Inspection on 03/11/08 for Brundall Nursing Home

This inspection was carried out on 3rd November 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brundall Nursing Home 11/07/07

Brundall Nursing Home 31/01/07

Brundall Nursing Home 27/06/06

Brundall Nursing Home 04/01/06

Extracts from inspection reports are licensed from CQC, this page was updated on 16/12/2008.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Brundall Nursing Home 4 Blofield Road Brundall Norwich Norfolk NR13 5NN     The quality rating for this care home is:   zero star poor 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: Ruth Hannent     Date: 0 3 1 1 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 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 27 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 Older People Page 3 of 27 Information about the care home Name of care home: Address: Brundall Nursing Home 4 Blofield Road Brundall Norwich Norfolk NR13 5NN 01603714703 01603716652 brundallnh@schealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Ashbourne (Eton) Limited care home 48 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: One (1) Service User (who is named in the Commission`s records) who is currently under 65 may be accommodated. Total number not to exceed 48. Twenty (20) Service Users who are elderly and have dementia may be accommodated. Twenty eight (28) Service Users who are elderly may be accommodated. Date of last inspection Brief description of the care home Brundall is a care home providing residential or nursing care for up to 28 older people and care for up to 20 older people who may have a diagnosis of dementia (a total of 48 service users). The home is situated in the village of Brundall a few miles to the east of Norwich. The home is a large detached building that has been extended. It is divided into two main wings, Verne House and Norfolk House. The latter caters for service users who have a diagnosis of dementia. The accommodation is located on both ground and first floors. There are single and shared rooms. There are garden and Care Homes for Older People Page 4 of 27 0 0 Over 65 20 28 Brief description of the care home patio areas to the rear of the home. There are local shops, pubs and other amenities within the immediate vicinity of the home. Brundall is one of several homes in Norfolk owned by the proprietors. The range of weekly fees for the home is #347 - #551. Care Homes for Older People Page 5 of 27 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: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection peterchart Environment Staffing Management and administration Poor Adequate Good Excellent How we did our inspection: We looked at the information written on The AQAA (Annual Quality Assurance Assessment) and sent into the commission in April. We collated all the information sent through surveys from residents, families, staff and health professionals. We looked at all the notifications and information that had been sent to us by the service over the past year. We checked the last inspection report to see if requirements had been met. Care Homes for Older People Page 6 of 27 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 7 of 27 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 8 of 27 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 9 of 27 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. All potential residents will have a full assessment before an offer of admission is made. Potential residents and their families can be assured that the home will meet the needs prior to admission. Evidence: We saw evidence in residents files of the pre assessment process that shows detailed assessments to ensure the potential residents would have their needs met. A few of the residents who were able to answer questions did talk about completing some questions and how they visited the home, saw the room they could have and how questions were answered before they moved in. Some residents have moved in directly from hospital and did not have the opportunity to visit the home but an assessment had been completed. Care Homes for Older People Page 10 of 27 Evidence: The home does not offer intermediate care. Care Homes for Older People Page 11 of 27 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. Residents needs are set out in a care plan for all staff to follow but need to move away from task focussed. Healthcare needs are supported but some areas need to be more person centred. Residents are safely supported with good management of medication. Privacy is upheld but some areas of dignity needed to be reviewed. Evidence: 4 care plans were looked at at random. One particular care plan was looked at in detail due the large amount of time input required for this person on this particular day. The information gave a clear picture of need. It was evident that a form of behaviour that was affecting this resident needing managing carefully. The care plan gave information about the triggers, how to prevent and what and how to handle the situation should the problems escalate. Clear records of day to day management were in place and the Care Homes for Older People Page 12 of 27 Evidence: latest reviews had taken place on the 16th October. Although the information is clear and detailed the way they are written appears more task focussed and not always person centred. On the day of this visit it was evident that the staff were struggling to carry out the tasks required due to the demands of the various residents and it was noted that some were not dressed as well as they could be with tights and socks missing. Some peoples clothes looked as if they had been washed at a high temperature and had become shapeless. The healthcare reports in each file shows the visits are recorded and follow up visits booked. On the day of the visit the CPN was in close contact with the home over some concerns regarding a resident. The infomation sharing was carried out in a professional manner by the staff and the support given by this person did benefit the resident. (Noted through observation). One area of some concern shared by a health professional in a comment we received, is the difficulty in offering more individual continence support to ensure each resident has a pattern to help them. The times and methods used at present appears more service led rather than individual support to promote continence for the individual person. The medication procedures and recordings were looked at in detail. All records, including controlled drugs were checked and were correct. Eye drops in the trolley were dated when opened and were all within date. Due to the problems of prioritising the care on the morning of this visit the morning medication round had been delayed and did not finish until 11.30. A note was made on each medication recording chart and the lunchtime medication was issued timely to ensure at least 4 hours had elapsed. The staff were noted to be respectful and provided care in a dignified manner, however one concern that dignity may be in compromised was the visable box of what appeared to be communal net knickers in the bathroom for all to use. This was discussed with the manager, recognised as not good practise, and is to be removed from the bathroom. The manager stated a system identifying peoples underwear to ensure they have their own is to be implemented. Care Homes for Older People Page 13 of 27 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. Although activities are available residents need support with stimulation and variety throughout the day. Residents families and friends do visit and are made welcome. Residents are helped to exercise some choice over their lives but this could be improved. The mealtimes could be more pleasant and the meals presented in a way that offers choice. Evidence: The home has an activities organiser who was noted to be interacting with residents throughout this visit. Before she came on duty people were placed near the television and the set was on, yet no-one was watching, listening or able to see the screen. The staff do need to think about occupation and stimulation at all times and not only when the designated staff member is on duty. Tables where placed for people to have drinks on them, but many tables had nothing on them. There were no photographs, Care Homes for Older People Page 14 of 27 Evidence: magazines, mirrors to look at or stimulating decor. One resident was walking about frequently with an obvious purpose, but without anyone trying to offer her something to do. Behing the door it was noted a hat stand had been placed with a scarf and hat on but no one could get to it, and if they could there was not a mirror for them to see what they looked like. In Verne House the people who require nursing were also left with little to do. One resident who was cared for in bed had a television that was on, yet hidden behind the bed tail board and could not be seen at all. One resident did have the crossword to do and had been given the paper by a family member. One staff member was cleaning a residents room and interacting in a cheerful way making the person smile. (It was also a comment on three of the surveys received that the domestic staff are very good and caring). Throughout the day visitors were coming to the home and during the afternoon a person came in to offer hand massages to different residents. One visitor spoken to comes to the home regularly and although is made to feel welcome stated it is sometimes difficult to find staff. The home could do with more staff as they are always rushing. I cannot always ask questions as the staff are so busy. Residents do bring their own possessions into the home and many rooms were noted to have photographs and ornaments that made their room appear homely. Residents spoken to commented of being encouraged to make the room their own. A meal was taken with the residents and conversations around the table took place. The meal was a choice of shepherds pie or chicken pastie with potatoes, carrots, green beans and gravy with a dessert of fruit compote and custard. Although the meal offered choice earlier in the day by the time the meals arrived many residents had forgotten what they had ordered. No further choice is then offered at the table. Everything is just on the plate. People do not have the option to choose how many potatoes or if they want only green beans etc. The custard was already on the fruit and no one was offered a choice of drinks. Choice at the table should be more available. The meal was presented by staff in plastic, personal care style aprons that are not dignified or suitable. Care Homes for Older People Page 15 of 27 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 will listen to and action any complaints received. The home will ensure all staff are competent to recognise any form of abuse and understand whistleblowing. Evidence: The home has a complaints procedure that is in the service users guide and also on the wall in the entrance. The surveys received say that residents and families are happy to talk to the staff and management. The new manager has not received any complaints that he has not been able to deal with on a local level. Staff spoken to understand the homes policy on protecting residents from abuse. A recent concern regarding a visitor to the home was higlighted when talking with staff members. This was reported on immediately and the manager was able to deal with this concern in the two days following this inspection. A number of staff are trained and have certificates to show they have received training in the protection of vulnerable adults. The home should ensure all staff are up to date with refresher training or basic training for new staff members. Care Homes for Older People Page 16 of 27 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 home enviroment could be improved and checks for safety in maintenance are not in place. The laundry facilities are in place. The cleanliness in the home needs improvement to ensure infection control is fully implemented. Evidence: The home is split into two areas within an old style house that has been converted at different times over the years. The area that is designated to people who have dementia is secure but is not ideal for the needs of the people it cares for. The lounge/dining room is very close to some bedrooms, the lighting is not suitable with fittings that are fragile and could be pulled off the walls. Bulbs regularly blow, according to staff and as 8 had blown in the lounge area, lighting was inadequate. From the hallway to the lounge there is a step/ramp which is a trip hazard and a number of falls had been recorded in this area. A recent problem with water damage has left the central area in need of decorating and although residents were in this area there was no-where for them to sit and rest. The lounge on the Verne side of the house was comfortable and new chairs that are suitable had recently been purchased. The dining room at the front of the house is attractive with nicely laid tables and large picture windows making it light and bright. There is a small attractive garden. Care Homes for Older People Page 17 of 27 Evidence: The home has recently replaced the fire alarm system. This left the home without a working system for some time and the home has no records of any fire alarm checks since April of this year. Maintenance checks are behind with the new staff member trying to bring them up to date. Each residents room was individual with some larger than others but all were cosy and had personal possession in them. Many rooms were noted to have profile beds to make the care of people who need help with transferring easier. Staff stated the home still needs more of these beds to help them carry out their duties as safely as possible. The staff who do the cleaning are mentioned in three of the surveys as being very good at their jobs. The home was clean in some areas but due to the size and needs of the residents it was taking a long time for the bathrooms to be cleaned. It was noted there was an overflowing bathroom bin with no bin bag and various items on the floor. The laundry room is a few yards from the house in a specially converted outbuilding. Appropriate equipment and machines are in place. It was noted that a trolley with dirty washing had been pushed inside the sluice room and was dragging all across the three slings used for the hoists that were hung on the back of the sluice room door. Due to the contact of these slings on the dirty laundry this is seen as unhygienic. Care Homes for Older People Page 18 of 27 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 does not have enough care staff to offer the timely care required, especially in the dementia unit. The residents are cared for by staff who are qualified. The Home has procedures in place that protect and support residents when recruiting new staff. Staff are trained but when dates are due for the update the training should be available Evidence: On the day of this visit there were 3 staff in the unit for people who have dementia (14 residents), and 4 staff plus a nurse in the nursing unit (19 residents). The staff in the dementia unit were very busy and the delays in administering medication and helping people to get up and dressed at 10.30 gave the indication that the staff numbers were inadequate. On discussing this further with the senior staff it was found that 10 of the 14 people in this unit need 2 staff members for transfers and personal care tasks. With one staff member usually administering medication it means no one is in the lounge with residents who are already up and dressed. As one resident required one to one care at the time of this visit the staffing levels were not considered adequate. Care Homes for Older People Page 19 of 27 Evidence: There are a number of staff who have the NVQ 2 qualification and they are evidenced on the homes personnel records. Two staff spoken to also talked about the qualification and their aim to achieve NVQ3. The recruitment procedure is robust. The personnel files of three staff were seen and each had all the relevant documentation, including an application, two references, two forms of identification, POVA First and CRB. It was noted there were some records of staff who have not had a CRB check for over three years, and must complete another disclosure form to ensure everyone has an up to date disclosure. The home has a training matrix that was discussed with the manager. The home has limited staff trained in infection control which is highlighted in this report and must be addressed. The rest of the stautory training is logged and most staff are nearly up to date. (There are some dates in 2007 that need to be recorded in the training records). Care Homes for Older People Page 20 of 27 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has no permanent manager who is able to offer management experience and stability. The home has limited information on the quality of the service of the home. Residents money is managed in a safe and secure manner. The staff need more supervision and support, especially at a time of management change. The home has limited safe working practises to protect staff and residents with their health, safety and welfare. Some improvements are required to ensure all areas of safe working practises are in place. Care Homes for Older People Page 21 of 27 Evidence: The home has no registered manager at present and has had three managers in the last year. The person reponsible is providing temporary management support until a new manager can be appointed. The staff spoken to commented that they are finding it difficult to work efficiently without consistency and direction. This acting manager is a senior member of staff who knows the home and the residents well, but does not hold the recognised management qualification. No quality assurance documantation was seen on this visit. The home does have regular visits from the operations manager for the company, and a report is written on the findings of the service during this visit. Once the home has a permanent manager quality assurance needs to be prioritised. The administrator was able to go through all the procedures for handling residents money. Receipts were seen and details of each persons account was shown on the computer, with monthly interest added by the bank where the account is held. Staff supervision has not taken place as often as is required (6 times per year). New staff are inducted and shadow staff until they are considered competent to work alone. This was discussed with one staff member who is now aiming for the NVQ 2 qualification after completing a probationary period. The maintenance records are not up to date. Training in health and safety areas needs to be in place. It was noted there is lack of infection control on the training matrix. This was also evident in the lack of good hygiene practise in the laundry area. Three taps were tested in different bedrooms and all had a thermostatic control valve fitted and the water was felt as hand hot. Staff have received recent COSHH training (Control of Sustances Hazardous to Health) and on talking to a staff member they were able to reflect on this training. Accidents and injuries are reported but not all notifications are sent to the Commission. Care Homes for Older People Page 22 of 27 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 30 18.1(c)(1) The Manager must ensure 01/01/2009 that staff receive training in dementia care. To ensure that the mental health needs of people using the service are met. REPEAT REQUIREMENT. The service must have a registered Manager. 30/11/2007 2 31 9 3 33 24.2 31/01/2008 The Manager must ensure that the views of people who use and are associated with the service are sought and included when making decisions that effect outcomes for people living at the home. REPEATED REQUIREMENT Care Homes for Older People Page 23 of 27 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 18 The home needs to implement care plans for each person. The wellbeing of each resident needs assuring with person centred care planning. 01/01/2009 2 10 13 The home must ensure that residents wear their own clothing and underwear. The residents should wear clothes worn by others. 01/12/2008 3 12 16 Suitable activities should be available to all residents as required. To assist in the care of residents, the recreational activities and social interests need to be in place. 01/01/2009 4 14 18 Staff need to be aware of how they offer choice to residents to maximise there ability to take part in there dignity 01/01/2009 Care Homes for Older People Page 24 of 27 Staff need to understand how important it is to empower residents. 5 19 23 The home must ensure all records of maintenance are current to ensure the environment is safe. Residents and staff must be protected by good record keeping of maintenance. 6 26 23 The Home must ensure that good infection control is maintained Residents, staff and visitors should know the home is adhereing to infection control policies to protect them at all times. 7 27 18 The home must ensure that there are sufficient staff on duty at all times Residents care should be at times to meet the individual needs of each person. 8 30 18 The training of staff must be 01/01/2009 up to date and include infection control. To ensure staff have the most current, up to date training for practise to be correct. 9 31 8 The home must appoint a permanent manager. The home needs strong leadership with experience and knowledge of the client group 01/02/2009 01/01/2009 01/12/2008 01/01/2009 Care Homes for Older People Page 25 of 27 10 33 16 The home need to ensure a quality assurance system is in place to audit the quality of the service that is provided. REPEAT REQUIREMENT Outcomes for residents change and monitoring of the service needs to be seen regularly to monitor this. 01/01/2009 11 36 18 The home must ensure that staff receive regular supervision. The staff need consistency and support on a regular basis to carry out their job correctly. 01/01/2009 12 38 12 The home must ensure all areas of health and safety procedures are in place. The staff need the health and safety training and the records of maintenance must show the home environment is safe. 01/02/2009 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 2 7 19 The care plans should be reviewed to ensure they are person centred rather than task focussed. The home needs to look at the environment to make it suitable and safe for the needs of the people living there. The light fittings should to be suitable. Care Homes for Older People Page 26 of 27 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). 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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