust Mrs Caroline Jane Cooper Care Home 48 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (48) Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users who may be accommodated at any one time is 48 No more than 14 service users with dementia aged 65 years and over may be accommodated at any one time No more than 6 service users aged 65 years and over with a mental disorder, excluding learning disability or dementia, may be accommodated at any one time 21st June 2005 Date of last inspection Brief Description of the Service: Stratford Court was originally purpose built by the local authority as a care home for up to 48 older people. The home is registered for up to 14 older people with dementia and up to 6 older people with a mental disorder. Two of the beds are offered to older people in the community for periods of respite care. The registered providers are The Orders of St John Care trust and the registered manager is Mrs Caroline Cooper. The accommodation is arranged over two floors, with additional day care facilities located on the lower floor. The home is opposite Victoria Park in Salisbury, close to the city centre. Those residents with dementia and mental disorder live alongside the other residents. The staffing rota provided 5 care staff including a care leader during the morning, 4 care staff during the afternoons and evenings and three waking night staff. The home also employs housekeepers, cooks, kitchen assistants and a handyman. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9.35am and 6.30pm. Mrs Cooper was present during the inspection and gave assistance with access to records. Five residents and 2 staff were spoken with. A tour of the building was made and the care plans, staff training records and complaints log were examined. What the service does well: What has improved since the last inspection? What they could do better: Current staffing levels do not support the home to achieve its full potential as described in the statement of purpose. Many of the requirements of this report are a symptom of poor staffing levels. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 6 When residents care needs change their care plan must be updated to reflect their current situation and any additional support that is needed; it is not sufficient to put directions in the daily report where they may be lost amongst general reporting. The home should be provided with the latest assessment tool in order to carry out proper pre-admission assessments. The tool being used at the time of the inspection only gave a list of headings and was not necessarily relevant to people who may have dementia. Training needs to be provided in tissue viability so that staff can assess and monitor residents who may be at risk of developing pressure sores. Staff also need to be trained regularly in caring for people with mental health problems as the home is registered for 6 places. The allocation of staff time to carry out cleaning tasks must cover the whole day and not just the mornings. The building is in different stages of refurbishment and some areas are looking well worn in contrast to other areas. Single glazed metal-framed windows are still in some of the bathrooms. Residents should be encouraged to make their views known and consideration should be given to different ways of achieving this if residents do not attend regular meetings. Particular areas for consideration are the food and letting residents know if someone has died. 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. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 7 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 Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Mrs Cooper is carrying out full detailed assessments with prospective residents so that potential residents can know whether the home can meet their needs. However the home is not supported by the organisation with provision of current assessment forms. EVIDENCE: The recommendation that the assessment tool used by the day service could be adapted for use in the home, to include the source of the information if the person was not able to verbalise and whether the assessment was observed, had not been actioned. The home was still using a yellow form also used as a long-term care plan. This takes the form of headings and does not have specific questions for assessment, particularly with regard to dementia and mental health. Other homes in the organisation are using a more comprehensive format newly introduced. The organisation is not consistent in providing current relevant forms to all of its homes. Mrs Cooper said she was currently carrying out all of the assessments on prospective residents. Mrs Cooper was advised to request the latest assessment forms from the organisation. The assessments included the organisation’s dependency profile but as this was numerical and used primarily for determining fees, it is not helpful when compiling the care plan. Some residents confirmed that someone Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 9 had been to see them either at home or in hospital before they were admitted to Stratford Court. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Care plans had generally improved and were more detailed giving a better picture of residents general care needs. However, although reviewed monthly, they were not regularly reviewed and updated as needs changed at other times. Residents had good access to healthcare professionals and staff were prompt in referring any concerns. Residents felt their privacy was respected. EVIDENCE: The requirement that any significant changes in residents need identified in the daily report must prompt an immediate review and revision of the care plan with clear guidance to staff on how that need is to be met had not been actioned in all cases. The care plans were improved with more detail on how needs were to be met. However there were examples of where incidents had occurred recently but no revision of the care plan had taken place. The inspector is of the view that the current staffing levels do not support staff to ensure that care plans are kept up to date. Discussions were held with regard to the home’s vulnerability in not keeping records up to date and strategies for how this was to be achieved. It was agreed that all the residents care plans would be reviewed immediately and an additional visit would take place after a month to check on compliance with this requirement. Failure to comply will result in enforcement action being taken. As a matter of good practice female Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 11 residents had been asked about their gender preferences for the provision of personal intimate care and this was noted in their care plan. As a matter of good practice it was noted that staff were paying attention to residents being well groomed with clean glasses, teeth, clothing and hair. The requirement that all residents’ weights must be regularly monitored had been actioned with records of weight on admission and monthly thereafter. Residents had good access to healthcare professionals. District nurses were noted to be attending patients and discussing care progress. The requirement that all medicines requiring cold storage must be kept between 2°C and 8°C at all times, monitored and any deviation addressed immediately had not been actioned. Whilst the temperatures were being recorded, it was clear that the fridges were not maintaining their temperatures thus compromising the safety of any medication stored. The inspector advised that the fridges must now be replaced as a priority. The requirement that all eye drops were dated on opening and discarded after 28 days had been actioned. The person responsible for medication had set up a system whereby all the eye drops were replaced each month. The requirement that all medication was recorded including external preparations had been actioned. The requirement that all care staff were trained in tissue viability had not been actioned. This health area does not have a tissue viability specialist nurse so the training has been difficult to access. Mrs Cooper had provided some of her own information on pressure sores for staff information. The organisation was to provide the training centrally. The requirement that written risk assessments were carried out with regard to residents’ risk of developing pressure sores had not been actioned. Following this inspection the organisation has confirmed that an assessment tool had been produced for its homes to use. Pressure relieving equipment was in place for some residents. The recommendation that where a resident was prescribed a choice of painkillers, the criteria for their use should be clearly marked on the administration record had been resolved; the resident was now only prescribed one type of this medication. One resident said that staff did not inform them when anyone had died. It had upset them when they found out a few weeks after the event when enquired about the resident’s whereabouts. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 The provision of activities has improved with the recruitment of a part time activities person. Residents were being given more opportunities to access the locality. Staffing levels not rising with increased dependency have restricted some routines that residents and relied on. Residents were offered a range of traditional choice menus but some residents need to be more involved in compiling the menus. EVIDENCE: Most residents were able to determine how they would spend their day; either in their rooms, in the sitting rooms or joining in the activity programme. There were a number of residents who liked to sit outside the front door chatting and evening at this time of year there were residents who sat and smoked outside. One resident was attending to the flower tubs. One resident who had a great deal to say about the quality of the food said that they missed their early morning cup of tea. Mrs Cooper confirmed that the earlier cup of tea had been stopped, due to increased dependency of some residents needing help with getting up, but residents did have a cup of tea later before their breakfast when they would have more tea or coffee. Another resident said that breakfast was often late, that sandwiches were served too often and that tea was often cold when it arrived. These comments are evidence of poor staffing levels at busy times of the day. These 2 residents when asked about being able to talk about the food at residents meetings said that none had been held. Mrs Cooper later said that they had been organised but no one attended. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 13 Other comments about lack of choice were disproved with a choice menu seen provided at both lunchtime and for the evening meal. However this does not negate these 2 residents individual experiences of the food provided and this should be an opportunity to discuss the meals in more detail with residents. This is in contrast to the home’s positive attitude to welcoming comments on the service from other parties. The 2 residents were advised to take their concerns directly to Mrs Cooper or the chef. All of the other residents spoken with made very positive comments about the quality and quantity of the meals provided. The provision of activities has improved since the appointment of a part time activities person. Mrs Cooper said that they were trying to offer residents more trips out which was difficult in the winter weather when residents often refused. Some of the residents had been to a pantomime at the local theatre the previous week and they were hoping to go Christmas shopping. The home has its own minibus. There was a list of the planned activities for Christmas with entertainers coming to the home as well as parties. Mrs Cooper said she had done a course in art therapy for people with dementia and hoped to implement arts and crafts. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home welcomes comments from people about the service and has a positive attitude to encouraging other parties to complain. However some residents had a lot to say about the food but did not attend the residents meetings. Any complaints are thoroughly investigated by the home and outcomes made known to complainants. Staff were familiar with the process of the local Vulnerable Adults policy. EVIDENCE: The home follows the organisation’s complaints policy which was available and displayed around the home. There was a folder with much of the paperwork associated with the investigations and conclusions. Mrs Cooper said that this needed to be collated to show responses and outcomes more easily. Records showed that Mrs Cooper and staff took all complaints and concerns seriously and that action had been taken to address issues and responses written to complainants. Some complaints were referred to the organisation for more independent investigation some of these responses were not readily available on file. Some residents had a lot to tell the inspector about the food and some routines but they did not attend the regular residents meetings. The home should consider other ways that residents can make their views known. All staff had been trained in the local policy for the protection of vulnerable adults and the home had had experience of the process and appeared to be confident in reporting any allegations or concerns to the relevant source. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home is in different stages of refurbishment and some areas need attention. The allocation of cleaning staff time throughout the week means that care staff are expected to also carry out some cleaning. Some toilets and door handles were poorly cleaned. EVIDENCE: The recommendation that the old single glazed windows in bathrooms should be replaced by modern double glazed windows had not been actioned. This was reported to be part of the fire year refurbishment plan, nearing its end, and was on the budget request for this financial year. This recommendation has been revised and the home is now required to inform the Commission when the windows will be replaced. Many of the corridors were in need of attention, particularly damage to woodwork, in contrast with large parts of the home which had been redecorated. Mrs Cooper showed the inspector some of the new bedding and curtains which were on order. She went on to say that she had a meeting the next day to discuss the removal and replacement of the vanity units in all the bedrooms. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 16 Some toilets were in need of a thorough cleaning. Some of the toilet grab rails surrounds were visibly clean on the top surfaces, but showed dried brown drip marks underneath. Some of the door handles were sticky. Toilet brushes were stored in water contrary to infection control guidance. Mrs Cooper said that one of the cleaners was on long-term sick leave and the care support worker who also may do some domestic duties as also sick. All other areas of the home appeared to be cleaned to a good standard and residents reported their satisfaction with the cleanliness of their bedrooms. Cleaning staff were only allocated during the mornings. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 30 Staffing levels both in care and domestic support do not support residents with their routines and provision of care. The main area of concern is ensuring records are kept up to date. Staff put great efforts into their keyworker roles in ensuring residents are well groomed, engaging positively with residents and developing good relationships with residents. Staff have good access to basic training and NVQs. More specialist training, for example, dementia care, is just being provided. However staff are not automatically trained to work with the 6 residents who may have a mental health problem. EVIDENCE: The requirement that consideration must be given to the numbers of care staff provided in relation to the needs of residents at all times and in relation to the objectives in the home’s statement of purpose had not been addressed. The organisation had produced a proposed staff increase in May 2005 but the only increase was for a part time care support worker who was not involved in personal care and for a part time activities person. The care staffing numbers remained the same. The care staffing rota showed a minimum of 1 care leader and 5 care staff during the mornings, 1 care leader and 4 care staff during the afternoons and evenings and 3 waking night staff. At the weekends the numbers went down to 4 care staff and a care leader in the mornings and a care leader and 3 staff for the afternoons and evenings. There were housekeepers during the morning and a laundry person 4 mornings a week. At other times staff were expected to carry out these duties. There was a housekeeper from 1.00pm until 6.00pm to help with the evening meal. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 18 Mrs Cooper reported that all staff were about to undertake a training course in dementia set up in conjunction with the Alzheimers Society. The course would take place over a number of weeks and staff were required to complete workbooks. Training had been given by staff at the falls clinic. Staff and Mrs Cooper said that some staff found it difficult to attend the organisation’s training courses held in Westbury as either they had no transport or it took an hour to get to Westbury. The home is registered to provide up to 6 places for people with mental health problems, yet this subject is not on the organisation’s mandatory training list for staff and no evidence of training having taken place. All new staff were inducted. Regular training included health and safety, first aid, moving and handling, fire prevention, food hygiene and NVQs with 15 of 28 care staff having Level 2 or above. All of the residents spoken with made very positive comments about their relationships with staff particularly their keyworkers. Staff were seen to engage with residents and were respectful of their private space when entering bedrooms. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 33 Mrs Cooper is very clear about developments for the home and the staff team. She has made significant improvements to the home which was without a permanent manager for some time. The home is run in the best interests of the residents. EVIDENCE: Mrs Cooper continues to aim to provide a good service to residents. She is not afraid to challenge bad practice and instigate strategies to improve working of the staff team. Current staffing levels do not support her to achieve many of the aims of the home, notably in continuing to provide routines which some residents have come to rely upon and ensuring that records are kept fully up to date. Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 20 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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X X Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement The person registered must ensure that significant changes in need identified in the daily report prompt an immediate review and revision of the care plan with clear guidance to staff on how that need is to be met. (Reviewing was improved but not as needs changed). The person registered must consider the numbers of care staff provided in relation to the needs of residents at all times and the aims and objectives detailed in the statement of purpose. (The organisation’s proposals had not been implemented). The person registered must ensure that medicines requiring cold storage are kept between 2 and 8c at all times, this must be monitored and any deviation addressed immediately. (this had not been actioned and the fridges must now be replaced as proper temperature are not achieved). The person registered must DS0000028322.V268420.R01.S.doc Timescale for action 19/01/06 2. OP27 18(10(a) 12/12/05 3. OP9 13(2) 01/03/06 4. OP8 18(c)(i) 31/03/06 Page 22 Stratford Court Version 5.0 5. OP8 13(4)(c) 6. OP3 14 7. OP19 23(2)(d) 8. OP30 18(1)(i) 9. OP19 23(2)(b) ensure that all care staff are trained in Tissue Viability. (There is no specialist nurse in the Salisbury area so the organisation was reported to be providing the training). The person registered must ensure that written assessments are carried out with regard to residents’ risk of developing pressure sores. (No progress made as no training implemented. The organisation has reported that a recognised assessment tool will be implemented). The person registered must ensure that the organisation’s latest paperwork is used for the carrying out of assessments. (a previous recommendation was that the day service assessment tool should be adapted to suit the needs of the home, particularly when assessing people who may not be able to verbalise). The person registered must ensure that allocation of cleaning staff throughout the home ensure that it is cleaned to infection control standards. The person registered must ensure that a staff training programme is in place for working with people who have mental health problems. The old single glazed windows to bathrooms should be replaced by modern double glazed windows. (This was previously a recommendation that was not actioned.) The person registered must submit and action plan to show when the windows will be replaced. 01/03/06 12/12/05 12/12/05 28/02/05 31/01/06 Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Stratford Court DS0000028322.V268420.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. 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