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Inspection on 06/08/09 for Aldercar Care Home

Also see our care home review for Aldercar Care Home for more information

This is the latest available inspection report for this service, carried out on 6th August 2009.

CQC found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

People living at Aldercar are generally very satisfied with the service they receive and they benefit from a well trained and committed staff team. Many have worked at the home for a number of years and this experience helps to provide people with continuity and stability. People told us that the staff are genuinely caring and the home has a lovely atmosphere. The interaction between staff and people living at the home was very good and staff were observed to be respectful at all times. The staff have developed excellent working relationships with the District Nurses who visit people at the service and they have demonstrated their skill in preventing people from developing skin problems. Care plans are comprehensive and are reviewed and up dated on a regular basis.

What has improved since the last inspection?

Four requirements and seven recommendations were made at the last key inspection. All of these had been met and the required methods put in place to sustain the improved practice. Staff from Aldercar have received training around the `Dignity Challenge` and a member of staff has been made dignity `champion`. The Dignity Challenge is a clear statement of what people can expect from a service that respects dignity. It is backed up by a series of `dignity tests` that can be used by providers, commissioners and people who use services to see how their local services are performing. Training has also included the Mental Capacity Act and Deprivation of Liberty and there is evidence within peoples care plans that these areas are always assessed and considered when a person is receiving support from staff. Staffing levels have been increased at the busiest times of day with provision to further increase as occupancy goes up or as peoples increased needs require. There has been further re-furbishment of the home, including new carpets.

What the care home could do better:

The pre-admission information could include more detail about an individuals care needs and written confirmation of an offer of a place at the home, could be retained on each persons file.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Aldercar Care Home 36 Wood Lane Hucknall Nottingham NG15 6LR     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Angela Starr     Date: 0 6 0 8 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Aldercar Care Home 36 Wood Lane Hucknall Nottingham NG15 6LR 01159637797 01159637797 ann-harris@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Amirchetty Anuradha Rao care home 28 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 28. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Old age, not falling within any other category - Code OP. Dementia - Code DE. Date of last inspection Brief description of the care home Aldercar is a 28 bedded home offering personal care to older people. The home is located in a quiet residential area in Hucknall, a small town, which has local community facilities, shops and there is easy access to public transport. The home is set in attractive gardens, providing a pleasant outlook for the majority of bedrooms and communal areas. There are 2 double and 24 single bedrooms. The majority of the Care Homes for Older People Page 4 of 28 Over 65 0 28 28 0 Brief description of the care home bedrooms are available on the ground floor and a stair lift provides access to the four single rooms available on the first floor of the home. There is a choice of lounge areas, including a conservatory. There are a variety of aids and adaptations throughout the home, including assisted bathing facilities. The homes current weekly fee range is £310.00 - £394.00 A copy of the most recent inspection report was available in the home. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The focus of inspections undertaken by the Care Quality Commission is upon outcomes for people who use the services and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. We ask managers to fill in a questionnaire called an Annual Quality Assurance Assessment, which tells us how well their service provides for the people who use it and how they intend to improve their service. We received this back from the manager within the required timescale and we used the information it provided us with to assist in planning our visit and deciding what areas to look at. Care Homes for Older People Page 6 of 28 We also reviewed all the information we have received about the service since we last visited in August 2007 and we considered this in planning the visit and deciding what areas to look at. The main method of inspection we use is called case tracking which involves us selecting a number of people who use the service and looking at the quality of the care they receive by speaking with them, observation, reading records and asking staff about their needs. We also sent Have your say surveys to a random selection of people who use the service, some relatives and some staff members. The information provided in the replies we received was also a contributory factor in the focus of our inspection visit. We spoke with 2 staff on duty, the manager, 3 people who use the service and 2 relatives to form an opinion about the quality of the service being provided. We also read documents, and medication was inspected to form an opinion about the health and safety of people who use the service. A copy of the latest inspection report can be found by visiting the Care Quality Commission web site at www.cqc.org.uk What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get Care Homes for Older People Page 8 of 28 printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 28 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The home does not provide intermediate care. Evidence: We saw the Statement of Purpose and the Service User Guide on display in the entrance of the home, along with a copy of the last Key Inspection and other documents including the complaints procedure. As part of our case tracking process, we looked at care files of three people living at the service, including the last person to be admitted. All three files contained preadmission information provided by the local authority and some basic information obtained by the manager. People we spoke with told us that they knew of the home and chose to live there Care Homes for Older People Page 11 of 28 Evidence: because they had heard good things about it. They also confirmed that they had been given copies of the Service User Guide, Statement of Purpose and complaints procedure. The written information provided to us by the manager told us We always ensure that we obtain an assessment from the social worker if one is involved and we carry out an assessment for privately funded people. The files we looked at all contained contracts that were signed by the person receiving a service or their representative. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are treated with respect and their dignity is maintained. They benefit from being involved in developing their care plans. Evidence: The written evidence provided to us by the manager tells us All care plans have up to date relevant information ensuring that the needs and preferences and person centred care needs of each individual are met to a high standard. As part of our case tracking process we looked at files for three people and found the care plans to be relevant, detailed and up to date. Care plans did have signatures of the person or their represenative, providing us with evidence that people had been involved in this process and reviews had been recorded at regular intervals or when a persons needs had changed. There was reference in each care plan, to the Dignity Challenge and it was evident that staff have a clear understanding of this and encorporate it into peoples daily lives. Care Homes for Older People Page 13 of 28 Evidence: The Dignity Challenge is a clear statement of what people can expect from a service that respects dignity. It is backed up by a series of dignity tests that can be used by providers, commissioners and people who use services to see how their local services are performing. People we spoke with were aware of their care plans but not necessarily about the details. The staff are very good and always know what to do. We looked at records of health care needs and saw that these are being met. We spoke to a district nurse who was visiting the home and she confirmed that they always receive good information about people and are able to intervene at the earliest opportunity, therefore preventing an uneccesary deterioration in peoples health. On the occasions that I visit Aldercar, the staff are always courteous and helpful in assisting me. We feel that the carers at Aldercar play an important role in the prevention and management of pressure ulcers. They always report any minor skin conditions and relay any concerns they may have. The care manager has developed a relationship with the local Doctors surgery to ensure that whenever possible, the same Doctor visits people at the home to ensure continuity of care and regular reviews of medication. The service can also offer Palliative care to people and evidence we saw told us that families are encouraged and supported to spend as much time as possible with their loved ones. Accommodation, meals and refreshments are offered during this time. We also looked at medication policies and noted that staff are following these. We saw the medication administration record sheets for the case tracked people and they were all completed correctly with no gaps or errors. Fridge temperatures have been recorded daily and the temperature in the room where the medications are stored. All records relating to medication were looked at and seen to be well maintained. There were no controlled drugs in use at this time but an appropriate storage facility and record book was available. We spoke with people living at the service and all said that they receive their mediaction on time and staff wait and observe them taking it. Each person has an assessment on file for the self administration of meds but none were currently self medicating. Care Homes for Older People Page 14 of 28 Evidence: A district nurse who was visiting the home at the time of the inspection told us If there is ever a problem they are in touch with us straight away. We, as a team, have excellent working relationships with the staff, people are well cared for and happy. The nurse went on to tell us We visit the home several times a week and people are always clean and look comfortable. We have never had anyone complain to us. A relative we spoke with told us Care for people is of a very high standard and I have no concerns about my relatives health and happiness at Aldercar. Care Homes for Older People Page 15 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People enjoy a range of activities and a flexible menu that suits their needs and wishes. Evidence: The written information provided to us by the manager tells us Friends and family always receive a positive welcome to the home and are offered refreshments. By ensuring we gather as much information as possible about people we are able to identify the individual needs and preferences and maintain peoples independence. A relative told us that they are always made welcome and visit four or five times a week. We looked at the records of activities and saw that there is a programme in place, detailing what the planned activities are. It is recorded when people decline to join in with things and in some cases a reason is given. People we spoke with told us there is always something to do and that the staff interact with them all the time. Some people said they do not want to take part in activities but enjoy watching others or doing something else. Care Homes for Older People Page 16 of 28 Evidence: Activities do include some outings and people visiting from the local community to provide entertainment. We also observed that some people do have their own telephones and this enables them to keep in contact with family and friends. One person told us that they enjoy going out to the local shops and try to do this most days. They told us that they feel part of the local community and enjoy the chats with people. Birthdays and special occasions are celebrated at Aldercar and the conservatory can be designated as a function room for family and friends to hold parties or gatherings. Care plans we saw did detail how staff might encourage people to be more independent and active and they included peoples likes and dislikes. There is a five week menu plan in place that is displayed in the dining room along with a board telling people what meals are being provided that day. There is always a choice of main course and we observed people being offered choices. We also observed people having lunch and they told us that the food is very good and there is plenty of it. One person said If I dont like something that is on the menu I am offered something else. We observed people who required assistance with eating, being supported by staff in a caring and discreet manner. Care Homes for Older People Page 17 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes procedures for addressing complaints and for protection from abuse are clear. People are confident that their comments and concerns will be listened to. Evidence: The written information supplied to us by the manager tells us A copy of the complaints procedure is on display on the notice board and we have policies and procedures in place which include the stages and timescales for a complaint to be dealt with. This information also tells us that no complaints have been received since the last key inspection. We looked at the records of complaints and none had been recorded. However, the process for recording and the subsequent actions were clear and staff we spoke with told us that they knew what to do if a complaint was made. We have not received any other information about the service since the last inspection and people we spoke with told us they have not made any complaints, but felt that if they needed to, they would be acted upon. When people move to the service they are given a written statement outlining the services aim to reduce the risk of complaints. It states that staff are trained and competent to meet peoples needs and to address any matters of concern and invites people to speak to the care manager at any time . Care Homes for Older People Page 18 of 28 Evidence: We have been notified of one safeguarding referral and it was not upheld. Steps have been taken by the home to ensure that a similar incident cannot happen in the future. We looked at files for three people and spoke to some people living at the home, some relatives and some staff. All told us that they are aware of the complaints procedure and would feel confident to make any complaint they felt necessary. A relative told us I wouldnt hesitate to complain if anything was wrong, but so far, I havent got anything to complain about. There is always someone around to discuss things with and whatever we ask for gets done. Staff told us that they respond immediately if anyone seems to be dissatisfied and that is why they believe there are no complaints being made. The manager told us she is very pro-active and will seek peoples opinions on a regular basis, therefore preventing issues that could develop into a complaint. We looked at staff training records and saw that Safeguarding Adults training has been delivered to all staff including non care staff and staff we spoke with demonstrated a good understanding of this process. Safeguarding Adults is a process of identifying and reporting suspected or potential abuse of vulnerable people and provides a framework of consistency to protect those individuals at risk. Care Homes for Older People Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, comfortable and pleasant environment that is suitable for their needs. Evidence: The written information provided to us by the manager tells us We identify any refurbishments that are required. The inside of the building is maintained and cleaned to a high standard The garden area is maintained and is kept safe and tidy at all times. We underook a partial tour of the home and saw all communal areas and some bedrooms. There are two lounges, a conservatory and a dining room. On the day of this inspection these areas were all clean, tidy and odour free. The outside areas and gardens are maintained to a high standard and provide comfortable and relaxing areas for people to enjoy. Vegetables and fruit are grown and are eaten by the people living at the service. There is a full time handyman employed and any maintenance issues are managaged by him, unless a contractor is required. There is a system in place where staff record what needs doing and it is then updated when a task is completed. Care Homes for Older People Page 20 of 28 Evidence: Staff we spoke with told us that they write down any tasks they identify and these are always attended to quickly and efficiently. Training records we saw told us that the housekeeping staff have gained National Vocational Qualifications at level 2 and have received training in areas including infection control and health & safety. People we spoke with told us that they are very happy with their bedrooms and have their personal possessions around them. A relative told us My relative has a lovely room that overlooks the car park so they can see everyone coming and going. Care Homes for Older People Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by well trained and safely recruited staff, who are available in sufficient numbers to meet their needs. Evidence: The written information provided to us by the manager tells us We have increased the number of staff on duty for each shift. All staff have completed mandatory training and other training relevant to their position. The previous inspection did make a requirement that staffing levels needed to be adjusted to meet the assessed needs of the people living at Aldercar and we were satisfied that this had been met. We looked at staff rotas and observed that there are always a minimum of two staff on each shift with an additional member of staff at peak times such as evenings and weekends. The care manager also assists care staff as required. The manager told us that as the current occupancy of the home increases, another member of staff will be employed on each of the day shifts. We noted that the majority of staff have worked at Aldercar for many years and there is a very low staff turnover. This provides people with support from staff who are experienced and committed to their work. Training is up to date with all staff having completed mandatory training as well as Care Homes for Older People Page 22 of 28 Evidence: additional training to support their work. We looked at the training matrix which showed us what is planned and booked. It also shows dates for when refresher training is required. A district nurse who was visiting at the time of the inspection told us The staff appear to be well trained. I have never observed anything but good practice. A relative told us All the staff at Aldercar are very special and it is an excellent care home. All staff at the service have completed training in Safguarding Adults, including the cooks, cleaners and maintenance person. There has been some training around the dignity challenge and this is referred to in peoples care plans. We looked at files for three staff members and we spoke with two who were on duty. All files contained all the necessary information relating to recruitment, including Criminal Record Bureau checks, references and proof of identity. We also looked at records of staff supervision and saw that it takes place at regular intervals. Staff we spoke with told us that they receive regular supervision and appraisal and find it a very useful practice that enables them to discuss and request training as well as seek feedback on their performance. They feel valued and supported and believe the residents to be safe and well cared for. Care Homes for Older People Page 23 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is well managed and the health, safety and welfare of the people who live there and staff is promoted. Peoples views and opinions are listened to and they are involved in decisions that affect them. Evidence: The Annual Quality Assurance Assessment tells us The manager accepts her responsibilities fully and the care manager has relevant experience and qualifications. The management team promote the health, safety and welfare of all service users and staff. Four requirements were made at the last key inspection, one of which related to regulation 37 notices to the Care Quality Commission. (This is a regulatory process which informs us of any reportable incidents that occur at a service.) We observed that this requirement had been met and we now receive all necessary information through this process. Care Homes for Older People Page 24 of 28 Evidence: We observed that the other three requirements had also been met and systems put in place to ensure that they continue to be implented. A recommendation was made regarding the homes internal quality audit information being used to inform the services annual business plan and we saw that this had also been implemented. The manager showed us records of the questionnaires given to people and how the information gained from them was collated and used to improve the service. We looked at the maintenance records and saw that the certificates relating to servicing were all in place and up to date. A new stair lift had been installed in recent months. The care manager and her staff work very much as a team and staff members spoken with said she was very approachable and accessible. Health and safety policies are well documented and demonstrate a clear commitment to ensuring the wellbeing of people living at the service. As part of our case tracking process we looked at the records for managing finances for three people. These were well maintained with clear evidence that peoples money was being correctly managed. Care Homes for Older People Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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