Inspection on 16/03/06 for Cameron House Nursing Home

This inspection was carried out on 16th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Cameron House Nursing Home 25/07/07

Cameron House Nursing Home 27/06/06

Cameron House Nursing Home 22/09/05

Cameron House Nursing Home 27/01/05

Cameron House Nursing Home 11/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Cameron House Nursing Home Cameron Street Bury Lancashire BL8 2QH Lead Inspector Kath Smethurst Unannounced Inspection 16th March 2006 10:30 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 Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 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. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cameron House Nursing Home Address Cameron Street Bury Lancashire BL8 2QH 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) 0161 764 8571 0161 763 6395 Ringdane Ltd (wholly owned subsidiary of Four Seasons Healthcare). Beverley Josephine Unsworth Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (39), Terminally ill (1) of places Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users, to include: Up to 39 service users in the category of OP (Older People); Up to 1 service user in the category of TI (Terminal Ilness under 65 years of age). The service should employ a suitably qualified and experienced Manager, who is registered with the Commission for Social Care Inspection. 22nd September 2005 2. Date of last inspection Brief Description of the Service: Cameron House Nursing Home provides nursing and personal (‘residential’) care for older people. Both permanent and respite places are available. The home is owned by Four Seasons Healthcare (a large national company). It is a modern, detached building on two floors (with a lift). All the bedrooms are singles. There is a small, enclosed garden to the rear and car parking to the front and side. The home is in a residential area, with a main road and public transport nearby. Bury town centre is approximately one mile away. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours during the morning and afternoon. The inspector looked around some but not all of the home, checked care plans and some records. To get more information about the home the inspector spoke to five residents, the manager and five staff. What the service does well: What has improved since the last inspection? Progress had been made by the manager to make sure that the things, which needed improving from the last inspection, had been done. Medicines are now being looked after more safely including, how waste medication is disposed of and records of; records of medicines coming into and go out of the home, and what each resident is taking. The strong, bad smell in one bedroom has been sorted out. Staff have a better understanding of what to do if they have concerns about how residents are treated. During the last inspection staff raised concerns about the way residents were looked after, in that some residents had a meal in wet clothes/continence pads, and that sometimes, some residents were taken to bed very early after tea (for the convenience of night staff). The manager took prompt action to address these concerns and staff spoken with during this visit said things were “much better” since some staff had left the home. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 6 What they could do better: 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. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 7 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 Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 Generally, a satsfactory standard of care was received, but more training is needed to ensure the specialist needs of residents are not overlooked. EVIDENCE: During the last inspection concerns were raised regarding some care practice namely when one carer move a confused resident without talking to or interacting with them. There was no evidence of such practice during this inspection. Staff were observed to be attentive to residents and were sensitive and discreet when providing assistance. All residents spoken to felt their needs were being met. One resident described the care as “very good”. During the last inspection it was identified staff were caring for residents with specialist needs, but had not been provided with relevant training. A requirement was made in this respect but to date has not been met. Discussion with the manager indicated some progress has been made in this regard. However it is important more specialised training (e.g. dementia care) be provided so care needs are not compromised, and to ensure staff are equipped with the specialist knowledge they need. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 10 The care planning process needs to be improved, as some records had not been completed, this meant important information had not been documented which could lead to residents needs not being fully met. Progress has been made in improving the way medication is managed in the home as a result any potential risks to resident’s health has been reduced. Personal support is offered in such a way as to promote residents privacy. EVIDENCE: Four care files were examined (2 Residential and 2 Nursing). Pre-printed, general (‘core’) care plans were in use. Care plans and risk assessments were in place and cover areas such as personal care, continence, and nutrition, dependency, health care, weight and daily progress records. The level of written information varied from care plan to care plan. For example in some of the plans sections had not been filled in or updated. In one plan the continence assessment was blank, while in two social care assessments had not been completed. Additionally key worker diary entries in two of the plans had not been completed. This was unfortunate as the completion of the social care assessments and key worker diary would provide Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 10 useful information relating to resident’s likes/dislikes, preferences and chosen lifestyle. All these areas need to be addressed to ensure residents care needs are not compromised. It was also unclear in some plans as to the personal care residents were receiving. One resident told the inspector she had not had an immersion bath for a few weeks. This was discussed with the manager who indicated the resident had not been well so this could be the reason. Yet this information was not indicated in the plan. Discussion with the manager took place on how best to record details of areas such as bathing. The manager offered assurances this issue would be attended to. On the 6 January 2006 the CSCI pharmacist inspector undertook an inspection. In the main medication procedures were on the whole found to be satisfactory although some improvements were needed. The requirements and recommendations resulting from the pharmacy inspection were followed up during this visit. Requirements made during the pharmacy inspection related to record keeping and management of waste medication. Both these requirements have now been satisfactorily met. A full report of the pharmacy inspection is available on request. Anecdotal evidence from residents indicated that staff respected their privacy and dignity. During the inspection staff were in the main seen to treat service users with respect and consideration, were attentive to individual needs and were discreet. Written evidence in care plans showed that resident’s needs in respect to dignity were considered important. For example in respect to personal care. In one plan staff were instructed to “ensure privacy”. Residents were observed to be well dressed and groomed. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 Visiting arrangements are good ensuring links between residents and their relatives and friends are maintained. EVIDENCE: The home has an open visiting policy. There are no restrictions on the time people visit and this was evident, with visitors observed during the whole of the period of the inspection. Further evidence was highlighted in the visitor’s book where entries showed residents friends and relatives visiting at different times during the day and evening. The only time restrictions would be imposed is when requested by residents. Anecdotal evidence from residents indicated staff encouraged links to be maintained. Further evidence of this was also observed, staff greeted visitors politely and took time to talk to them. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home has a satisfactory complaints system with some evidence that residents feel their views are listened to and acted upon. The policies and practices of the home protect service users from abuse. EVIDENCE: A detailed complaints procedure is in place. Details of how to complain are contained in the “Service User Guide”. A system is in place for recording complaints. Concerns raised were related to the laundry service. This now appears to have been resolved. In the past year the CSCI has received one complaint relating to care practice. The investigation undertaken by a CSCI inspector found the complaint to be upheld. The findings of that investigation are detailed in a separate complaint report. The manager cooperated fully with the investigation and took prompt action to address the resulting requirements. No further complaints have been received by the CSCI. Anecdotal evidence from residents indicated they felt able to approach staff with any concerns and these would be taken seriously. None of the residents spoken to had made a complaint but all indicated they were aware of how to do so if the need arose. A corporate Adult Protection and Prevention of Abuse policy is in place, which incorporates, whistle blowing. The home ensures all staff completes a POVA Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 13 and CRB (Protection of Vulnerable Adults Register/Criminal Records Bureau) before they commence work. Resident’s monies are securely stored with records kept of monies credited and debited. Representatives of Southern Cross audit monies on a regular basis. As a result of concerns raised about care practices during the last inspection a requirement was made for staff to undertake abuse awareness training. It is understood this has been addressed. The manager advised that staff are to be provided with further refresher training in the coming year. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 In the main the standard of the environment within the home is satisfactory but some improvements are needed to ensure residents continue to live in an attractive, safe, homely and supportive environment. EVIDENCE: Cameron House is in the main well maintained internally and externally. The Home has a number of lounge/dining areas. These areas are furnished with domestic style furniture. Ornaments, pictures and flowers enhance the homeliness of these areas. The garden areas are tidy, well maintained, safe, secure and accessible for residents. Residents spoken with made no adverse comments about environmental standards in the home. Discussion took place regarding maintenance and refurbishment plans. The manager advised that new carpets and 30 new lounge chairs are to be provided. This is welcomed as some carpets and chairs are showing signs of age. For example some of the lounge chairs are stained and damaged and as such need to be replaced. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 15 While the standard of decoration is on the whole satisfactory it was noted that some of the paintwork is damaged and the wallpaper in parts of the home is torn and beginning to look dated. As part of the future programme of renewal plans should be made to redecorate to ensure standards don’t fall below an acceptable. Another area the person responsible is asked to consider is in regard to storage facilities. It was evident sufficient storage space was not available and should be looked at. A sample of bedrooms was examined. All showed evidence of personalisation with photographs and personal mementoes on display. All bedrooms are lockable and lockable storage space was available for residents to store items for safekeeping. It was noted that in one bedroom the door to the en-suite toilet was missing. This needs to be replaced to ensure resident’s privacy is maintained when using this facility. It was also observed that some residents like to spend time in their bedrooms and they preferred to have their doors open. In order to ensure their safety in the event of a fire (and to allow them to have the door open) consideration should be give to providing either self closing devices or fire stops, which are activated by sound. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Staffing levels are satisfactory ensuring consistency of care for people living in the home. Recruitment policies and procedures are robust and staff delivering care have been appropriately vetted, so ensuring residents are protected. A training programme is in place, but staff have not received specialist training which could compromise the quality of care provided for people living in the home who have complex needs. EVIDENCE: The manager advised ratios met guidelines set by the previous health authority inspection unit. On the day of inspection sufficient staff were on duty to meet residents care needs. Staff spoken with indicated that currently staffing levels were in the main sufficient to meet resident’s needs. The only issues identified by staff regarding ratios related to some staff reporting sick at short notice, which resulted in cover being difficult to obtain at short notice. During the visit staff were observed to respond speedily to requests for assistance made by residents and also spent time socialising with them. Residents spoken with said that staff looked after them well and were complimentary about the care provided. A written rota is maintained. The manager works on a supernumery basis and is supported by a deputy manager. Domestic and catering staff support Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 17 nursing and care staff seven days a week. In addition an administrator, activity co-ordinator and maintenance person are also employed. A staff development programme is in place and staff’s mandatory training needs have been met. Recent courses undertaken include fire training, moving and handling, food hygiene, Protection of Vulnerable Adults and infection control. One area the manager needs to address is in regard to the way staff training records are maintained. It was difficult to ascertain exactly what training staff had undertaken as details were kept in a number of different files. This is an area the manager should address. The manager advised the deputy manager has designated responsibility for training. Unfortunately she was on leave on the day of the inspection so it was not possible to discuss her role or examine all training records maintained by this member of staff. Therefore this will be explored further during the next inspection. Staff spoken to said that on the whole sufficient training was provided. One member of staff described training opportunities as being “OK”. During the last inspection it was identified that staff had not received training to work with residents with specialist and complex needs. For example dementia care, including how to understand and support residents on both a practical and emotional level. This is an area, which still needs to be addressed as part of future training. Discussion took place regarding with the manager on how this could best be approached. Of the twenty care staff employed seven are in receipt of NVQ (National Vocational Qualification) level 2. This needs to be monitored to ensure progress in meeting the required 50 target is met. The manager was able to demonstrate staff are selected and recruited following a robust recruitment procedure. Four staff files were examined to find that thorough pre-employment checks had been carried out. All contained 2 satisfactory references, Criminal Records Bureau Check, verification of identity and a signed declaration of physical and mental fitness. POVA (Protection of Vulnerable Adults Register) and CRB (Criminal Records Bureau) checks are completed prior to staff commencing their duties. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 & 36 The manager has a good understanding of the areas that the home needs to improve upon and has plans in place how improvements are to be implemented. The home reviews aspects of its performance through a programme of selfreview and consultations, which include seeking the views of residents, staff and relatives. A satisfactory accounting system was in place, which protects resident’s interests. The supervision system needs to be improved to ensure staff are well supported. EVIDENCE: Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 19 The current manager of the home is a qualified nurse, is very experienced in caring for older people. There is evidence the manager has continued her professional development and she is currently undertaking the NVQ level 4 registered managers award. The manager has made good progress in implementing many of the requirements made during the last inspection. During the last inspection a number of concerns were raised regarding poor care practice and low staff morale. The manager took action prompt action to address these issues. This included consultation with both residents and staff regarding the areas of concerns raised. Discussion with staff during this inspection indicated that many of the problems highlighted related to certain staff that have now left. Staff spoken with said things were “a lot better now”. Internal and external quality assurance systems are in place such as resident and staff meetings. Southern Cross representatives visit the home on a monthly basis to audit records and speak to residents and staff. A written report is then produced of the findings, which is then forwarded to the CSCI. Annual relative satisfaction surveys are undertaken. The surveys ask relatives views on areas such as information provided, staff, meals, housekeeping and satisfaction with the quality of care. The home has a system for recording the complaints of those who don’t wish to complain formally. Residents are informed of CSCI inspections and inspection reports are available for visitors and residents to read. A satisfactory accounting system is in place. All monies held for safekeeping are kept in the homes safe. A record is kept of monies credited and debited and receipts were obtained for financial transactions. Representatives from Southern Cross audit monies regularly. Managers and senior staff on a daily basis supervise staff. Examination of staff supervision records indicated they are not receiving formal supervision at the required frequencies. Staff spoken with also said they were not receiving formal, one to one supervision. This needs to be addressed to ensure staff receive the support they need to do their jobs properly. Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 20 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 X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X X Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 21 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 OP4OP30 Regulation Requirement Timescale for action 30/06/06 2. OP7 3. 4. 5. 6. OP19 OP19 OP28 OP30OP37 7. 8. OP31 OP36 12, 14, 18 Additional training must be provided to care staff working with residents with specialised needs (e.g. dementia). Prospective residents must not be offered a service unless the home can meet their needs. Timescale 31/03/06 not met. 15 Care plans must reflect full details of service users assessed needs, be kept up to date and reviewed regularly. Timescale 31/12/05 not met. 23 New lounge chairs must be provided. 23 The missing en-suite door must be fitted. 18 50 of staff must be in receipt of NVQ level 2. 17,18 A review of staff training records must be completed in order to provide evidence staff have received the training they need. 9 The registered manager must complete the NVQ level 4 registered managers award. 18, 21 All care and nursing staff must receive regular, formal, one to one supervision. Timescale DS0000017340.V286322.R01.S.doc 01/05/06 31/08/06 01/05/06 01/12/06 01/05/06 31/08/06 01/05/06 Cameron House Nursing Home Version 5.1 Page 22 31/12/05 not met. 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 OP19 OP22 OP22 Good Practice Recommendations As part of the planned programme of renewal and refurbishment consideration should be given to redecorating communal areas (lounges and corridors). Consideration should be given to providing doorstops, which are activated by sounds for residents who like to spend time in their rooms. (See body of report for details) A review of storage facilities should be undertaken. (See body of report for details) Cameron House Nursing Home DS0000017340.V286322.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 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. 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