Inspection on 15/09/08 for Ardgowan House

This inspection was carried out on 15th September 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ardgowan House 09/10/07

Ardgowan House 12/01/07

Ardgowan House 03/07/06

Ardgowan House 16/01/06

Ardgowan House 22/07/05

Ardgowan House 28/02/05

Ardgowan House 02/09/04

Ardgowan House 27/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 01/12/2008.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Ardgowan House 4 Middle Street Newsham Blyth Northumberland NE24 4AB     The quality rating for this care home is:   one star adequate 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: Karena Reed     Date: 1 5 0 9 2 0 0 8 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. the things that people have said are important to them: They reflect 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 Adults (18-65 years) 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 Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) 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.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Ardgowan House 4 Middle Street Newsham Blyth Northumberland NE24 4AB 01670-367072 01670546391 annie@anniejobson.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs A Jobson Type of registration: Number of places registered: Mrs A Jobson care home 13 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home Ardgowan House is a large, detached house with a small front garden and rear yard. The home is registered to provide personal care to twelve adults with mental health problems and one adult with a learning disability. Five of the places are for people over sixty-five years of age. Nursing care is not provided. The home is situated in a residential area on the outskirts of Blyth. It is close to local shops and pubs. The town centre and coast are also close by. Each person has their own bedroom and they share communal areas that include a dining room/combined lounge, separate lounge, conservatory and a quiet room. A passenger lift is not available but some bedrooms are situated on the ground floor of the property. There are two bathrooms, two shower rooms and sufficient lavatories for the needs of residents. A bathroom and shower Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 5 1 7 Brief description of the care home room are fitted with equipment to assist physically dependent people. A Statement of Purpose and service user guide are available for prospective residents and their relatives to give them information about the services provided by the home and the relevant charges. Fees payable for living at the home at the time of inspection in September 2008 are 395 pounds. Additional charges are payable for hair dressing, personal toiletries, private chiropody, holidays and outings. Care Homes for Adults (18-65 years) Page 5 of 30 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: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means that the people who use the service experience adequate quality outcomes. We have reviewed our practice when making requirements,to improve national consistency.Some requirementsfrom previous inspection reports may have been deleted or carried forward into this report as recommendations,but only when it is considered that people who use services are not being put at significant risk of harm.In future,if a requirement is repeated,it is likely that enforcement action will be taken. How the inspection was carried out: Before the visit: Care Homes for Adults (18-65 years) Page 6 of 30 We looked at: Information we have received since the last visit. · How the service dealt with any complaints & concerns since the last visit. · Any changes to how the home is run. · The provider’s view of how well they care for people. · The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on date 15/09/08. During the visit we: . Talked with people who use the service,relatives,staff,the manager and any visitors. . Looked at information about the people who use the service and how well their needs are met. . Looked at other records that must be kept. . Checked that staff had the knowledge,skills and training to meet the needs of the people they care for. . Looked around the building to make sure it was clean,safe and comfortable. . Checked what improvements had been made since the last inspection. We told the provider what we found. Surveys were sent to 12 residents, 7 were returned. Surveys were sent to some staff, 3 were returned Surveys were sent to care professionals, 2 were returned. What the care home does well: What has improved since the last inspection? What they could do better: This was a much improved inspection and the deficits in health and safety were all that stopped the service rating improving to a higher level. A record must be kept of any accident to a resident and a regulation 37 notice must be sent to inform the regulating authority of any serious injury. A risk assessment must be carried out for the kettle used in the bedroom. A CRB check must be carried out for the proprietors husband as he often visits the home and carries out maintenance work. Staff files must contain staff photographs and proof of staff identity. Care Homes for Adults (18-65 years) Page 8 of 30 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.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 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, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. 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 the person 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. There are good arrangements in place to ensure that prospective residents and their relatives can make an informed choice about the home and that the home can meet their needs. Evidence: Records for three residents showed that when they were admitted to the home an assessment of thier care needs had been carried out before their admission. The resident and relevant people who knew them were involved in the initial assessment. The assessment form encourages staff to explore issues relating to equality and diversity as it refers to gender,cultural,religious,spirituality,educational and social histories,preferred daily routine and preferences. It also looks at mood,speech,behaviour,mental health,risks,sexuality and living skills. This information and the care managers assessment of the resident care needs were used to ensure all the needs of the resident could be met by staff. The records contained a range of information. Residents have the opportunity to visit the home as often as they need in order to decide if they wish to live there. A resident may come for meals, have Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: overnight stays and be introduced to other residents at the home at a pace suitable to the individual. Some residents living at the home have lived there for several years and all are involved in deciding who may come to live with them when a vacancy occurs. Comments include:My care manager explained what the home was about and the care and activities going on for the residents. Up to date contracts are available detailing the costs and services provided by the home. Care Homes for Adults (18-65 years) Page 12 of 30 Individual needs and choices 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 needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are good arrangements in place to ensure that residents care and support needs are recorded and to ensure that residents are involved in decision making in their lives. Evidence: There are detailed assessments in the residents care plans. Staff are allocated responsibility for a small number of residents and are known as their key worker. The keyworker together with the resident are responsible for updating the care plan at least three monthly or sooner if a residents needs change. There has been an improvement in the care planning system,care plans being more person centred however they do not show fully the amount of support that is required to assist the resident in certain areas. The tasks are not broken down to give new staff clear instructions aabout the amount of care and support that is required for the task. Residents are asked individually and consulted about decisions involving themselves Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: and the running of the home. Meetings are held regularly with residents about the running of the home, choice of food,activities and outings. Comments include:I make my own decisions in listening to music and composing poetry. The home supports residents to remain independent and take risks in order to live a more fulfilled lifestyle and upto date risk assessments were present in most residents care records. Residents care records all contained statements of confidentiality to remind staff what information could or could not be disclosed about a resident. Care Homes for Adults (18-65 years) Page 14 of 30 Lifestyle 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 can take part in activities that are appropriate to their age and culture and 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 and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. 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. Residents have access to a range of activities both inside and outside of the home which helps them to enjoy a more varied life. Residents are also supported to keep in touch with their families. Evidence: Residents records and residents meeting minutes provided evidence that all residents are consulted and asked their opinion and encouraged to make decisions. Conversation with residents and staff show that residents are provided with the necessary levels of support to help the resident maintain some level of independence and retain some skills to be more self sufficient in aspects of everyday living. Residents are encouraged to pursue their own interests and hobbies and are supported to do so;writing poetry,kareoke,listening to music,reading and jigsaws.Residents also enjoy meals out at local pubs, shopping,attending relaxation classes,card playing,board Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: games,bingo,dominoes and whatever is of interest to the resident. Small groups of residents have enjoyed a holiday at Berwick this year and plans are being made to visit Blackpool. Activities also take place such as pie and pea suppers and entertainment at a local social club to raise funds for outings. Comments include more money to fund entertainment and social activities. More staff needed for activities and outings. Within the home some residents bedrooms are equipped with their own televisions,radios, books,pictures and whatever is of interest to the resident. Residents care plans and case records detail any family involvement. Conversation with residents also provided evidence that residents are encouraged to maintain contact with family and friends, if they wish to do so, with staff providing any support that may be required. Residents are asked individually what they wish to eat each day. A light snack is available at lunch times and a larger cooked meal is served in the evening. On the day of inspection spaghetti bolognese or shepherds pie,followed by apple charlotte and custard or fruit and yoghurt was available for the evening meal. Some residents attend local church. Care Homes for Adults (18-65 years) Page 16 of 30 Personal and healthcare support 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 receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people 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. If people are approaching the end of their life, the care home will respect their choices and help them to 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are adequate arrangements in place to ensure that residents health and social care needs are met. Evidence: Three care plans and case records were inspected. The daily records detailed the care and support required for different needs. They reflected the changing needs of service users as they become older. The home respects the wishes of an individual when dealing with their increased dependency. Most service users do not have any moving and handling needs. Most service users need minimal help with personal care tasks, such as bathing and dressing. Privacy and dignity are respected at all times. Comments include:the service does assist the needs of clients e.g health,personal and social care. Service users care records showed that they have access to external health care services. Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: G.Ps visit when necessary. Service users are referred for specialist health care if appropriate. All service users receive regular health care checks from opticians and dentists. Staff who have completed relevant training administers medication. A sample of medication records was examined. Clear directions were recorded and each dose of medication was signed for, or a code entered to verify the reason not given. No resident administers their own medication currently. A system could be put in place to oversee the medication of residents if they should retain and administer their own medication. Privacy and dignity issues are built into the homes policies and procedures and staff training. All personal care and medical examination/treatment is carried out in private. Care Homes for Adults (18-65 years) Page 18 of 30 Concerns, 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. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. 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. There is a clear complaints procedure and systems are in place to protect residents from abuse. Evidence: There is a complaints procedure that includes what complainants should do if they are not happy with the homes investigation and response. The procedure is written in a way that ensures service users understand its contents. One resident said that staff always listened to any concerns and always dealt with them fairly. Comments include: I have a key worker who is always on hand to listen and advise me. The home keeps a record of complaints. Three complaints have been received since the last inspection but they did not contain enough information to allow thorough investigations to take place. The home has a Whistle Blowing policy and the Local Authorities Vulnerable Adults procedures. Staff have received training about Protection of Vulnerable Adults and Prevention of Abuse. Residents can deposit money for safe keeping in the homes safe and records are kept Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: of accounts. Care Homes for Adults (18-65 years) Page 20 of 30 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, comfortable, 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. People have enough privacy when using toilets and bathrooms. 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 home provides a comfortable and safe environment for those living there and areas are clean, tidy and free from offensive odours. Evidence: There is a programme of redecoration and improvement around the home. The home was clean, well decorated and well maintained. The home has an appropriate amount of sitting, recreational and dining space. There are enough rooms for a variety of activities to take place. Residents can see visitors in private in their own rooms. Furnishings and fittings were domestic in design and in good condition. Lighting was bright and domestic in design. Residents bedrooms have opening windows. The rooms were centrally heated. All bedrooms were personalized according to individual taste. There was emergency lighting throughout the home. Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: Water is stored at over 60°C. Valves at water outlets ensure water is provided close to 43°C to prevent scalding. The home was clean and free from offensive odours. The laundry facilities are well organised. The washing machines have the specified programme to meet disinfection standards. Care Homes for Adults (18-65 years) Page 22 of 30 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, qualified 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. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. 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. There are enough staff who are appropriately recruited and well trained to meet the needs of the residents. Evidence: 7. 00am- 11:00pm 2 - 3 staff members 10.00pm-8.00am 1 sleep in and 1 waking night staff These numbers include the manager.A senior management structure has been created to run the home in the absence of the manager ,who is also the proprietor. There has been a high turn over of staff in the past but a more stable staff team seems to have been created.There are twleve members of staff who usually work on a part time basis. Staff members carry out cooking and cleaning duties. Staff stated that they enjoyed working in the home and were observed to be kind, caring and respectful to residents. There is now an excellent level of staff training. 10 members of staff have now achieved National Vocational Qualifications at levels 2 and 3 so over 80 of the work force are qualified. Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: Staff and their records showed that they also receive training or advice in other areas such as falls awareness, continence, vision,sexual awareness and learning disabilities, challenging behaviour with mental health and dementia, diabetes awareness,infection control, moving and handling,medication training,podiatry,bereavement,equal opportunities,food management,dementia care,health and safety,capacity and consent,person centred planning and fire training. Staff receive regular supervision. Comments include: All staff have been very keen to do the training provided by the manager,Care Alliance etc and have found it beneficial. Our performance and supervisions are currently being updated to a better standard. We are all doing various training courses and NVQs which is helping to keep us upto date with policies and procedures and changes that our service users may experience. Im going on regular training which is relevant to our service users needs. Some of our service users have lived here a few years now and are naturally facing problems due to age etc. We have carried out training such as diabetes,bereavement,first aid all of which is essential within our jobs. The home provides a homely,safe environment for service users who are vulnerable people and need regular support and reassurance with day to day problems. Service users seem to be happy and contented to be in this home. They know they can go to any member of staff for help and guidance whenever they want. Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the 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 have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because 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. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health,safety and welfare of the residents are not always promoted and protected. Evidence: The manager has the appropriate qualifications, experience and management skills necessary to manage the service. Residents living at the home have lived there for some time and appear to like living there. Comments include: Service is very friendly, experienced. All our residents are extremely happy and contented to be in this home. I am quite happy to be in Ardgowan House. The health ,safety and welfare of residents are promoted and protected apart from a risk assessment was not available for a resident who used a kettle in his bedroom. Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: There is a health and safety policy and a range of associated procedures. The staff receive training in health and safety and safe working practices fire safety, moving and handling, first aid, food hygiene, and infection control. Servicing and maintenance agreements are in place for facilities and equipment. Records as required by the Care Homes Regulations were mostly well documented and completed. There was evidence that the home was not keeping a record of all accidents to a resident or notifying CSCI of any accident to a resident, a regulation 37 notification had not been completed when a resident sustained an injury and there was no written evidence about the accident. The necessary checks are being carried out prior to workers being appointed. Two written references were available on staff files examined from the most recent employers. An application form had been completed for each staff member. CRB checks are carried out before a person is appointed however the owners husband who is present at the home with her most days had not had a CRB check carried out. Not all staff files contained proof of identity. Not all staff files contained a photograph of the staff member. All fire safety checks, tests and instructions to staff are conducted at the required frequency and recorded. Water storage tanks, gas and electrics are checked annually. Staffing records looked at contained all the relevant information apart from they did not all contain proof of identity or a recent staff photograph. Care Homes for Adults (18-65 years) Page 26 of 30 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 Adults (18-65 years) Page 27 of 30 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 1 41 12 A record must be kept of any 16/10/2008 accident to a resident and CSCI notifed if necessary. Health and safety,statutory record keeping. 2 41 13 Staff files must contain proof 31/10/2008 of identity and an upto date staff photograph. Protection 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 1 42 13 A risk assessment must be 16/10/2008 carried out for the use of the kettle in the bedroom. Health and safety 2 42 13 A CRB check must be carried 31/10/2008 out for the proprietors husband. Protection. 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 1 6 Care plans should be broken down to give clear instructions Page 28 of 30 Care Homes for Adults (18-65 years) to staff to show the amount of care and support that is required for the task, 2 39 To continue to consult with residents. Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: 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 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 © (2008) Commission for Social Care Inspection (CSCI). 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