Inspection on 17/05/07 for Bybrook House Nursing Home

This inspection was carried out on 17th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bybrook House Nursing Home 16/12/08

Bybrook House Nursing Home 25/07/08

Bybrook House Nursing Home 19/09/07

Bybrook House Nursing Home 02/06/06

Bybrook House Nursing Home 30/09/05

Bybrook House Nursing Home 29/04/05

Bybrook House Nursing Home 08/10/04

Bybrook House Nursing Home 02/07/04

Bybrook House Nursing Home 11/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bybrook House Nursing Home Middlehill Box Wiltshire SN13 8QP Lead Inspector Tim Goadby Unannounced Inspection 17th & 29th May 2007 07:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000015894.V339283.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000015894.V339283.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bybrook House Nursing Home Address Middlehill Box Wiltshire SN13 8QP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01225 743672 01225 744281 pen.b@talk21.com Avon Care Homes Limited Mrs Rosemary Ann Goff Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability over 65 years of age of places (6), Terminally ill over 65 years of age (2) DS0000015894.V339283.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. No more than 30 persons aged 65 years and over may be accommodated at any one time No more than 28 persons aged 65 years and over may be in receipt of nursing care at any one time of which no more than 2 persons may be in receipt of terminal illness care No more than 6 persons with a physical disablement aged 65 and over may be accommodated at any one time. These persons may not also be in receipt of nursing care Rooms 25, 26, 27 & 28 may not be used for nursing care due to unsuitable access The staffing levels set out in the Notice of Staffing Levels issued by Wiltshire Health Authority on 20 March 2000 must be met at all times Only the one, named, female service user referred to in the application dated 31 August 2004 may be aged 64 years and under 2nd June 2006 Date of last inspection Brief Description of the Service: Bybrook House provides care and accommodation for up to 30 older people. Most service users have nursing care needs. The home is privately owned by Avon Care Homes Ltd. The company has another nursing home in Wells, Somerset, where its administrative operations are based. The principal company director is Mrs Maria Cristina Bila, who regularly visits Bybrook House. The home is in a rural area, close to the village of Box. The city of Bath is approximately five miles away. The house is an older building set in extensive grounds, with views of surrounding countryside. Most service users have single rooms. There are three bedrooms which may be shared, if people wish. These can also be occupied as singles, for a higher fee. There is a passenger lift serving the home’s three floors, but some rooms can only be accessed by small flights of steps. A number of bedrooms have en-suite toilets, and two have baths also. There are five baths for general use, with at least one per floor. There is an adapted bath on the first floor. Fees charged to service users vary, depending whether nursing care is being provided by the home. Without such input, the lowest weekly fee is £637. With nursing care, the minimum charge is £791 per week. The highest weekly DS0000015894.V339283.R01.S.doc Version 5.2 Page 5 rate is £1132, or £1600 for a larger room. All of these figures are the rates charged to new service users. Existing residents may be paying less. Service users staying for short-term care can be charged at a daily rate. Information for prospective service users is available on request from the home. It includes a brochure and a service user guide. The home also has a website with brief introductory details and a selection of photographs. Prospective service users and their representatives are encouraged to visit Bybrook House. At the home, various relevant information is on display in the entrance hallway. This includes contact details for the CSCI, and a copy of the home’s most recent inspection report. CSCI contact details are also contained in service users’ contracts, and in the home’s complaints procedure. DS0000015894.V339283.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was completed in May 2007. It included a review of regulatory contact since the previous main inspection of June 2006. There was a shorter inspection in January 2007 which followed up on the main issues arising from the June visit. Findings from the January inspection are also restated in this report, where they remain relevant. As well as reviewing contact with the service, we considered a range of written information. Some documents were supplied by the service at our request. Survey forms were also provided for the home to distribute to service users, and three of these were returned, which had been completed by relatives. Relatives of service users were also contacted directly, and eleven responses were received, by a mixture of letters, phone calls and e-mails. Seven staff of the home also gave comments, some in writing and some by phone. Fieldwork took place by two unannounced visit to the home. The first took place at 07.00, to check on concerns raised about aspects of overnight care. These concerns were not upheld. The second visit included a meeting with the registered manager. A total of 12.75 inspector hours were spent in the home. Fieldwork included looking at records, with case tracking of some service users; touring the home; observing care practices; sampling a cooked meal; and speaking with service users, staff and management. The first visit included the pharmacist inspector, to look at all aspects of medication practice. After the inspection, there was a telephone discussion with the home’s director, Mrs Bila, to review the main findings and get her feedback on comments raised. Following the draft report we met with Mrs Bila and the home’s prospective new manager to discuss the service and their improvement plan. Some of the additional evidence they presented has been included in this final version of the report. What the service does well: Service users can feel confident that they will receive appropriate and effective nursing care. Health care at Bybrook House has consistently been complimented by service users and families as a particular strength. The home has also taken steps to develop specific areas of expertise, such as end of life care, through links with a local hospice. Service users can be confident that a decision about moving into the home will be based on suitable assessment. The home has an effective assessment DS0000015894.V339283.R01.S.doc Version 5.2 Page 7 system, and clear information about which needs it can or can’t meet. These are explained in its Statement of Purpose. Service users have their privacy and dignity upheld by the way in which staff provide care. This is done respectfully. Intimate care is always provided in private. Personal wishes and preferences are shown in individual care plans. Service users are able to maintain relationships with their families and other significant people. Visitors are made welcome, and have opportunities to meet with service users in private. Service users also have the option of having their own telephone line in their bedrooms. Relatives confirm that they are informed and consulted about important issues to do with the care of service users. This includes participating in discussions about care decisions if issues of concern arise. This approach helps to reassure relatives about the care being provided, and ensures that service users are represented in the decision making process. Service users have some opportunities to make choices in their daily lives. This includes in areas such as when to get up or go to bed; what to have to eat; and where they would like to spend their time. The home provides a pleasant environment for service users. It is attractively furnished and decorated in most areas, and is kept to a good standard of cleanliness. Individual rooms reflect the tastes of their occupants, and there is also a choice of communal areas, including two lounges and a small conservatory. One service user said that, although they had mixed feelings when they first moved in, they now wake up every morning feeling pleased that they are at Bybrook House. What has improved since the last inspection? Service users can be confident that they are protected by most aspects of the procedures for handling medicines. The pharmacist inspector made a thorough check of all systems and practices during this inspection. The requirements identified at the previous main inspection have all been addressed. Concerns raised about some aspects of medication practice were not upheld. Information is now readily available about the procedures for responding to any allegations of possible abuse, including details of the multi-agency process within Wiltshire. Service users and their supporters can be confident that the home is able to take the required action if any concerns arose. Staff recruitment records show that all the required checks are carried out, and that new employees do not begin work until they have the necessary minimum clearance. This helps to promote the protection of service users. DS0000015894.V339283.R01.S.doc Version 5.2 Page 8 The necessary checks and practices to support fire safety in the home are being carried out and recorded at the expected intervals. This helps to minimise risks in this important area. The home’s boiler, which had been leaking badly, has now been replaced. This has helped to provide a more effective system for heating and hot water. What they could do better: Bybrook House has a high number of requirements arising from this inspection, including some which are unmet from the previous main inspection a year ago. This indicates that there are a range of problems which need to be addressed, so that service users can be confident that the home’s strengths are not being undermined by these failings. Service users are placed at risk by the lack of a safe system to control hot water temperatures. These are regularly well above the maximum safe level, including in baths where the risk of serious injury is greatest. The service has temporary control measures in place but these are not a suitable or sufficient long-term solution. All hot water outlets which place service users at potential risk need to be regulated to the required temperature. The home’s director has reported since the inspection that this work is to be carried out soon. Service users and staff are placed at risk by deficits in arrangements for the moving and handling of service users. There are particular issues of concern within the home, arising from factors such as the limited space available in some rooms and the suitability of available equipment. There is no evidence of appropriate risk assessments or management plans to respond to these issues. Service users cannot be confident that there is effective management and leadership of the home. Staff report a range of concerns which they do not feel have been addressed appropriately. They are critical of the response of the registered manager and the home’s director. Both of these acknowledge that they have been struggling to address some difficulties within the service. There will now be a further period of change, as the registered manager is to step down from her role. A replacement is being recruited. The home is also without a deputy manager at present, which is disliked by staff and relatives, as they feel it makes the lines of accountability within the home unclear. A new appointment should also be made to this role. Service users are placed at risk by serious problems within the staff group. These are detrimental to effective teamwork and the overall atmosphere. The problems have been present, to varying degrees, for some time. Recently they have resurfaced as a major concern. The home’s director has recognised this within her monthly visits and reports. Steps taken by herself and senior DS0000015894.V339283.R01.S.doc Version 5.2 Page 9 staff to try and address the problems have not yet proved successful. Further progress in this area is crucial to the smooth running of the home. Deployment of staff is limiting the effective delivery of care and restricting some choices for service users. Most service users are allocated the support of two staff for all care tasks, although this may not be necessary. With four or fewer staff on duty, this limits their availability to other service users. This is demonstrated by factors such as the long waits some service users have before receiving personal care, and the slow response times to call bells Service users do not have opportunities to fulfil all their social and recreational needs. The home has been without an allocated staff member to lead on activities for many months now, although efforts have been made to recruit. The pressures which other staff are working under limit their ability to offer any such input to service users. Individuals who are less able to occupy themselves are especially disadvantaged by the current situation. Service users’ care plans fail to demonstrate that there are effective measures to respond to all of their assessed needs. Some important topics such as pressure area care and continence are not properly set out and recorded. This places service users at risk that they may not receive the care they require. The home is supporting some service users with additional needs, such as dementia. It is not fully clear how these needs are being supported. This must be done effectively, either by the home adjusting its own resources, or by ensuring that the support is provided from elsewhere. Individual service user plans must demonstrate that all needs of each person are being met. The home does not have a suitable training plan. This needs to provide evidence of the topics covered, and show that all staff members receive a minimum three days paid training per year. This will help to demonstrate that service users benefit from the support of suitably trained staff. Systems for individual supervision of all staff need to ensure that their conduct and practice is regularly reviewed and developed. This will help to drive up the overall standard of care in the home, to the benefit of its service users. Quality assurance measures need updating and to result in a service development plan. Previously actions have been identified following various measurements and surveys, but there is no evidence of these being followed up. A plan needs to show evidence of continuous service development, and that this is in line with the wishes and preferences of service users. The input of staff also needs to be shown. The home’s team have given a lot of input at inspections, indicating how keen they are for their views to be heard, and to make a difference. Staff are a key group in the success or otherwise of any service and should be enabled to contribute to its review and development. Service users cannot be confident that the home’s arrangements for responding to complaints and concerns are effective. Complaints records are DS0000015894.V339283.R01.S.doc Version 5.2 Page 10 not available in the home, so it is not possible to see whether or not recent complaints have been investigated effectively. Staff also report that they are not satisfied with the arrangements for them to raise concerns. Some repairs are needed at the home to improve the quality of the environment for service users and to remove a possible hygiene risk. There are some areas of exterior woodwork which are rotten and in need of replacement. There is evidence of rainwater damage from a leak in a bedroom on the upper floor of the building. At the rear of the property, a drain is partially blocked by tree roots and periodically overflows with foul water and other waste material. The home’s director has reported since the inspection that action is already underway on addressing these issues. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000015894.V339283.R01.S.doc Version 5.2 Page 11 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000015894.V339283.R01.S.doc Version 5.2 Page 12 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have their needs assessed, so that a decision can be agreed about whether or not the home will be able to meet these. Service users are not effectively supported with all their needs, because resources and facilities in the home are not being kept under review. Standard 6 is not applicable to this service. EVIDENCE: There are effective pre-admission and assessment processes. The format used by the home covers all required areas. Service users are re-assessed following hospital admissions. The home has clear information about which needs it can or can’t meet. These are explained in its Statement of Purpose. DS0000015894.V339283.R01.S.doc Version 5.2 Page 13 Most care needs are being met. Comments from service users and families show satisfaction with how Bybrook House is doing this. But records, including care plans and risk assessments, are not all sufficiently clear and up-to-date to provide satisfactory evidence of how the home plans and cares for people with additional needs, such as dementia. Three sets of service user records relating to people with known dementia were checked during this inspection. One of these had very clear and detailed information about the nature of the individual’s needs and how these should be supported. But the other two contained only a very limited and general summary of the same areas. There was no suitable guidance for staff about how to support the dementia care needs of these two service users. Bybrook House does not have the registration category for provision of specialist dementia care. So it needs to show how anyone with such needs has these met, within their overall individual care. Some staff mentioned that they have received training in dementia, which they found useful and interesting. DS0000015894.V339283.R01.S.doc Version 5.2 Page 14 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do not have all of their abilities, needs and goals reflected in their individual plans. Service users are supported to address their personal and health care needs effectively. Service users are protected by the home’s procedures for the handling of medicines. However there are two areas where risks would be minimised by the use of different equipment. Service users have their privacy and dignity respected. EVIDENCE: DS0000015894.V339283.R01.S.doc Version 5.2 Page 15 Bybrook House has consistently been praised by service users and relatives for the quality of care it provides. Similar feedback was received on this occasion. Examples were given of service users whose health has stabilised or improved as a result of the care given. The home has developed some particular areas of expertise. For instance, there are good links with the local Dorothy House hospice, and Bybrook has used these to develop its ability to offer end of life care. Support given by staff is carried out respectfully. Intimate care tasks are always carried out in private. The needs and preferences of service users are set out in their individual care plans. Consultation with relatives about issues to do with the care of their family member is clearly shown within individual records. Feedback from relatives also expresses confidence in the arrangements for keeping them informed. Some quote specific examples of when they have been involved in discussions about developing care needs. We conducted the first of these unannounced visits at 7 am, and checked on all service users during the first part of that visit. Staff on duty were friendly and helpful. They were knowledgeable about the needs of all the service users and had an obvious rapport with them. All service users appeared well cared for. They were confident in their interactions with staff and with the inspection team. Most were able to speak with us and confirm that they are very satisfied with their care, including at night. Staff on duty showed proper respect for the privacy and dignity of service users during this early morning tour of the home. They checked each room before entering. If any service users were not in an appropriate condition for the inspection team to enter the room at that point, this was explained politely, and we were able to return at a more suitable time. There were twenty-one service users when this inspection took place. Seven sets of service user records were checked. Assessments on key topics are in place and are kept up to date. Daily notes provide good detail and evidence of the care being provided in response to developing issues. Health care needs are identified and followed up. There is clear evidence of input from various professionals. People with more complex needs have access to specialist advice. Plans also address emotional and psychological needs, such as supporting people through bereavement, or identifying the activities they may enjoy. DS0000015894.V339283.R01.S.doc Version 5.2 Page 16 However, care plans vary in the descriptive information they contain, and some necessary content is lacking. Not all the topics covered in assessments have been developed into care guidance once this need has been identified. One area of concern raised about overnight support was continence care. We saw no evidence of poor practice. However, when we identified service users with support needs in this area, we were unable to find suitable evidence in their care records about the help they are getting. In some cases it is not noted as a care issue, even when we saw that it is. In all cases, if the topic is addressed, the information recorded is about daytime support only. When service users are assessed as needing support with pressure area care, this is not developed into care plan guidance. If service users need interventions by staff, to ensure they change position at set intervals to minimise risk of skin damage, no record was seen to show that this is happening. The provider and new manager have now indicated that such records are available within care plans. The pharmacist inspector looked at arrangements for the handling of medicines. As the inspection started early in the morning we were able to see how service users are given their morning medicines. Some are given by the nurse on night duty as people get up and have breakfast or a morning drink; the rest are given later by the day staff. All medicines were taken individually to residents from a locked trolley and signed at the time of administration. Medicines were stored and recorded appropriately. Self medication was available to residents who wanted it and risk assessments had been drawn up. Some residents used oxygen and this was suitably signed as a fire hazard in all areas except one room which only had a paper sign. This must be replaced with an appropriate sign. Blood monitoring equipment for diabetics did not comply with recent safety guidelines from the Medicines and Healthcare Regulatory Authority. Unused medication is recorded and sent for disposal. The actual number of controlled drugs which are destroyed should be recorded in the register, instead of assuming that it was all of the remainder. DS0000015894.V339283.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good overall, but only adequate in respect of recreational interests and needs. This judgement has been made using available evidence including a visit to this service. Service users are not provided with a range of activities and opportunities, so that not all of their recreational interests and needs are met. Service users are able to maintain and develop appropriate relationships with family and friends. Service users are supported to exercise choice and control in all aspects of their daily lives. Service users are offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. Recent concerns about some aspects of meals provided in the home are being addressed. EVIDENCE: DS0000015894.V339283.R01.S.doc Version 5.2 Page 18 Bybrook House has been without a specific staff member with responsibility to lead on activities for many months. There have been repeated efforts to recruit someone to this role, but these have so far proved unsuccessful. In the meantime, the ability of other staff to offer any such input has been severely restricted, due to the pressure they are under simply to meet all of service users’ essential care needs (see also the ‘Staffing’ section of this report). A number of relatives and staff expressed concern about the lack of opportunities for recreation that service users now receive. On both days of this inspection visit there was no evidence of any opportunities being offered, either individually or in groups. Service users also commented that they are not having any sessions at present. Some are able to occupy themselves with their own interests and hobbies, but others lack this degree of motivation. Service users have regular contact with family and friends. Visitors are often seen in the home, and feedback from relatives confirms that they visit frequently and are always made welcome. Most service users tend to receive guests in their own rooms. A number also have their own phone lines. Service users who are able to do so continue to do things outside the home. Often they may go out with their families. The home has also arranged trips and outings occasionally. Some service users attend events in the local village, such as concerts at the church. Service users can choose where to spend their time, and what they would like to do during the day. They commented that staff are good at responding to their needs and wishes. Individual reviews are an opportunity for service users and their relatives to have input into decisions about overall care. Feedback from relatives and staff about the provision of meals in the home was mixed. Some were very complimentary. Others raised concerns, relating to a reported dip in standards over recent months. The chef was absent for a period and then had to resign. A new chef has been appointed, but there has been a shortage of other staff to help in the kitchen. Criticisms were made about the training of catering staff, but this was discussed during the inspection, and found to be suitable. The main concern raised by several relatives and staff was the serving of evening meals. These had been left ready when the chef went off duty in the early afternoon, and then served by carers some hours later. This sometimes involved reheating items such as soup. By the time of this inspection, the home had already reviewed its practice. The hours during which the kitchen is staffed have been adjusted so that this covers up to the evening meal. DS0000015894.V339283.R01.S.doc Version 5.2 Page 19 Menus are drawn up in advance. Each service user is then asked, during the morning, which options they would like for lunch and tea. Choice is always available, and the chef said that she is very flexible in preparing whatever alternatives service users might request. The main midday meal on the second day of this inspection visit was sampled, in the company of eleven service users. It was of good quality, and fresh ingredients had been used. Portion sizes seemed appropriate to most service users, although one person felt their meal was too large and left most of it. Any service users who need staff support with eating have the same person sitting with them throughout the mealtime. Support is given appropriately, at a pace suitable to the service user. People can have meals in their own rooms if they prefer. Some service users said that they like to do this. But some also mentioned that, if they choose to have hot meals sent to their own rooms, these can be cold when they arrive. Service users also confirmed that drinks and snacks can be requested at any time. During the early morning visit we observed service users having breakfast in their rooms, and several confirmed that they get cups of tea during the night if they are unable to sleep. Bybrook House can support people with special dietary needs and preferences. This may include vegetarians and people with diabetes. Service user records include nutritional risk assessments and information about particular issues, such as swallowing difficulties. One service user spoke about how they have been helped to lose weight over the past year, in line with medical advice, and the benefits this has brought them. DS0000015894.V339283.R01.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures designed to uphold the protection of service users are in place to respond to complaints or possible abuse. The home is unable to demonstrate if these procedures are applied effectively, due to failure to keep required records available for inspection at all times. Staff do not have confidence in the arrangements for raising concerns, which could mean that appropriate action is not being taken. EVIDENCE: The home’s complaints procedure is displayed in the main entrance hall, and included in the service user guide. Contact details for the CSCI are shown. Relatives who gave feedback confirmed that they are aware of how to raise any concerns they may have. The Commission received two complaints about various aspects of the home’s practice since the previous inspection. Both were referred to the service for its own investigation. The complainant in one case then alleged that the home had not carried out an effective investigation. At this inspection it was not possible to assess this, as the required records were not available on site. DS0000015894.V339283.R01.S.doc Version 5.2 Page 21 The home has also received some complaints about meals, in line with the issues mentioned in the previous section. The changes now being made in practice are partly in response to these complaints. There are procedures to show how the service responds to any possible abuse. They include a link to Wiltshire’s multi-agency procedures for safeguarding vulnerable adults. Information about these is available in the home. The service has not needed to make any referrals recently. The service also has a procedure about how staff may raise any concerns they have about practice. This is usually referred to as ‘whistle blowing’. The procedure discusses the channels that are available for staff to take up concerns within the organisation, such as approaching the manager or the company director. But some staff report that, when they have done so, they have not been satisfied with the response. They do not believe that appropriate actions have been taken, and they are also unhappy that boundaries of confidentiality have not been respected. The procedure and its application should be reviewed to address these concerns. It should also make clear that there are possible external disclosure routes for staff, and sources of independent advice and support to help them. DS0000015894.V339283.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment does not provide a level of safety and comfort that meets all the service users’ needs. Service users are placed at risk by a failure to take effective action to manage the hazards arising from unregulated hot water temperatures. EVIDENCE: All parts of the home which are currently occupied were seen during these two unannounced inspections. This included a visit to each service user bedroom on the first occasion. DS0000015894.V339283.R01.S.doc Version 5.2 Page 23 Bybrook House provides pleasant accommodation for service users in most parts, both in individual rooms and communal areas. It is attractively furnished and decorated. A range of improvements have been carried out in recent years, benefiting the overall quality of the environment. Further attention is needed in some areas. The wooden door to the ground floor conservatory is rotten. Viewed from ground level, there is evidence of damage to roof tiles and woodwork around the dormer window of Room 31, on the second floor. Inside the home, rainwater damage is evident above the door to Room 30 on the same floor, indicating a leak somewhere in this part of the roof. The home’s director has reported that some of these issues have already been addressed since this inspection visit took place. Service users commented on how much they like their rooms. They can bring in personal items, such as furniture and pictures, to make their room feel homely. Some like to spend a lot of time in their own rooms, commenting that they feel comfortable there. But others also confirmed that they enjoy using communal areas, such as the lounges and dining room. Some service users were observed using the main lounge during these inspection visits. Bybrook House also has grounds and gardens available for service users to relax in. Some service users enjoy the opportunity to use these for short walks. They also like simply having nice views from their windows. Some staff commented that they felt use of the gardens could be increased if work is carried out to improve access. Not all bedrooms are accessible to all service users, because some can only be accessed by small flights of stairs. This is reflected in the home’s current conditions of registration. When existing service users become more frail, it is occasionally possible that they may need to move to a different room. This is done by agreement with the individual or their family. There are a number of bathrooms at the home, including some en-suite facilities. But the increasing care needs of most service users mean that some bathrooms are no longer suitable. Several staff mentioned that the provision of an accessible shower for service users would be a helpful development. The home has not yet taken effective measures for the safe regulation of hot water temperatures. Since the previous main inspection risk assessments have been carried out, and these identify the need for action to be taken, but this has not yet happened. Some hot water temperatures are consistently recorded as above the safe level of 43°C. The home’s own most recent checks before this inspection showed that 27 of the 31 outlets tested were above the safe level. Of these, 17 were at 50°C or higher, with the highest being 59°C, for two handbasins. Most DS0000015894.V339283.R01.S.doc Version 5.2 Page 24 seriously, two baths were recorded with temperatures of 54°C. The risk in baths is much greater because of the possibility of whole body immersion. Signs have been fitted to warn of hot water, and staff are instructed to run and check all baths. But these measures can only be temporary solutions, and action must be taken to provide a safer system of managing this risk. The situation was discussed with the home’s director after the inspection visits, who reported that action is to be taken shortly. Some comments from relatives and staff raised concern about standards of cleanliness in the home. However, it appeared clean and hygienic in all areas seen during these two unannounced visits. Bybrook House employs domestic staff who carry out a range of tasks, including cleaning and laundry. Flat linen, such as bedding and tablecloths, is sent to be washed by an outside contractor. All other laundry is done at Bybrook House. There are appropriate arrangements for collecting items for washing, and dividing them into loads. However, some relatives expressed concern that items of clothing sometimes get damaged by being washed on the wrong cycle. Infection control risks are minimised by the approach used. For instance, heavily soiled items are placed in special bags, which then go straight into the washing machine. This reduces the need to handle the laundry. The washing machine has a suitable programme to get such items clean and disinfected. The representative of one service user was especially complimentary about how well the home responded when the individual was admitted with a known infection. Staff adopted all the appropriate care practices and as a result were successful in helping the service user to become clear of infection. A problem has arisen with the drains at the back of the house. These have become partially blocked by tree roots, which means that they periodically back up and overflow. Quotes are being obtained to remedy this problem. This work needs to be carried out as soon as possible, due to the hygiene and safety risks arising when material from the drains overflows. DS0000015894.V339283.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users have their needs supported by staff, but further review is needed to ensure that there are suitable numbers to do so promptly and effectively. Service users are protected by effective practices in staff recruitment. There is insufficient evidence that staff receive relevant training to assist them in meeting service users’ needs effectively. EVIDENCE: Bybrook House was registered under previous care and nursing home legislation. This means it has to maintain staffing at least at the same level set before April 2002. Staff numbers vary, depending how many service users are in residence. At the occupancy level at the time of this inspection, the home was usually running on four staff in the mornings; three for afternoons and evenings; and three waking staff overnight. DS0000015894.V339283.R01.S.doc Version 5.2 Page 26 Because the home is registered to provide nursing care, a qualified nurse is on duty at all times. Sometimes there are two nurses on the same shift, depending on the particular skill mix. Nursing staff are supported by a team of carers. Bybrook House also employs its own staff for other key tasks, such as catering, cleaning, and maintenance. Several relatives and staff raised concern about available levels of staff at Bybrook House. These are in line with the minimums set before 2002, but it is not clear that they remain suitable in light of the greatly increased dependency levels of many service users. Staff on duty during these inspection visits, including senior nurses and the registered manager, reported that most service users need two staff for all personal care, because of aspects such as safe moving and handling. These staff reported working under constant pressure, and observations during the inspection visits supported this. It was also seen that staff did work in pairs with nearly all service users. On the first occasion, when we arrived at 07.00, work had already begun on helping all service users with their essential morning personal care. This continued non-stop throughout the morning, and had not finished by 12.30 when the main meal was due to be served. Evidence supplied by the provider and proposed new manager after the inspection stated that fewer than half of Bybrook’s House current service user group actually require the support of two staff for personal care. They are reviewing care plans and the deployment of staff to reflect this position. Staff on duty during these inspection visits, including senior nurses and the registered manager, also reported that they are unable to keep to minimum targets such as each service user having at least one bath per week. The provider and proposed new manager have responded that evidence is available to prove that this is not the case. During both these inspection visits we observed that call bells went unanswered for long periods. This appeared to be simply because all staff were already engaged in other tasks, which they could not leave straight away. Relatives also commented on how difficult it is to get telephone calls to the home answered, particularly at busy times of day. And some mentioned that, when visiting the home, they find it hard to locate staff when they need them. Staff expressed concern that some service users are disadvantaged by having to wait so long to receive care. They also regret having no available time for extra social contact with service users. With the lack of specific activities staff, as discussed in the ‘Daily Life and Social Activities’ section, they are conscious that service users are missing out in this area. The manager reported that she would try to have five staff in the morning if possible, because this is when personal care needs are highest. But it is not DS0000015894.V339283.R01.S.doc Version 5.2 Page 27 often possible to achieve this within current staff levels. With four staff on duty, and if the nurse in charge has to attend to managerial or administrative tasks, this seriously limits the availability of staff to attend to service users. Another issue raised by several staff is that ‘handover’ time is not included on the rota. This means that the nurse in charge of a shift is due to finish at the same time as a colleague arrives to take over the next. In reality, the first nurse has to stay on, giving up their own unpaid time, to give the second an update about events in the home and the care needs of service users. ‘Handover’ is an important aspect of the effective operation of the service, and should be properly allowed for in the planning of rotas. The service needs to review its staffing levels again and show that the ratios of staff to service users are appropriate to the needs and dependency levels of the current occupants. Measures such as an audit of call bell response times could also provide objective evidence of the impact of current staff availability on the quality of service delivered to service users. The proposed new manager has informed the Commission that these measures have now been carried out. Staff training includes courses, distance learning packages and in-house discussions on relevant topics, sometimes with external speakers. Some training sessions also take place in the company’s other nursing home in Wells, and staff from Bybrook House can attend these. However, training opportunities have reduced recently. Sixteen staff attended training on moving and handling earlier in 2007. But records show little evidence of other training at present. However, the manager did report that a number of courses are being undertaken via Swindon College, including food hygiene, dementia, safe handling of medicines and stress management. There is also continuing progress on National Vocational Qualifications (NVQs) for care staff. Eight people have already obtained this award at Level 2, and another three are currently working towards it. It is also hoped that some carers will go on to do NVQ Level 3. There is no suitable overall plan to show how training fits the needs of the service; to ensure all staff access a minimum amount each year; and to show how this is funded. At present staff contribute to the cost of some of the courses they undertake. The plan must show how this is balanced with the service meeting its own obligations under the relevant standard. The home provided a training and development plan after the last main inspection in June 2006. This was very basic and has not been updated effectively since then. It still fails to demonstrate that all staff members receive the required minimum of three days paid training per year. However, one staff member did mention in feedback that 24 hours of study time are paid for if taken. DS0000015894.V339283.R01.S.doc Version 5.2 Page 28 There is an ongoing issue about reduced access to training for staff from overseas, who are not eligible for the same funding as their colleagues. This topic should be specifically addressed within the service’s overall training plan. Comments from staff have previously highlighted that induction for new starters was not always effective. Some people felt that they did not know enough about the needs of service users before they had to start working with them. For carers, it is important to ensure that induction is linked to the relevant national standards for the social care workforce, which serve as a pathway into National Vocational Qualification training (NVQs). Records need to be maintained to provide evidence of each employee’s induction. There have been no new care staff appointed since a requirement was set about this topic, so it has not yet been possible to assess compliance. There has been very little staff recruitment since the previous inspection. Two sets of records were seen on this occasion, both for catering staff. These showed that all the required checks had been carried out, including obtaining the minimum clearance necessary before they began working in the home. DS0000015894.V339283.R01.S.doc Version 5.2 Page 29 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are placed at risk by a failure to deal with serious issues amongst some parts of the staff team. Leadership and management has not been effective in addressing and resolving these problems, which can impact directly on service delivery. Quality assurance measures need to be applied more effectively, to ensure the home is conducted and developed in line with service users’ needs and preferences. Staff are not supported and supervised effectively, which hinders their delivery of a service to meet its users’ needs. Service users and staff are placed at risk by a failure to have effective methods DS0000015894.V339283.R01.S.doc Version 5.2 Page 30 of working in place for all health and safety topics. EVIDENCE: The registered manager of Bybrook House at the time of this inspection was Mrs Rosemary Goff. However, she has indicated her intention to step down from this role in the near future, and the home is therefore taking steps to recruit a new manager. The proposed new manager has met with the Commission to discuss the home’s improvement plan following this inspection. The home previously had a deputy manager, but since the last postholder was removed from this area of responsibility it has not been reassigned. There was widespread agreement from staff and relatives that it is important to have clear lines of accountability in the management structure, especially when the manager herself is not present. Therefore, all those who commented would welcome a deputy manager being appointed once more. The principal director of Avon Care Homes, Mrs Maria Cristina Bila, acts as the ‘responsible individual’ for the company. Mrs Bila meets the statutory requirement of completing monthly reports on the conduct of the home, based on her visits to Bybrook House, and meetings with service users, visitors and staff. These reports address a number of criteria prescribed by regulations. Copies are supplied to the CSCI. They provide useful evidence of how progress in the home is being monitored and reviewed. The most serious issue arising around the time of this inspection was information in complaints and from staff feedback about problems within the staff team. Various difficulties have arisen between different individuals and groups, leading to some ill feeling. Mrs Goff and Mrs Bila have both become involved in trying to resolve these issues, but to date this has not been successful. Indeed, problems seem to have worsened in some respects, with a number of staff being very critical of the approach that they took. These concerns were discussed with Mrs Bila following the inspection. It is clear that further work is necessary to try and resolve the issues within the team. Unless this happens, the atmosphere within the home is likely to remain strained, to the detriment of the smooth running of the service. These issues are heightened by the pressure which staff are working under, and by the deficits in training, supervision and support. Issues relating to staff numbers and training are discussed in the previous section of this report. There is also an outstanding unmet requirement to carry out individual supervision meetings with all staff at regular intervals. Such sessions give the DS0000015894.V339283.R01.S.doc Version 5.2 Page 31 opportunity for staff to contribute their ideas and raise any concerns. They also give senior staff scope to encourage all team members to reflect on and challenge their own values and practices. Steps were taken after the previous main inspection to put in place a system of regular supervision meetings for all staff. But the necessary frequency has not been maintained, and there was no evidence of any recent meetings taking place. There is no up-to-date service development plan. Previously actions have been identified following various measurements and surveys, but there is no evidence of these being followed up. A single plan would help to provide clearer evidence of continuous service development, and could show how this is done in line with the wishes and preferences of service users. The input of staff also needs to be shown. The home’s team have given a lot of input to this inspection, indicating how keen they are for their views to be heard, and to make a difference. The staff team are a key group in the success or otherwise of any service, and they should be enabled to contribute to its review and development. This could be another way of helping to address the serious difficulties that have arisen within the team. A staff survey was carried out a while ago, but the responses have not yet been analysed or any actions put in place as a result. Another survey of service users’ relatives is due to be carried out soon. This will ask for feedback on a number of topics, including environment, activities, care, dining and domestic tasks. The home does not get involved in the management of service users’ money. If service users are no longer able to manage it themselves, they need to have a relative or someone else who will help them. All service users have lockable storage in their rooms, where they can keep any money and valuables. The home’s fire log book showed required checks and practices relating to fire safety as being carried out and up to date. The fire alarm was tested during the first of these inspection visits. The fire service attended in response to a false alarm in April 2007. As part of this visit they completed a short report on fire safety measures at the home, which were noted as being appropriate. Records of staff instruction show a handful of staff not having received this for the first quarter of 2007. Some serious deficiencies in health and safety practice were identified. These included hot water temperatures, as mentioned in the ‘Environment’ section. Staff also raised concerns about issues relating to the personal care of certain service users. They feel that they do not have all the necessary equipment, and that space is too restricted in some service users’ rooms. DS0000015894.V339283.R01.S.doc Version 5.2 Page 32 A particular example was considered during this inspection. The service user concerned needs two staff to support them for all care tasks, and the use of equipment to help with moving and handling. Space in their room is limited, and their bed is usually against the wall, meaning there is not access to both sides, as required for this person. To give care, staff have to move items of furniture, including the bed, and then struggle to cope in the space created. Other risks are also present in the room, such as a range of electrical items all plugged into one extension cable, which is situated directly under a handbasin. The service user’s records contain a manual handling risk assessment which indicates that there is very high risk, and highlights restricted space as a factor. But this has not been developed into guidance about the individual’s personal care, or moving and handling needs. Nor is there any risk assessment about the working environment in the room. As mentioned in relation to medication, there are also health and safety issues about blood testing devices and oxygen signage which need addressing. Criticisms were also made about food hygiene. However, practices were checked and seen to be appropriate. The kitchen and food storage areas are clean and well ordered. All food is stored appropriately, with suitable stock rotation. Fridge and freezer temperatures are checked twice a day. DS0000015894.V339283.R01.S.doc Version 5.2 Page 33 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 1 2 X 3 2 X 2 DS0000015894.V339283.R01.S.doc Version 5.2 Page 34 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP4 Regulation 12-1 14 Requirement The persons registered must demonstrate that the home meets all assessed needs of service users, by a review of care plans, leading to an action plan with suitable timescales. (Timescale of 28/07/06 not met) Each service user’s plan of care and associated records must set out the actions to be taken to meet all their needs, and must be updated to reflect changes. (Timescale of 28/02/07 not met) Where service users need to have their positions changed regularly to prevent pressure damage, records must be kept of such interventions. All service users must have opportunities for leisure and recreational activities which suit their needs and preferences. Records must be kept of all complaints and the actions taken by the persons registered in DS0000015894.V339283.R01.S.doc Timescale for action 31/07/07 2 OP7 15 31/07/07 3 OP8 17-1a Sch31&3m 29/05/07 4 OP12 16-2m&n 31/07/07 5 OP16 17-2 Sch4-11 17-3b 29/05/07 Version 5.2 Page 35 response. Such records must be kept in the home and available for inspection at all times. 6 OP19 23-2b Repairs must be made to all rotten wood and areas affected by water leaks. COMMENT: The provider has reported that this work is already being addressed. 7 OP25 13-4 Following risk assessment of hot water temperatures, suitable actions must be taken where identified as necessary for the protection of service users. (Timescale of 31/03/07 not met) Suitable action must be taken to ensure that drains to the rear of the home do not overflow with foul water and other waste. 31/07/07 31/10/07 8 OP26 13-4 16-2j 31/07/07 9 OP27 18-1a Review of staffing levels must be 31/07/07 carried out, to demonstrate that ratios of care and nursing staff to service users reflect the assessed needs of service users. There must be a staff training 31/07/07 and development plan to ensure that all staff receive training to meet the aims of the home and the needs of service users. This must include a minimum of three paid days training per year for all staff. (Timescale of 28/07/06 not met) All staff must receive suitable induction training, in line with national targets for the social care workforce. (Timescale originally set at 30/09/06) COMMENT: This Requirement could not be assessed at this DS0000015894.V339283.R01.S.doc Version 5.2 Page 36 10 OP30 17-2 Sch4-6g 18-1c 11 OP30 17-2 Sch4-6g 18-1c 30/09/08 inspection. 12 OP32 12-5 The persons registered must take steps to promote an open, positive and inclusive atmosphere for all staff of the home. The quality assurance system must include an annual development plan based on a cycle of planning, action and review. From this point forward, all staff must have regular, recorded supervision meetings at least six times a year. (Timescale of 13/06/06 not met) The persons registered must ensure that the safety of staff and service users is not compromised by the use of inappropriate blood testing devices. Recent information from the MHRA (Medicines and Healthcare Regulatory Agency) must be actioned. Suitable signage must be available for all areas of the home where oxygen is kept, to warn of the fire risk. Risk assessments must be carried out for all safe working practice topics and suitable management systems put in place as a result of the findings. 31/10/07 13 OP33 24 30/09/08 14 OP36 18-2a 29/05/07 15 OP38 13-3 31/07/07 16 OP38 23-4 29/05/07 17 OP38 13-4 31/07/07 DS0000015894.V339283.R01.S.doc Version 5.2 Page 37 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP9 OP15 OP18 Good Practice Recommendations Quantities of controlled drugs that are destroyed should be entered on the record of that destruction. Arrangements for distributing hot meals to service users wishing to eat in their own rooms should be reviewed. The whistle blowing policy should be reviewed, to provide more information for staff about routes for raising concerns, and give them more confidence in its operation. Consideration should be given to installing a shower which is suitable to the needs of service users. ‘Handover’ time should be included in the staff rota, to ensure that effective communication between senior staff is not dependent on their giving up unpaid time. The service’s training plan should give specific attention to the equality issues for staff appointed from overseas. A deputy manager should be appointed, to give service users, staff and others a clearer understanding of lines of accountability in the home. Records of fire safety instruction for staff should be kept up to date. 4 5 OP19 OP27 6 7 OP30 OP31 8 OP38 DS0000015894.V339283.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000015894.V339283.R01.S.doc Version 5.2 Page 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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