Inspection on 21/01/09 for Birdsgrove Nursing Home

This inspection was carried out on 21st January 2009.

CSCI found this care home to be providing an Adequate 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.

Other inspections for this house

Birdsgrove Nursing Home 22/03/10

Birdsgrove Nursing Home 07/12/09

Birdsgrove Nursing Home 30/01/07

Birdsgrove Nursing Home 07/02/06

Birdsgrove Nursing Home 29/09/05

Birdsgrove Nursing Home 13/12/04

Birdsgrove Nursing Home 04/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 18/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Birdsgrove Nursing Home Warfield Road Bracknell Berkshire RG12 2JA     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: Denise Debieux     Date: 2 1 0 1 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. 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 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 42 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.csci.org.uk Internet address Care Homes for Older People Page 3 of 42 Information about the care home Name of care home: Address: Birdsgrove Nursing Home Warfield Road Bracknell Berkshire RG12 2JA 01344422261 01344423629 birdsgrove@asterhealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable): Southern Counties Care Limited (Aster Healthcare) The registered provider is responsible for running the service Name of registered manager (if applicable) Ms Mary Jane Katherine Slater Type of registration: Number of places registered: care home 87 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Service users not to be admitted under 60 years of age for long term care. Service users under 60 years of age to be admitted for respite care only. Date of last inspection Brief description of the care home Birdsgrove Nursing Home is registered to provide personal and nursing care for up to eighty seven older people, twenty of whom may have a primary diagnosis of dementia. The home is situated on the borders of Bracknell in a residential area on the main thoroughfare to the village of Warfield. The home is divided into three wings Care Homes for Older People Page 4 of 42 Over 65 0 67 20 0 Brief description of the care home determined by the development of the establishment over time. The Surrey Wing (23 places) was originally a large domestic home which has been converted, the Berkshire Wing (35 places) a purpose built two storey extension, and the Kent Wing (20 places), a single storey extension built in the 1990s for service users with dementia. Care Homes for Older People Page 5 of 42 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 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 Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This unannounced visit formed part of a key inspection and was carried out by Denise Debieux, Regulation Inspector. The Registered Manager was present as the representative for the establishment. It was a thorough look at how well the service is doing. It took into account detailed information provided by the manager and any information that CSCI has received about the service since the last inspection on 30th January 2007. People who use this service are referred to as service users. For clarity and consistency this term will be used throughout this report. Care Homes for Older People Page 6 of 42 During this visit the inspector was also accompanied by an expert by experience, who spent four hours at the home between 10am and 2pm. An expert by experience is a person who has direct experience of using social care services, including carers, and visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The expert by experience spent her time speaking with service users and also had lunch with them. Observations fed back to the inspector by the expert by experience have been included in this report. A tour of the premises took place. On the day of this visit the inspector spoke with fifteen of the service users and eight on duty staff. Prior to the inspection, survey forms were sent to service users, staff employed at the home, health professionals and care managers. Survey forms were returned by thirteen service users, thirteen members of staff, three health professionals and two care managers. These comment cards were correlated and the results were shared with the manager during the inspection. Comments made on the survey forms, both positive and negative, were included in the correlation and shared with the manager. Care was taken to exclude any comments that could identify the writer. The manager demonstrated a very pro active attitude to the results of our survey and plans to explore any concerns raised further as part of the homes quality assurance process. Some of the comments made to the inspector and made on the survey forms are quoted in this report. The home had completed an annual quality assurance assessment (AQAA) and service users care plans, staff recruitment and training records, menus, health and safety check lists, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Fees range from 576 to 740 pounds per week. This fee does not include chiropody, hairdressing or personal items. This information was provided on 21st January 2009. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this visit and the service users, staff, health professionals and care managers who participated in the surveys. 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. Care Homes for Older People Page 8 of 42 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 Older People Page 9 of 42 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 42 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. Each service user is only admitted to the home following a comprehensive needs assessment to ensure that the home can meet the service users identified needs. The home does not offer intermediate care. Evidence: The inspector was advised that, on the first enquiry from a prospective service user or their representative, the service user or their representative will be invited to visit the home. Following the initial visit to the home, and if the service user wishes to continue, the manager, or one of the registered nurses, will visit the service user and carry out a pre admission assessment to ensure that the home can meet the service users needs and wishes. Five care plans were sampled during this visit. In each case comprehensive pre Care Homes for Older People Page 11 of 42 Evidence: admission assessments had been carried out to ensure that the home could meet the service users identified needs. Data provided in the homes AQAA does not identify any service users with specific religious, racial or cultural needs at this time. However, from the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. In the AQAA, to demonstrate what the home does well, the manager stated that: All service users have a preadmission and evaluation completed prior to admission with input from interested professionals. This forms the basis of the initial Care Plan. All prospective service users and their representatives are invited to visit the Home prior to admission and to move in on a trial basis. The evidence seen at this inspection supported this statement. Of the thirteen service users surveyed, ten felt they had received enough information prior to moving to the home and three answered no. One relative commented: Went to view it and was impressed at how homely it was set out and how nice the staff came across. One of the care managers who returned a survey form commented: When I have placed service users within Birdsgrove the assessments that have been completed have been accurate and I have been able to see them and the care plan without delay. Care Homes for Older People Page 12 of 42 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal and health care support is planned by staff and was seen to be provided to a high standard and in a respectful and sensitive manner. However, service users are not actively involved in planning the care and support they receive, care plans do not include details of social care needs and staff are not always following the actions set out in the care plan. Policies, procedures and practices are in place to ensure the safe administration of medication. Evidence: The care plans sampled during this visit were all based on pre admission assessments and had been drawn up either on the day of, or shortly after each service users admission to the home and included appropriate risk assessments. These care plans were very detailed and clearly set out the actions which need to be taken by care staff to meet the health and personal care needs of the service users and protect them from identified risks. Care plans are reviewed on a monthly basis and daily notes are kept that reflect the care given. These daily notes demonstrated that any changes or new Care Homes for Older People Page 13 of 42 Evidence: concerns are promptly acted upon, although not always added to the care plan. However, the daily notes were mostly general and did not evidence that staff are working to or referring to the care plans. There was, however, some evidence that staff are not following the instructions set out in the care plans or complying with identified risk reduction methods, for example, one service user had a history of falls and the care plan included that he should wear shoes, use a walking frame and be supervised when walking. On the day of this inspection the service user was wearing bedroom slippers and walking unsupervised with the aid of a walking stick. The inspector was advised that the service user did not use a walking frame and that that had been the information provided to the home on his admission. The service user had fallen a few weeks after moving to the home but there was no evidence that staff had re evaluated the care plan and amended the actions needed to minimise the risk of further falls. This care plan had been reviewed one month after admission by one of the registered nurses and a note made that the service user had fallen but no changes had been made to the care plan, despite the fact that parts of the care plan were inaccurate. The staff do not routinely carry out falls risk assessments for service users unless there is a history of falls or if the risk has already been identified. Current best practice guidelines place the emphasis on early detection of an increased risk of falls so that preventative action can be taken beforehand. Contact details for the Bracknell Forest Borough Council falls prevention team were given to the manager for her information. At present there is minimal involvement by service users or their representatives in the drawing up of their care plans and there was no evidence to show that service users were aware of or had agreed to the content. The care plans, although very detailed and well set out, do not include detailed plans to meet service users social care needs, although care is taken to obtain a life history and details of previous hobbies, pastimes and preferred activities. A requirement has been made regarding care plans, the need for quality assurance monitoring is addressed in the Management and Administration section of this report. Of the thirteen service users surveyed, seven said that they always receive the care and support they want, five answered usually and one left this answer blank. One service user added the comment: I have found the staff to be polite and ready to listen and back me up if I have any problems. Comments received from health professionals included: I feel the nursing care is exemplary at Birdsgrove. I have had nothing but good response from families who have loved ones placed there. Whenever I have gone in for reviews etc. service users always look well and cared for and I have heard from service users and families that they have been happy with the care provided. Care Homes for Older People Page 14 of 42 Evidence: Feedback received by the inspector from the expert by experience relating to care provided included: The service users were clean, tidily dressed and observed to be carefully cared for. The long awaited building work has not yet taken place. I believe the contractors met with the service users representative on the day of the inspection. I believe most of the staff are offering the best support they are able to in an area of increasing difficulty. In the AQAA, to demonstrate what the home does well, the manager stated that: All service users have a Person Centred Care Plan in line with the Companys policies and procedures which is initially based on the pre assessment but is then expanded upon with the involvement of the service user and their representative. This statement is not fully supported by the findings at this inspection for the reasons set out above. The lunchtime medication round was observed and the medication administration records, medication storage, controlled drug storage and recording were all sampled and found to be in order. The three health professionals who returned survey forms all stated that the staff at the home always support individuals to administer their own medication or manage it correctly where this is not possible, with one commenting: Staff ensure medication is given correctly and on time. In the AQAA, to demonstrate what the home does well, the manager stated that: All service users have access to NHS services. The Home ensures that the Registered Nurses have an added qualification to promote wound care; infection control etc. All trained staff have attended medication training and complete updates as required. Privacy and Dignity are paramount and all staff receive instruction on maintaining these on commencement of employment and during staff meetings and hand over. This statement is supported by the findings at this inspection. During the tour of the home staff were observed to always knock before entering the service users bedrooms and all interactions observed between staff and service users were seen to be caring and respectful. All service users spoken with stated that they felt their privacy was always respected. Care Homes for Older People Page 15 of 42 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The daily routines at the home are flexible and there is an activity programme available for service users to participate in if they are able. However, more work needs to be done to meet all service users social care needs and to ensure that each service user is provided with opportunities to engage in social activities that are meaningful to them. Contacts with family and friends are encouraged. Meals are well balanced and varied with individual choices and preferences catered for. Evidence: The routines of daily living are arranged, where possible, to suit individual service users preferences and choices. Feedback received by the inspector from the expert by experience relating to choices available to service users included: Service users are able to choose the content of their breakfast, their own choice of clothing from their own wardrobe. There was little choice for the service users in Berkshire but to stay in their rooms because, since many of them were wheelchair bound if out of bed, there was no large enough gathering place available. I observed two service users who were mobile, walking Care Homes for Older People Page 16 of 42 Evidence: about in both the Berkshire and Surrey wings, these are accessible, flowing from one area to the other. One gentleman was distressed having lost his room. He was thoughtfully assisted back to his room and assured that that was indeed his own chair and bed. The other service user found himself a pleasant seat in the Surrey communal room. The home employs one activity coordinator and there are organised activities available during the week for those that are able to or wish to attend. During this inspection it was observed that the majority of service users on the Kent wing were involved in activities that were meaningful to them for most of the day, much helped by the fact that the majority of these service users are able to walk around and make their own choices as to where to go. On Surrey wing a number of service users spent their time sitting in the Surrey lounge although there was little social interaction or stimulation observed during the morning and, as observed by the expert by experience, these service users spent most of the morning asleep. The Berkshire wing has no communal lounge so service users spend the majority of their day alone in their own rooms, there was very little social interaction or meaningful activity observed outside of times when people were being assisted with personal care or at mealtimes. These findings are very similar to those found and reported on at the last key inspection. At that time the inspector was advised that the home had drawn up plans for major rebuilding that would include providing a communal lounge on the Berkshire wing. It was stated that the work was expected to be carried out in 2007. It is disappointing that there is little change in this situation two years later and the service users on Berkshire wing are still without any communal space. In the care plans sampled, life histories were seen which included peoples previous hobbies and pastimes. Staff take the time at the pre admission stage to make sure that they have detailed information on activities that are important to people. However, in the files sampled the activity plans were very limited and had not been individualised. For example, in one care plan sampled it was noted that the service users main interest was snooker, the activity plan did not mention snooker, simply to encourage the service user to attend organised activities. There was no evidence that, after recording the service users past interests, anything further had been done to find ways for him to continue with this activity. The need for social care/activities to be included in the care plans has been addressed in the previous section of this report. From observations made at this inspection, comments received on survey forms and some comments made by staff on the day of this inspection, it is clear that the manager and her care team have a strong belief in and commitment to providing person centred care. However, the majority of staff time is taken up with providing the good quality personal and healthcare that they are rightly proud of and there does Care Homes for Older People Page 17 of 42 Evidence: not appear to be any time left or provided to address peoples social care needs. All people were very complimentary about the work done by the activity coordinator and the time she is able to spend with them but it would not be possible for one person to meet the social care needs of all service users, especially as many of the sixty two service users currently living at the home have very high care needs and limited ability to mobilise independently. A requirement has been made and the home must now focus on providing all service users with individualised plans that detail how their social care needs are to be met, taking into account their previous interests and present abilities. It is important that each service user is enabled to engage in activities that are meaningful to them and that reduce the very real risk of social isolation for those that spend the majority of their time alone in their rooms. The requirement already made under the Health and Personal Care section of this report (to include social care needs in care plans) has a relatively short timescale as it is important that the home begins to address this issue without delay. The requirement made under this section of the report has been given a longer timescale in order to give the manager time to develop a plan, obtain additional advice and guidance, source and provide additional training to staff (if deemed necessary) and to implement the plan, improve the homes social care provision for all service users and meet the requirement made in full. It is acknowledged that the design and layout of the building, together with the service users differing abilities to participate in group activities, present challenges but this is not a new situation for the home and does not alter the fact that the provider is required to meet the social care needs, as well as the personal and healthcare needs, of all service users already accommodated at the home or to whom they offer accommodation. The inspector discussed and left details of the National Association for Providers of Activities for older people (NAPA). This is a voluntary organisation dedicated to increasing the profile and understanding of the activity needs for older people, and equipping staff with the skills to enable older people to enjoy a range of activity whilst living in care settings. Further information can be found on the NAPA website at: http:/www.napa-activities.co.uk/m This organisation also provide a free self assessment document Activity Provision: Benchmarking good practice in care homes that is available for download from that site and that the home may find helpful. Feedback received by the inspector from the expert by experience relating to social interaction and activities included: When I arrived at Birdsgrove I was informed that the Activity Leader would be showing me round. She was found playing catch with a chair bound gentleman in his room. They had clearly also been playing draughts as the Care Homes for Older People Page 18 of 42 Evidence: pieces were put away before she left. He was asked if he would like to join the afternoon Bingo game and was promised that the Activity leader would collect him. I enquired and was informed that she was alone in her post. It was immediately apparent that the majority of the service users are elderly and very frail. Many were in their bed or had been moved to a chair in their own room or, where available, to a communal area. The seven service users in the Surrey wing remained in their chairs all the time I was in the home. They were woken to be assisted to drink coffee at 11.00am and woken again to be given their midday main meal at about 12.15pm. In the Kent wing the service users were generally much more active and communicated with their fellow service users and the staff. It was pleasingly apparent that the staff knew most of the service users and where they had come from. In the whole of the rest of the building there appeared to be only two others who were fit and able enough to walk freely about the building. Other service users would have walking aids and wheel chairs to enable them. This clearly made communal gathering more difficult because of the time and space needed to facilitate such events. However the staff were all appropriately supportive to all the service users. Group activities normally take place in the Berkshire activity room, but very few would be able to take part due to the limited space available. I understand that the activity leader is able to take individuals on shopping trips in the summer months. Two of the thirteen service users surveyed stated that there were always activities they could participate in, seven answered sometimes, three answered never and one left this answer blank. Additional comments included: Activities mostly not to my liking, Ive lost the use of my legs, which makes activities very limited, The activities are always available but my relative doesnt mix, so doesnt take part in them. They have tried endlessly to involve him, There could be more activities for clients who are unable or unwilling to leave their rooms. The TV is on in my relatives room at all times. My relative has not ever really enjoyed the television and prefers to listen to the radio and The person who does the activities is very good but it is not always possible to keep people with dementia entertained as they like to do their own thing. Additional comments received on survey forms from care managers included: Changes need to be made further to the environment to ensure more social stimulation and community spirit maintained throughout the home. Too many service users spend their days in isolation in their rooms, with staff only popping in to provide personal care, medication and meals and Some shortfalls with social interaction as some areas do not lend themselves to social activities, no dining area, shortage of lounge areas and staff often too busy to spend quality time with service users. There are no restrictions to visiting times and staff support and encourage service users to maintain family links and previous friendships. Care Homes for Older People Page 19 of 42 Evidence: The lunchtime meal was taking place during this visit, the food was well presented and there were enough staff available to offer help and assistance as needed. Feedback received by the inspector from the expert by experience relating to the lunchtime meal included: I visited and talked with eight service users in their rooms and had my lunch at an individual table, as did the seven service users in the Surrey communal area. It was pleasing to note that initially assistance (essential) was given to two service users and, when they had finished assisting service users in their rooms, two more carers arrived to assist with feeding two more in need. The meal content was appropriately soft and for those who required, it had been liquidised. The meals were served from a hot trolley, each meal having been prepared for a specific individual. There did not seem to be a choice in what was on the plates, but each service user could leave what they did not like. A choice of juices was freely available and tumblers observed to be empty were topped up if required. In the AQAA, to demonstrate what the home does well, the manager stated that: Activities are tailored to the needs and wishes of our service users. Religious clergy visit regularly. Some service users attend day centres and clubs. We have an open door policy for visitors. Service users and their families may bring in personal possessions. All service users and their families complete a food preference form, the Chef visits them and where necessary a nutritional care plan is commenced which is current and reviewed monthly or as required. The above statement is mostly supported by the findings of this inspection. The need to develop and expand social care at the home has already been discussed. Of the thirteen service users surveyed, two said that they always liked the meals at the home, ten answered usually and one answered sometimes. Additional comments included: The chef tries to ensure my wishes are met within his financial limits, My relative seems to enjoy most things given to eat and has put on some weight and There is plenty of variety. The food is nutritious and traditional. Yoghurts, tinned fruit and ice cream are always appreciated. Care Homes for Older People Page 20 of 42 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 home has a simple, clear and accessible complaints procedure which includes timescales for the process. Policies and procedures are in place to protect service users from potential harm or abuse. Evidence: The home has a complaints procedure in place that is available to all service users and their relatives and is also included in the service users guide. No complainant has contacted the Commission with information regarding a complaint or allegation made to the service since the last inspection. All service users surveyed confirmed that they knew how to make a complaint. There is a whistle blowing policy in place and the home have a copy of the latest Berkshire Safeguarding Adults Policy and Procedure. Training in safeguarding adults is included in the homes staff induction and the manager and senior staff are aware of the requirements of the Mental Capacity Act and have training planned for the Deprivation of Liberty legislation that comes into effect on the 1st April this year. Concerns relating to current staff recruitment practices are addressed in the Staffing section of this report. In the AQAA, to demonstrate what the home does well, the manager stated that: Care Homes for Older People Page 21 of 42 Evidence: Company complaints procedure is followed through to its conclusion with all parties involved. Complaints procedure displayed in the entrance hall, copies of the procedure included in the information pack given to all service users and their representatives. Staff undertake protection of vulnerable adults and crisis prevention and intervention training. The above statement is supported by the findings of this inspection. Service users spoken with said that they felt safe at the home with one service user adding: Oh yes, very safe, the staff are all lovely and look after us. Care Homes for Older People Page 22 of 42 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The layout of the buildings and accommodation and facilities provided at the home are adequate, but not ideal for their stated purpose. The maintenance and refurbishment work carried out since the last inspection has improved areas of the environment and is providing service users with a more comfortable and homely environment in which to live but essential work expected to be completed in 2007 has yet to be started. All bedrooms and communal rooms are supplied by the call bell system but action needs to be taken to ensure that all service users are able to obtain assistance should they need it. Evidence: The home is made up of three wings, Surrey, Berkshire and Kent. There is a large secure garden to the back of the premises which is well maintained and provides pleasant additional seating in the warmer weather. The home was toured during this visit. The personal bedrooms were seen to be personalised to the individual service users wishes. Since the last inspection there have been a number of improvements to the communal and individual areas of the home, as set out by the manager in their AQAA: The new owners have decorated all bedrooms, changed the light shades, supplied new curtain rails and curtains and new furniture. A new nurse call system has also been installed in Berkshire Nursing Wing. Care Homes for Older People Page 23 of 42 Evidence: All carpets within bedrooms have been renewed, some of the flooring has been replaced. All rooms are furnished to ensure comfort and where necessary adjustable beds are provided. At the last inspection two years ago CSCI were advised that some older parts of the building were to be demolished and replaced with accommodation which would meet current standards. The kitchen and staff room were to be relocated from the first to the ground floor providing space for a communal area for service users on the Berkshire Wing. A plan for the development of the site had been drawn up and CSCI were advised that the implementation of the plan in 2007 would present an opportunity to address a number of problems in the environment. However, the work had not been carried out in 2007 and in an AQAA provided by the home in October 2007 it was stated that: Planning permission has been obtained from Bracknell Forest Borough Council and this work to the building will be commencing in the New Year. (January 2008). On the day of this visit it was found that the promised work had not been started in January 2008 and had still not been started. The provider visited the home during this inspection and advised the inspector that he was there to sign off the plans and that work would be starting on the new kitchen on the following Monday. There is currently no detailed information available at the home for the service users, their representatives or the staff that relates to the proposed works. This work would appear to be extensive and will present substantial disruption to all at the home and those visiting. Service users and staff spoken with are looking forward to the benefits the completion of this work will provide but it is not acceptable that they have not been kept fully informed of progress. A requirement has been made that the provider draw up a plan of works, fully detailing the work that will be done, together with proposed start and completion dates for each stage. This plan must be made available at the home to all service users, their representatives and the staff and they must be kept informed of any substantial changes to the plan of work or timescales that take place. Feedback received by the inspector from the expert by experience relating to the environment included: Birdsgrove Nursing Home is a mixture of old and newer accommodation. It does not present as a comfortable building/home since most of the service users individual rooms are floored with a practical washable surface. In the older parts of the building there are beautiful stained glass windows and wide staircases. There is a large communal sitting room in the Surrey wing and a small and a larger one in the newer Kent wing. The activity area in the Berkshire wing is small, crowded and inadequate. Of the thirteen service users surveyed six said that the home was always fresh and Care Homes for Older People Page 24 of 42 Evidence: clean and seven answered usually. In July 2008 concerns were raised with the home that staff were not routinely ensuring that service users were left with their call bells within reach when they were alone in their rooms. The inspector was advised that, once the concern was raised with the home, all staff had been notified that they must make sure when leaving service users rooms, that they are able to reach their bells. During the tour of the home on the day of this inspection it was again noted that not all service users sitting in their rooms had their call bells placed within reach. Out of fourteen rooms seen on one wing, only three people were able to reach their bells. The nurse accompanying the inspector promptly rectified the problem in the rooms visited and asked another member of staff to check any rooms not seen. However, it is disturbing that this is still an issue at the home and that staff are continuing to leave service users with no means of calling for help or assistance, this could lead to an increase in service users feelings of isolation, does not promote their independence or choice and is potentially placing them at risk of harm or injury. Also during the tour of the home, when entering the lounge on the Kent wing, there were two service users attempting to help another service user up from the floor, there were no staff members in the lounge or nearby to supervise. There was no way to call for additional assistance as, although there was a call bell point in the lounge, there was no bell attached to it. At present two thirds of the service users at the home have varying degrees of dementia. The inspector was advised that, even if left within reach, many of the service users do not use their call bell. The home do carry out an assessment of someones ability to use a call bell on admission, however there were no follow on care plans seen that described staff action needed where someone was assessed as not being able to use a call bell (e.g. scheduled checks to see if someone wanted help, the potential of using dementia signage, alternative bell or button attachments to use with the current call bell system etc.) The staffing levels, especially during times of peak activity, do not indicate that the need for increased supervision has been taken into account. A requirement has been made regarding ensuring service users are able to obtain assistance when they need it. The need to review staffing levels is addressed in the Staffing section of this report and management issues relating to these concerns are addressed further in the Management and Administration section of this report. Laundry facilities are sited in the basement with washing machines suitable for the needs of the service users at the home. In the AQAA, to demonstrate what the home does well, the manager stated that: Infection Control policies and procedures are followed in respect of in house laundry and the trained nurse who is responsible for infection control training in house revisits this at least three monthly. Care Homes for Older People Page 25 of 42 Evidence: On the day of this visit the home was found to be warm and clean with individual bedrooms seen to be personalised with service users own possessions. Care Homes for Older People Page 26 of 42 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home needs to ensure that staff are available in sufficient numbers, at all times, to meet the personal, health and social care needs of all service users. Current staff recruitment practices are potentially placing service users at risk of harm and/or abuse. The home has a staff training programme which is designed to ensure, as far as reasonably possible, that service users are supported and protected. Evidence: The care team comprises the registered manager, twelve registered nurses and thirty five care assistants. The manager advised that the home do not use agency staff. Staffing numbers were discussed and the staff rota was sampled for the week prior to this inspection. There are three shifts at the home, the morning shift runs from 8am to 2pm, the afternoon/evening shift runs from 2pm to 8pm and the night shift is 8pm to 8am. Each unit is staffed independently as follows: Berkshire wing (currently has twenty nine service users) has two registered nurses (RN) and six care assistants on the morning shift, two RNs and four care assistants on the afternoon shift and one RN plus two care assistants overnight. Surrey wing (currently has fifteen service users) has one RN and three care assistants on the morning shift, one RN and two care assistants on the afternoon shift and one RN plus one care assistant overnight. Kent Care Homes for Older People Page 27 of 42 Evidence: wing (currently has eighteen service users) has one RN and three care assistants on the morning shift, one RN and three care assistants on the afternoon shift and one RN plus two care assistants overnight. In discussion the manager stated that staffing levels had recently been increased at weekends in response to comments received from staff. As discussed earlier in this report, the layout of the building, the high level of dependence of many of the service users and the need for increased supervision in some areas and at some times of the day are of concern. The management needs to review the current staffing levels and ensure that they are sufficient to enable the home to meet all the personal, health and social care needs of all service users. This need is also reflected in the comments received from staff, service users and their relatives on survey forms received prior to this inspection. Of the thirteen members of staff surveyed, four said that there were always enough staff to meet the individual needs of the service users, six answered usually and three answered sometimes. A number of additional comments were received from staff relating to staffing levels, these included: Improve the staffing levels which are really a concern for everyone. It is hard to provide the required personalised or individual care when you are short staffed, Ensure there are always enough staff working on shifts to make sure all service users care is met and all their needs are catered for, We need enough staff, especially at the weekend. Provide more staff at the weekend and provide staff according to the number of service users so that excellent care can be delivered, We do have to work short staffed sometimes, which limits the care we can provide to each individual and it would be nice to spend more time with each person and Always enough staff within the home. Some additional comments had been added to service user survey forms by their relatives, these included: It would help if there were more staff employed to cover all duties. Some staff have to double up, The staff are very obliging but I try not to burden them as sometimes, if one of the carers are dealing with one service user, there is only one carer left to watch over the rest, Staff slow to answer emergency bell, Staff seem to work to time limits and if there were more staff they wouldnt be so rushed, especially at bedtimes and The staff available do a very good job but I feel there is insufficient staff to manage the amount of service users. Of the thirteen service users surveyed, five stated that staff are always available when needed, seven answered usually and one answered sometimes. Of the thirty five care assistants, nineteen hold a National Vocational Qualification (NVQ) level 2 or above in care. Care Homes for Older People Page 28 of 42 Evidence: During this visit the files of three recently recruited members of staff were sampled. All files were seen to contain proof of identity, two references and a completed application form. However, the home were unaware of new regulations that came into force in July 2004 and had not been verifying applicants reasons for leaving previous employment with vulnerable adults; had not been obtaining full employment histories and some gaps in employment had not been explained or explored and although the home had obtained Criminal Records Bureau (CRB) certificates for two of the people and had carried out checks on the protection of vulnerable adults (POVA) list as required, one of these was invalid as the CRB certificate application form had been completed incorrectly and had not included the persons full name. The third person was working on a POVAfirst check while awaiting the return of a full CRB check. The home were not aware of the restrictions and provisos in place for people starting work on a POVAfirst check and were not meeting some of the requirements. The provider must refer to the Department of Health POVA guidance document available on their website. Only in exceptional circumstances can someone start work before a full CRB and check of the POVA list have been received and only then if all the information required of Schedule 2 of the Care Homes Regulations has been obtained. There was no explanation of what the exceptional circumstances were in regards to the employment of this person, there were two gaps in employment, one of three years and one of sixteen years, one reference came from a care home that the person had worked at but had not included on their list of previous employments and no verification had been received of why the person had left previous employments working with vulnerable adults. The homes current recruitment practices are placing service users at risk of harm and/or abuse. The amended Schedule 2 of The Care Homes Regulations 2001 was reviewed with the manager and a requirement has been made that must be actioned without delay. The CSCI guidance documents: Criminal Records Bureau Checks and the associated annex 2 set out the changes to regulations and explain the latest recruitment requirements, copies of both documents were left at the home. It is positive to note that the manager took immediate action to begin to address these concerns. On the day following this inspection, the manager contacted CSCI via an email and stated: All the personnel files have been diligently checked this morning. Correct full names on all forms including CRBs. One staff member highlighted yesterday has completed a new form detailing full name, form now sent and now off duty. Staff induction is in line with the new, mandatory Skills for Care common induction Care Homes for Older People Page 29 of 42 Evidence: standards and the inspector was advised that staff are supervised until they have completed their induction. Staff are booked on additional training and updates as the courses become available. Evidence seen at this inspection showed that the home have a strong commitment to staff training, which was also reflected in comments received from staff. Some of these comments (quoted above) demonstrate that the staff have received training in person centred care and try their best to provide the same. Also worthy of note is that all staff, including domestic staff, have received training in dementia care even though only one of the wings is dedicated to people with dementia. The home employed the use of an interpreter to ensure that staff for whom English is a second language fully understood and were able to participate in the dementia training provided. It is possible that the concerns raised in the last section of this report, relating to staff continuing to leave service users without a means of calling for assistance, indicate a need for further training to ensure that staff fully understand the importance of this for promoting service users safety and their level of independence. This was discussed with the manager who plans to assess this possibility, and if indicated, arrange further training. When asked if their induction covered everything they needed to know when they started their job ten of the thirteen staff who returned survey forms answered yes and three answered mostly. All confirmed that they receive training which is relevant to their role, helps them understand and meet the individual needs of service users and keeps them up to date with new ways of working. Additional comments included: I was given a lot of support and full induction related to my job when I started, Birdsgrove has a good induction programme that helps people when they start the job and There are in house trainers who help you with any questions and needs that you have. In the AQAA, to demonstrate what the home does well, the manager stated that: We do not employ agency staff and we meet our NVQ ratio. All new staff are processed in house. All care staff undertake Common Induction Standards and records are kept of all training undertaken. The evidence seen at this inspection supported this statement. When asked if the staff listen and act on what they say, eleven of the thirteen service users surveyed answered yes, one answered usually and one answered sometimes. One relative commented: I must praise the carers who are always pleasant to my relative and I. My relative is well cared for and has improved since being here. Care Homes for Older People Page 30 of 42 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from the clear management approach at the home providing an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users but the registered person needs to ensure that there is a system in place to monitor and ensure that the home is complying with all current legislation relating to the operation of a care home. The homes procedures protect service users financial interests. All policies and procedures are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff. Evidence: The manager is a registered nurse, holds a Registered Managers Award and has been the manager of Birdsgrove Nursing Home for the past thirteen years. Her management style is inclusive and the service users benefit from the ethos, leadership and clear management approach of the home. Care Homes for Older People Page 31 of 42 Evidence: Of the thirteen staff members who returned survey forms all said that the manager meets with them to give support and discuss how they are working. Additional comments included: The home manager is always there for us whenever staff need help or support in all aspects related to care and personal and I have an assigned mentor who guided me through induction programme. If they cannot help, my manager is always ready to help. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users and their relatives. Service user and relative meetings are held quarterly. The manager explained that the home carry out yearly service user and relative surveys, that the results are correlated and that action is then taken to address any concerns raised. The correlation of the results are available to service users and their representatives. It was discussed with the manager that the home needs to expand the system further so that service users, their representatives and interested stakeholders are made aware of the action that the home is taking/has taken in response to the survey results and that follow up consultation takes place to ensure that the actions taken have been successful. The need for the provider to keep service users, their representatives and staff informed of the situation relating to the proposed building work has been addressed in the Environment section of this report but the failure to keep people informed reflects on the management and administration of the home, especially as people had been informed initially that the work was planned for completion during 2007. The manager stated that the home does not handle the financial affairs for service users. Health and safety monitoring check sheets were sampled and found to be well maintained and mostly up to date. The manager has delegated the responsibility for health and safety monitoring checks to the maintenance person. A number of checks were slightly overdue as the maintenance person has been off recently. This was discussed with the manager and, at present, there is no system in place that ensures that someone else will ensure that these tasks are carried out as required. There are a number of fridges around the building on each unit. The inspector was advised that staff are aware that only unopened meal supplements are to be kept in these fridges but the inspector found food (e.g. sandwiches, opened milk, yoghurt) in one and there is no effective system in place to ensure that staff are complying with the management instructions on the use of these fridges, which are not monitored or included in the fridge temperature recording required for food storage fridges. Care Homes for Older People Page 32 of 42 Evidence: The inspector was advised that work is planned to commence at the end of this month on the building of a new kitchen. During the tour of the home a few areas of concern were noted in the present kitchen. The local Environmental Health Department were contacted relating these concerns, which will be followed up by one of their officers. This is a large home and the manager has a deputy manager, an acting manager and an administrator to assist her in the management of the home. The responsibilities for different aspects of the running of the home are also delegated to other members of appropriate staff, e.g. the kitchen and the provision of food, domestic services, training, provision of nursing and personal care, activity provision, health and safety monitoring, maintenance. Requirements have been made under this section of the report relating specifically to the monitoring of service users care plans and to monitoring that service users are not being left alone without call bells within reach. However, it must also be remembered that, although tasks may be delegated, the overall responsibility remains with the registered persons to ensure that the requirements of the Care Homes Regulations 2001 and other relevant legislation, e.g. in regard to: health and safety, food hygiene, environmental health etc. are complied with. A requirement has been made and it was discussed with the manager that additional systems need to be put in place that enable the manager to ensure that staff are working to and complying with all legislation related to the running of a care home. These systems need to include actions to be taken if a delegated person is off work for any reason. In the AQAA, to demonstrate what the home does well, the manager stated that: The Quality Assurance programme is completed with records kept. The Home portfolio is updated and kept in an area accessible to service users and their representatives. Some service users handle their own financial affairs if this is not appropriate their family/appointed advocate does so. The registered manager is not an appointee for services users monies. All staff undertake all statutory and mandatory trainings. Accidents and Incidents are all recorded and where necessary reports sent to appropriate agencies. All maintenance is carried out by Head Office approved contractors. All directives, policies and procedures received from Head Office are cascaded to all appropriate staff. When necessary formal and informal discussion on these subjects is undertaken. This statement is supported by the evidence found at this inspection. When staff were asked on our survey forms what they feel the home does well, comments included: Person centred care to individual service users; listen to staff problems and find ways of assisting; relatives are always informed of progress and changes to their relative, We give choice to service users, We include relatives and Care Homes for Older People Page 33 of 42 Evidence: families in care planning, Provides caring and devoted staff to care for the service users in a safe environment and I am very satisfied and feel proud that we provide an excellent service. We try to provide the best care. When asked on the survey forms if there was anything else people would like to tell us, one relative commented: Without these homes and staff to look after people with failing health, I do not know what the likes of me would do, they are my life-line. My relative is settled and very happy. Many thanks. Care Homes for Older People Page 34 of 42 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 35 of 42 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 1 7 15 The registered persons must 31/03/2009 ensure that all service users have an up to date plan of care setting out actions that staff need to take to meet the needs of the service users. The plans must include social care needs as well as personal and health care needs. Daily notes need to evidence that staff are following the actions set out in the plan to meet the service users needs and reduce any potential risks to their health or wellbeing. The home also needs to evidence that service users or their representatives have been involved in and agreed to their plan of care. This requirement also applies to National Minimum Standard 8. In order that service users can be confident that they or their representative will be Care Homes for Older People Page 36 of 42 fully involved in the planning of their care, that all aspects of their personal, health and social care needs are met and that the care provided is consistent and takes into account their personal wishes and preferences. 2 12 16 The registered person must provide facilities for recreation and make arrangements to enable each service user to engage in meaningful social activities that are based on their individual preferences and abilities, particular attention should be paid to those with dementia, cognitive impairment, sensory impairments and physical disabilities. In order that service users can be confident that the home can meet their social care needs and takes steps to reduce the risk of social isolation. 3 19 12 The registered provider 18/02/2009 must draw up a plan of proposed building works, setting out the work that will be done, together with proposed start and completion dates for each stage. This plan must be made available at the home to all service users, their representatives and the staff and a copy supplied to CSCI. Service users, their representatives and staff 21/06/2009 Care Homes for Older People Page 37 of 42 must be kept informed of progress and advised if there are any substantial changes to the work planned or the timescales identified. In order that good personal and professional relationships between the management, service users, their representatives and staff can be maintained and that the manager and staff can plan and implement ways to reduce, as far as possible, the disruption caused while the work is in progress. 4 22 13 The registered person must ensure that at all times, all service users have access to a means of obtaining assistance should they need it. The registered person must make sure that staff never leave a service user without a call bell they can reach and are able to use. If it is assessed that an individual service user is not able to use the call bell system in place, then their care plan must identify and include details of actions staff need to take instead. In order that all service users are able to obtain assistance should they need it and that they can be confident that the home is run in such a way as to 21/02/2009 Care Homes for Older People Page 38 of 42 promote their independence, health and wellbeing. 5 27 18 The registered person must 21/02/2009 ensure that staff are available in sufficient numbers, and at all times, to meet the personal, health and social care needs of all service users. The registered person must ascertain and take into account the number of staff needed to provide the level of supervision indicated by the difficulties presented by the layout of the building and the numbers of service users who are unable to use the call bell system if they need assistance. In order that service users can be confident that their personal, health and social care needs will be met and that the home is staffed so as to protect and promote their health, safety and independence. 6 29 19 The registered person must 21/02/2009 ensure that all staff involved in recruitment are fully aware of, and adhere to, the requirements of the Care Homes Regulations 2001 as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004 and ensure that no person is employed to work at the home without all the Care Homes for Older People Page 39 of 42 required checks and documents having first been obtained. In order to protect the service users from the potential risk of harm or abuse. 7 33 10 The registered person must ensure that there are methods in place for the manager to monitor that staff are aware of and complying with the policies and procedures of the home and any legislation that applies to the running of a care home. In order that service users can be confident that the home is run and managed in their best interests and in a way that protects and promotes their health, safety and independence. 8 33 24 The registered person must 21/02/2009 put in place a quality assurance system to monitor that appropriate actions are being taken to ensure that service users are able to obtain help and assistance whenever needed. (e.g. call bells always within reach and/or monitoring of alternative methods indicated in their care plans for those that are unable to use the call bell system). In order that service users can be confident that the 21/03/2009 Care Homes for Older People Page 40 of 42 home is run and managed in their best interests and in a way that protects and promotes their health, safety and independence. 9 33 24 The registered person must 21/02/2009 put in place a quality assurance system to monitor and ensure that staff are following the requirements for care planning, meeting assessed needs and reducing potential risks, as set out in the Care Homes Regulations 2001 and their own policies and procedures. In order that service users can be confident that the home is run and managed in their best interests. 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 41 of 42 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 © (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. 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