Inspection on 08/12/09 for Carr Bank House

This inspection was carried out on 8th December 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 32 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carr Bank House 12/01/10

Carr Bank House 22/10/09

Carr Bank House 30/06/09

Carr Bank House 17/06/08

Carr Bank House 05/07/07

Carr Bank House 11/06/06

Carr Bank House 31/10/05

Carr Bank House 03/07/05

Carr Bank House 18/08/04

Carr Bank House 01/04/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Carr Bank House 9-11 Heywood Street Bury Lancs BL9 7EB     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Grace Tarney     Date: 0 8 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 44 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 44 Information about the care home Name of care home: Address: Carr Bank House 9-11 Heywood Street Bury Lancs BL9 7EB 01617977130 01617631747 jocarrbank@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Pauline Jones care home 14 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The home is registered for a maximum of 14 service users, in the category of Adults with Mental Disorder (MD) 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. Date of last inspection Brief description of the care home Carr Bank House is a privately owned care home for 14 adults with mental health needs. There has been no change in relation to the weekly fees. These are 365.00 pounds per week. However this may vary depending on the persons level of assessed need. The home is located in a residential area, close to Bury town centre, within easy reach of buses and trams, shops, cafes, and other local amenities. The house consists of 2 adjoining properties that have been adapted to form a large house. There is a small garden at the front and a large enclosed garden at the side. There are 12 single rooms and one double. Three bedrooms also have en-suite facilities. There are 2 lounges, an activities room, and a dining room. Care Homes for Adults (18-65 years) Page 4 of 44 Over 65 0 14 3 0 0 6 2 0 0 9 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The staff at the home were not told that this inspection was to take place although many weeks before the inspection comment cards were sent out to all of the residents and some of their relatives asking for their views on the service provided. To date, non have been returned to us. Also before the inspection we (The Care Quality Commission) asked the manager of the home to complete a form called an Annual Quality Assurance Assessment(AQAA) to tell us what they did at present,what they felt they did well and what they needed to do better. This helps us to see the service they provide the same way that we do. Two inspectors spent 9 1/2 hours at the home and during this time we looked at care and medicine records to make sure that health and care needs were being met. We also looked at what activities were available and whether they were given choices about how they spent their day. We looked at what the residents were having for their meals to make sure that there was a choice of menu and that they were varied and wholesome. Care Homes for Adults (18-65 years) Page 5 of 44 We also looked around all of the building to check if the rooms were clean warm and well decorated. We checked how many staff were provided on each shift to make sure that the residents needs were being met. We then looked to see if management recruited and trained the staff properly and safely. In order to get more information about the home we spent time talking to 2 of the residents. Care Homes for Adults (18-65 years) Page 6 of 44 What the care home does well: What has improved since the last inspection? What they could do better: The majority of the requirements from the last inspection remain outstanding. The manager and provider must address the requirements. These were issues in relation to: Care plans that still do not give enough information about the current and changing needs of the residents. The absence of risk assessments in relation to the hazards that could cause a risk to the health and safety of the residents and people working in or visiting the home. The lack of activities both inside the home and out in the wider community. The lack of training for the staff in areas such as the safeguarding of people, challenging behaviour, medicine management and the management of clinical and mental health conditions. The environment, which remains poor in the majority of areas. In addition the manager and provider need to ensure that: The menus improve. The menus offer very little choice of food. The meals are not varied and balanced. Some special diets are not catered for. Infection control procedures need to be adhered to, especially in the food preparation areas. This will help to prevent or reduce the spread of infection. More encouragement is needed for the residents to undertake any hobbies, college courses or any form of employment. The management of the medicines is unsafe. Management need to ensure that staff receive training in the management of medicines and that the policies and procedures Care Homes for Adults (18-65 years) Page 7 of 44 for safe management of medicines are complied with. Unsafe medicine management practices put the residents at risk of harm. Management must make sure that a complaints procedure is in place to ensure that residents know who to complain to and to assure them that their concerns will be listened to. A system must be in place so that the residents are able to access their own money at all times. Enough staff must be provided at all times so that the assessed needs of the residents are met. Management must ensure that the home is kept warm and comfortable. The management must ensure the security of the residents and staff within the home. Management must ensure that the residents and staff do not smoke in non designated smoking areas. It is a fire risk and is not in accordance with the law. Management and all staff must make sure that all fire exits remain clear at all times and that fire safety checking procedures are undertaken in accordance with requirements. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 44 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 44 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The admissions process does not always ensure that peoples care needs are properly assessed by the staff at the home. This does not give an assurance to people that they will receive the right type of support and care. Evidence: There have been no new admissions to the home since the last inspection so we looked at the assessment of a person who used to live at the home for short respite periods and 2 assesments of people who had been living at the home for quite a while. We also asked the manager to tell us about the procedure that is in place at the home for assessing any prospective residents. An assessment looks at what help and support a resident may need in all aspects of their daily life. The manager told us that as well as receiving information from the people who pay for the care, normally the local authority, the home staff undertake their own assessment. We saw no evidence of the homes assessment in 2 of the care files that we looked at. Care Homes for Adults (18-65 years) Page 10 of 44 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans do not contain enough information to show what the residents needs are or how they are to be supported and cared for. This puts the residents health and wellbeing at risk. Evidence: We looked at the care records of 4 of the residents. They were not detailed enough, not always dated nor signed and were not as up to date as they should have been. 1 of the care plans was not dated and when asked when was it written we were told initially by the manager that she did not know. She later told us that it was 3 weeks ago. 1 page of the care record had very blurred typing and was impossible to read. We then saw in this care record it had been documented that there had been an incident and the document was a form of risk assessment. When asked when had the incident occurred, as the document was not signed nor dated, we were told by the manager quite a while ago. We then saw attached to the document a medication sheet dated September 2009. As the document makes reference to the attached medication sheet we found it very confusing and were unsure if the risk asssesment was relevant. There Care Homes for Adults (18-65 years) Page 11 of 44 Evidence: had also been concern expressed in this undated document about the residents eating and drinking. There was no plan of care to address these concerns. This resident was also of the Jewish Faith but there was no reference to his cultural dietary needs anywhere in his care records. We saw in this residents care file 2 other care plans. 1 dated 6/7/06 and 1 dated 6/6/07. We were told that these were not relevant now. It was suggested that they be filed away so that staff can eventually have a clear record on file of just what is up to date and relevant to the needs of the resident. Included in this care file was a risk assesment judging if it was safe for the resident to take his own medicines. It was dated 15/3/06. It was difficult to elicit from this if he was or had been taking his own medicines. We asked the manager if he was self medicating now and she told us No. There was also in his file a consent form for the staff to administer his medication. It had not been filled in by anybody. The 2nd care plan that we looked at was dated for the 29/7/2008 and was reviewed on the 30/1/09. We saw a post it note in the file that made reference to a very serious illness. On asking the manager what the information was about we were informed by the manager that this resident had recently been in hospital and had been seriously ill. There was nothing in his care file to show when he was admitted and discharged from hospital and there was no care plan in place in relation to the care he needed following his discharge. This resident also had a medical condition that needed emergency treatment at times. There was no care plan to show staff how to look after him routinely and what to do in an emergency. This resident had also previously lost weight. In his care plan of 29/7/08 it was stated that a full detailed description of his dietary intake should be completed. It documented that he should be weighed weekly. There was no evidence to show that this was done weekly. He had been weighed in in June 2009 and then again in September 2009. The records in relation to professional visits were also not up to date. The 3rd care file had information in about the residents behaviour but there were no risk assessments to show how staff were to reduce or manage the risks that had been identified. This resident was of the Muslim Faith but in 1 part of the care file it made reference to ensuring that he was given a Kosher diet, which is Jewish. The 4th care file looked at had some information to show how the resident liked to spend her day and what she needed support with. It made reference to this resident needing to lose weight but no reference to the fact that a special diet was needed to help address a medical condition. We were shown the book that recorded daily statements about the residents. The names of the residents were not always written down on the report sheet. We were also shown key worker diaries kept for each of the residents. These were not always kept up to date. Care Homes for Adults (18-65 years) Page 12 of 44 Evidence: 1 of the residents told us that he gets up when he wants to and spends the day doing whatever he likes. He told us that he can not go out on his own as it is not safe for him to do so. From inspection of care records and from observation of practices within the home it was seen that there were hazards that could cause a risk to the health and safety of the residents and people working in or visiting the home. Risk assessments were not in place to reduce or manage the risks. Care Homes for Adults (18-65 years) Page 13 of 44 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are limited choices for activities and involvement in the community and a limited choice and variety of wholesome, nutritious food. Evidence: We asked the manager if any of the residents went out to work or attended any college courses. We were told that nobody had any sort of employment or the desire to attend college. The AQAA document sent to us informed us that several of the residents are actively involved in community services such as accessing college courses and finding part time paid and voluntary work. This clearly contradicts what we were told during the inspection. We did see in 1 of the care files a referral form to access and develop computer skills and develop self confidence. This was dated 18/9/07 but we were told that the resident had shown no interest in attending the course. We saw no futher evidence of Care Homes for Adults (18-65 years) Page 14 of 44 Evidence: management and staff trying to encourage the residents to access any college courses or employment. Neither did we see any encouragement for the residents to pursue any hobbies. We were told that the residents are encouraged to keep their own rooms tidy, wash their own laundry and make their own breakfast. We saw that the rising and retiring times were flexible and that residents sat in the various lounges or spent time in their bedrooms. They seemed to do very little except smoke and watch television. We looked through the activities book that is used to log what activities have been undertaken. The main things that were written in were local shopping trips for just 4 of the residents. Only 2 in house activities had been undertaken in May 2009. There was nothing documented after August 2009. The AQAA document sent to us informed us that they are offering larger choices in activity than ever previously offered. We saw no evidence of this. We were told that visitors are welcome at any time and they can see their relative or friend in their own room or in any of the lounge areas. We were made aware that 1 of the residents regularly visits and spends time away with her partner. From the evidence seen, very few residents are able to visit the local shops, leisure centres and pubs on any regular basis. Those residents that do need to be escorted by staff are not able to go out on any evening, or on a Friday, Saturday and Sunday. This is due to the fact that there is only 1 care staff member on duty. We went into the residents kitchen and the main kitchen to look at the food stocks and menus. We were told that the residents make their own breakfast. The menu states that it is cereal or toast for breakfast. We saw bread but no butter and no other food stocks in the fridge. The menus for the week of the 7/12/09 showed that there was no fresh fruit available and we saw no evidence of fresh fruit either in the kitchen or elsewhere in the home. The menus did not always show a choice of meal and there was no dessert on offer for lunch and only on 1 occasion for the evening meal. On the day of inspection the lunch and evening meal served did not correspond with what was on the menu. 1 of the residents had a large mound of green beans served on his plate. When asked by us if he liked them he said that he did not and he wanted baked beans instead. The menu that we looked at was not varied and offered very little choice. Beans were being served 4 times in 1 week. We saw no evidence of special diets being catered for although we were aware that 2 of the residents needed a special diet for medical reasons. We did see in the fridge however, that the resident who was of the Jewish Faith had a section in the fridge for Care Homes for Adults (18-65 years) Page 15 of 44 Evidence: his meat. On the day of inspection we saw that a care assistant was working as the cook. We were told that there is no designated cook. She did not wear any protective clothing, such as an apron or a hat. We were told by the manager that this was normal procedure and they did not wear protective clothes in the kitchen. This carer had worked as a carer in the morning. We saw 2 mops and 2 buckets left in the kitchen. We were told that 1 of these was for the bathroom. To prevent the spread of infection, protective clothing should be worn in the kitchen and mops for other areas of the home should not be stored in the kitchen. Care Homes for Adults (18-65 years) Page 16 of 44 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of medicines is unsafe and puts the residents at risk of harm. Evidence: We were told by the manager that each resident was able to manage their own personal care, although some residents sometimes needed prompting. The care plans that we looked at however, did not always make this clear. As previously stated in this report in the issues about care plans, 1 resident had lost weight but the weight loss and action to address it had not been followed. We saw records of where some of the residents had attended reviews about their care with their social worker. On the day of inspection we were made aware that a social worker from the Mental Health Team was visiting one of the residents. We saw that 1 of the residents regularly manages his own medical condition by taking samples of his blood himself. There was however nothing in his care plan about the fact that he does this. We were told that some of the residents have regular visits to the chiropodist or dentist but there was no regular recording of when these visits were made. Care Homes for Adults (18-65 years) Page 17 of 44 Evidence: We looked at how the staff manage the medication system within the home. The medicines are stored in a locked cupboard in the staff office. The staff office is kept locked by a keypad. The medicines are dispensed from cassettes that are filled up by the pharmacist. The key to the medicine cupboard is left in an unlocked key cupboard on the wall. The manager was advised that the key needs to be kept on the person in charge or the person responsible for managing the medicines that day. We asked the manager who was the designated person responsible for managing the medicines that day. We were told that no designated person is appointed and that staff ask each other about who has had their medications. We were also told that the pharmacy contacts the GP surgery for repeat prescriptions, picks them up from the surgery and then dispenses them to the home. This means that the staff at the home do not see the prescriptions at all and are not able to check just what has been prescribed and if it is correct. We looked at the stocks of medications in the cupboard. Medicine containers were mixed up in baskets in no stock rotation order. This can lead to overstocking or medicines being stored that are out of date. We found medicines not being stored in the container they were dispensed in and unknown loose tablets in the bottom of the storage baskets. We also saw in the cupboard a medicine pot containing several unknown white tablets. We were told that these had been found in a residents room and were being shown that day to his social worker. Staff were told to return them to pharmacy at the earliest opportunity. Whilst we were in the office we saw, on 2 occasions, staff take out the medicines and give them to 2 of the residents without checking the medication administration record sheet(MAR). We told the manager that this was a dangerous and unacceptable practice. An inspection of the MAR sheets showed that lots of the medicines had not been signed for as being given. Serious concerns were expressed about whether or not a contraceptive pill had been given regularly, as the MAR sheet showed many omissions. We saw that 1 of the residents had been given some reddish liquid at approx 1.30pm on the day of inspection. We asked the manager and 1 of the carers what it was and we were told that it was his medication. It was prescribed to be given at 9am and then again at 9pm. It had been signed for as being given at 9am. 2 of the residents were to be given their medication on an as required basis. There was no care plan for the staff to follow to know when it should be given. Having detailed care plans helps make sure people get their medicines when and how they need them. We saw that despite 1 medication having been discontinued, it had been written down that it had been given 3 times since it had been discontinued. There was no controlled drug cupboard installed. It is a legal requirement to have one. Care Homes for Adults (18-65 years) Page 18 of 44 Evidence: We asked the manager if the staff responsible for managing the medicines had received training in the management of medicines. We were told that they had but were shown no evidence of this. In view of the serious concerns identified during this inspection we have requested that a Specialist Pharmacy Inspector from the Care Quality Commission visit the home to undertake a pharmacy inspection. Care Homes for Adults (18-65 years) Page 19 of 44 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are not in place to ensure the safety and protection of the residents. Evidence: We looked at the complaints procedure given to us. It was for the sister home and not for Carr Bank. We explained this to the manager and asked for the complaints procedure for Carr Bank but it was not given to us. We were told in the AQAA document sent to us that there was now a new Service User Guide and Statement of Purpose so we asked to see this. This was so that we could hopefully access the complaints procedure. This was not made available to us. The AQAA document stated that no complaints have been made to the home in the last 12 months. It also stated that they have updated the complaints procedure. We looked at the complaints log that is kept by the home. We saw that pages had been ripped out of the book that was in use. No complaints have been made to us in the last 12 months. We were told that safeguarding training had recently been undertaken by the local authority. We saw the document that outlined the content of the training but despite asking for the training files we saw no evidence of who had done the training. The AQAA document informed us that the management of the home had put together training packages on safeguarding and that training had been undertaken. We saw no evidence of this. We were not able to look at the system for the protection of the residents money Care Homes for Adults (18-65 years) Page 20 of 44 Evidence: because the person who had the safe keys was not available. We advised the manager that the senior person on duty should have access to the key so that the residents can access their money at any time. Care Homes for Adults (18-65 years) Page 21 of 44 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents live in a poor environment that is in need of further redecorating and refurbishment. It is neither safe nor comfortable. Evidence: We looked around all areas of the environment. We also looked to see if the requirements from the last inspection had been complied with. There was poor security within the home. When we entered the home at 9:30 am and until we left at 19:00 hours the front and back doors were continully left open. Throughout the inspection day we continually had to shut the back door to make the home more secure and to try to keep warm. The manager told us that the residents liked the door left open as they were coming and going all day. We did not see a lot of evidence of this. Rubbish remained in the back yard and in the front garden. The whole home was very cold. Most of the downstairs windows were left open. We were told by the manager that the residents opened them and wanted them to stay that way. We stated that we felt this would be difficult for them to do as the windows were so high that they would need a ladder. We also saw that the smoking lounge that Care Homes for Adults (18-65 years) Page 22 of 44 Evidence: leads onto the garden had the doors continually open. We were told that this was because they needed the ventilation and that an extractor fan was going to be fitted before Christmas. We noted that all the radiators in the home were cold. We went to the control system in the main kitchen and saw that the heating was turned off. We asked the manager to turn it on immediately, which she did. We were told by the owner that a resident must have turned it off. The owner was advised to put systems in place to ensure that the resident was not able to do this. We visited a bedroom where the resident told us that he was cold and it was regularly cold. We took the temperature of the room and it was 16c. The temperature should be a minimum of at least 23c. Both the downstairs shower rooms were cold. 1 was out of action as a new shower tray was about to be fitted. It was identified during the last inspection that the floor was sinking. We were told by the manager that new tiling had been fitted but the floor continued to sink so they were now trying a shower tray. The upstairs bathrooms remained in need of redecoration and refurbishment. The dining room had recently been redecorated but the damp stains were still evident. This will be checked on the next inspection. We looked at both of the lounges at the front of the home and found that 1 of them was also being used as a designated smoking lounge. The home therefore had 2 rooms allocated for smoking. In addition we saw that residents were smoking in the downstairs corridor and in their own bedrooms. We did also see that at the top of the cellar stairs there was a cardboard box with cigarette ends in it. Smoking in non designated smoking areas is dangerous. It is a fire risk and is not in accordance with the law. No fire risk assessments were seen for smoking anywhere in the home. The other lounge which was designated non smoking, was very dimly lit and the arms of the settees were very stained. There was an unguarded radiator in this room. We then looked at all the bedrooms. Most of the bedrooms were dimly lit and several were without a reading lamp. The one resident whose room temperature we tested also showed us that he had 2 duvets on the bed and his own blankets to keep warm. Another resident told us that she had her coat on to keep warm. Several of the bedrooms had unguarded radiators, 2 of which were very close to the bed. We advised the manager to undertake risk assessments for these as a matter of urgency,as there is a risk of accidental burning to the resident if and when the radiators are turned on. Care Homes for Adults (18-65 years) Page 23 of 44 Evidence: Several of the bedrooms were also in need of cleaning and redecoration. We saw that 1 mattress had springs sticking out and no sheet on. Some other bed sheets looked thin and worn. We were told by the manager that the mattress would be changed that day. We saw that there had been some progress in relation to meeting some of the requirements from the last inspection. The stairs and landing had been redecorated and new carpet had been fitted. We did note however that there was a dip underneath the newly fitted carpet in the landing. This is a trip hazard. The manager was advised to contact the carpet fitters to have the problem resolved. Some of the bedrooms had also been recently redecorated. The decorators were in the home during the inspection day. We saw later on in the day that the paint tins and equipment had been stored in the front vestibule, blocking the fire exit. We asked the manager to get it removed immediately. Due to the concerns that we had in relation to the fire safety log book, we had contacted the local fire safety officer who visited the home very shortly after we made contact. He identified that there was a defective smoke detector in 1 of the rooms and informed the manager that she was to contact him when it had been fitted. We noted that there were no call bells throughout the home for the residents and staff to summon assistance if necessary. We were aware that the residents were self caring but this needs to be given consideration if the needs of the residents change. Infection control procedures were not as good as they should have been. Liquid soap and paper towels were in place in the bathrooms/shower rooms. However it was noted that there was also block soap in use,which can harbour germs and there were no waste bins to collect the used hand towels. The manager was told to remove the block soap. We saw that 2 of the bedrooms were without handbasins. As previously stated in this report the infection control procedures in relation to basic food hygiene in the kitchen were not acceptable. Care Homes for Adults (18-65 years) Page 24 of 44 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Inadequate staffing numbers and the lack of staff training puts the residents at risk of harm. Evidence: The AQAA document sent to us informed us that all 12 of the staff had obtained their NVQ level 2 qualification in care. When we requested evidence of this it was not available. The manager then told us that only 2 staff had this qualification. Again we saw no evidence of this. We looked at the staff rota for the week of the 7/12/09 to find out how many staff were on duty at any one time. We saw that there is normally from Monday to Thursday 1 care assistant on duty plus the manager working from 8am to 3pm, or 9am to 3pm. Presently this manager is also supporting the sister home that is without a manager. Sometimes the owner will work 9-5 for 1 day a week. This means that on every evening of the week, plus every night, there is only 1 care assistant on duty. Also on a Friday there is 1 care assistant only, plus the cook who works from 3pm to 5pm Monday to Friday and the cleaner who works 9-12 Monday to Friday. On a Saturday and Sunday the only staff member on duty is 1 care assistant. This care assistant has the responsibility for caring, cleaning and cooking. 1 resident told us that he can not go out at weekends as he can not go out on his own. We were also made aware from inspection of care plans that some of the residents could have unpredictable behaviour. We were also made aware from inspection of the Care Homes for Adults (18-65 years) Page 25 of 44 Evidence: fire log book that fire drills /instruction had not been carried out. In the event of any incident within the home the residents are at risk of harm with 1 staff member only on duty. Having only 1 care assistant on duty for the 11 residents within the home is not adequate. As we had previously undertaken an inspection in October 2009 to check on recruitment only, we checked the recruitment file of just 1 of the staff members. This person was being safely recruited. Several requirements in relation to training had been made at the last inspection so we asked for information about what training had been undertaken. The manager informed us that training had been undertaken with the Local Authority. This we were told included:- safeguarding of people, care plans and risk assessments. We were also told that medication training had been undertaken by the local pharmacist. Despite several requests to see evidence of this training we were not given any. We called in the local fire safety officer on the day of inspection due to concerns in relation to other fire related issues. He inspected the fire training records and reported that he had seen evidence of fire training but no evidence of any fire drills. The 2 training files that we were given to look at showed that most of the training that had been given needed updating. Care Homes for Adults (18-65 years) Page 26 of 44 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is not being managed effectively or safely. This puts the residents at risk of harm. Evidence: The manager of the home has been registered with us since 2003. She has not yet obtained a management qualification. Following the last inspection of June 2009 management were required to send us an improvement plan. We have not received one. Previously the manager has been supporting both Carr Bank and the sister home Laburnum House due to the manager there being on maternity leave. We have been informed that the manager of Carr Bank is once again supporting Laburnum House. In view of the concerns that we have found during this inspection we informed the manager that as Carr bank was not being managed effectively and safely, it is not acceptable for her to be managing Laburnum House. The AQAA document makes no reference to a quality assurance system being in place. It does make reference to the manager and the owner carrying out unannounced inspections at weekend and in the evenings but we saw no evidence of this. The Care Homes for Adults (18-65 years) Page 27 of 44 Evidence: manager told us that she has introduced residents meetings where different topics were discussed such as food. We did not see any notes from this meeting. We did see an annual quality assurance report on the staff notice board for the year 2008. We did discuss with the manager that in view of all the concerns that we have identified during this inspection that she needs to undertake regular checking of lots of things within the home to make sure that things are being done safely and properly. The AQAA document sent to us was not filled in fully in relation to the maintenance of equipment. No dates of servicing of equipment were provided. We looked at the service records in respect of the electrical equipment and gas. They were up to date. We then spent some time looking at the fire safety log book. The last recorded entries for checking the fire safety of the home had been made in August 2008. In view of our concerns at the lack of fire safety checking we contacted the local fire safety officer who visited the home straight away. His visit and report identified that the weekly means of escape and weekly fire alarm tests had not been carried out. Also the monthly emergency lighting and fire fighting equipment checks had not been carried out. He also identified that 1 of the smoke detectors was defective and this had been identified during an annual service in June 2009. There was also no evidence of fire drills. The management were told to contact the fire officer when the defective smoke detector was replaced. A requirement from the last inspection was in relation to the water temperatures being too cold. We checked the water temperatures and they were reading at 43c which is the correct temperature. We had a discussion with the owner in relation to whether or not thermostatic control valves were fitted on the baths and showers. We were told that they were. We asked if they were serviced and were informed that there is nothing to service. We later then asked the manager for evidence to show if the water temperatures are checked regularly. We were told that they were checked but we saw no evidence of recordings. It is a legal requirement that the manager sends us notification of when a resident has been admitted to hospital. We were made aware by reading some information and by speaking to the resident concerned that he had been admitted to hospital and had been seriously ill. We have not received any notification in relation to this. Care Homes for Adults (18-65 years) Page 28 of 44 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 Information recorded on the care plan should reflect the current and changing needs of people. Without this information there is no assurance their needs and wishes will be met. 30/09/2009 2 9 13 Comprehensive risk 30/09/2009 assessments need to be reviewed and updated ensuring information is accurate. Where additional concerns have been identified these too should be included. Providing staff with information about the level of support required so that people are kept safe. 3 19 15 Adequate monitoring and 30/08/2009 recording must be made with regards to the weight and dietary needs of people where concerns are identified in the care plan ensuring the appropriate support and intervention can be provided should concerns continue. 4 19 12(1) Accurate records must be maintained with regards to 30/08/2008 Care Homes for Adults (18-65 years) Page 29 of 44 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action peoples dietary needs as well as accurate monitoring of their weight ensuring they are supported fully and their health and well being is maintained. 5 20 13 Medication administration records must be completed in full along with explanations where medication has not been given ensuring people are given their medication as prescribed and their health and well being is not affected. 30/08/2009 6 20 18 All staff who administer medication must receive accredited medication training ensuring they have the competence needed to administer peoples medication safely. 30/10/2009 7 23 18 All staff must complete Safeguarding training in line with the local authority procedure. So that they are clear of their responsibilities ensuring people are protected 30/10/2009 8 23 18(1)13(4) Arrangements should be made for staff complete Safeguarding training in 30/09/2008 Care Homes for Adults (18-65 years) Page 30 of 44 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action relation to the local authority procedure so that they are aware of the procedure to follow ensuring people are kept safe. 9 23 23 The exterior of home needs to be cleared of rubbish and the garden and yard tided so that people living at the home are able to enjoy it. 30/09/2009 10 23 23 Each of the bathrooms are in 30/11/2009 need of redecoration and refurbishment so that they provide comfortable, safe and clean facilities for people to use. 11 23 23 The sunken floor in the downstairs shower room need attention so that people are not placed at risk and further damage to the property is prevented. 30/08/2009 12 24 23 The sunken floor in the downstairs shower room need attention so that people are not placed at risk and further damage to the property is prevented. 30/08/2009 13 24 23 The exterior of home needs to clear of rubbish and the garden and yard tided so that people living at the home are able to enjoy it. 30/09/2009 Care Homes for Adults (18-65 years) Page 31 of 44 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 14 24 23 Each of the bathrooms are in 30/11/2009 need of redecoration and refurbishment so that they provide comfortable, safe and clean facilities for people to use. 15 33 18 Rotas should be kept under review ensuring that sufficient staffing are provided to meet the needs of the service. 30/09/2009 16 33 18(1)(a) Staffing levels should be kept 30/08/2008 under review ensuring staff are provided in sufficient numbers at times which best meet the needs of people living at the home. 17 34 19schedule 2 All relevant information and 30/08/2008 checks needs to be in place before staff commence any work at the home ensuring people are not placed at risk. 18 35 18 All staff must be provided with good quality training specific to the needs of people living at the home. This should include areas such as mental health awareness, challenging behaviour, epilepsy as well as mandatory courses. This is to ensure staff have the knowledge, skills and 30/10/2009 Care Homes for Adults (18-65 years) Page 32 of 44 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action competences needed to support people safely. 19 35 18(1)(c) (i) A programme of training 30/09/2008 needs to be developed for the forthcoming year so that staff receive all necessary training relevant to their roles and responsibilities ensuring they are competent to carry out their role safely. 20 37 12 The registered person must 30/08/2009 ensure that the care home is conducted in such a way as to promote and make proper provisions for the health and welfare of service users ensuring their safety and protection. 21 39 24 Quality assurance systems need to be improved and clearly evidence that the service is being monitor and reviewed ensuring the improvements needed are addressed and a quality service is proivded. 30/09/2009 22 42 37 All incidents which may affect the well being of residents must be reported to us evidencing the appropriate action has been taken. 30/08/2009 23 42 37 Any incidents, which occur that may affect the wellbeing of people, must be 30/09/2008 Care Homes for Adults (18-65 years) Page 33 of 44 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action reported to the CSCI in line with Regulation 37. Care Homes for Adults (18-65 years) Page 34 of 44 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 6 15 Care plans must detail the health and social care needs of the residents. So that the current and changing health and social care needs of the residents can be met. 04/01/2010 2 9 13 Staff must make sure that any risk to the health and safety of the residents is identified and action taken to reduce or stop any identified hazard. To ensure the health and safety of the residents. 04/01/2010 3 17 16 A more varied menu must 04/01/2010 be provided that is nutritious and offers choice. Special diets must also be provided for. To ensure that the dietary and cultural needs of the residents are met. Care Homes for Adults (18-65 years) Page 35 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 17 13 Protective clothing must be worn when preparing and serving food. To help prevent/reduce the spread of infection. 04/01/2010 5 19 15 Where concerns are 04/01/2010 identified in a care plan,adequate monitoring and recording must be made with regards to the weight and dietary needs of the resident. Ensuring the appropriate support and intervention can be provided should concerns continue. 6 20 13 All medicines must be stored 31/12/2009 safely and securely. Medicines must be stored safely to make sure they can not be mishandled and put peoples health at risk 7 20 13 There must be an effective 31/12/2009 auditing process in place to ensure that managers are confident that medicines are being handled safely. To help make sure that people who live in the home are kept safe. 8 20 13 Effective arrangements must 22/12/2009 be put in place at the home to ensure that all medication Care Homes for Adults (18-65 years) Page 36 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action records regarding receipt, administration and disposal are completed accurately. So that medicines can be fully accounted for to prevent mishandling. Records must also show that medicines are being given correctly and peoples health is not at risk from harm. 9 20 13 There must be effective systems in place to ensure staff that handle medicines are trained in medicines handling and are competent to do so safely. To help make sure that people who live in the home are kept safe. 10 20 13 Effective arrangements must 22/12/2009 be put in place at the home to ensure that all medication is administered to residents in exact accordance with the prescribers directions. Because receiving medicines at the wrong dose, wrong time or not at all can seriously affect their health and wellbeing. 11 20 13 A Controlled Drugs cabinet must be obtained which complies with current legislation under the Misuse 04/01/2010 04/01/2010 Care Homes for Adults (18-65 years) Page 37 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action of Drugs Act (safe custody) Regulations, and must be fixed to a suitable wall in compliance with that legislation. To ensure the safe storage of controlled drugs and to comply with legislation. 12 22 22 A complaints procedure must be in place and a copy supplied to every resident and to any person acting on their behalf. So that people know how to complain and action is taken to listen to their concerns. 13 23 13 All staff must complete safeguarding training in line with the local authority procedure. So that they are clear about their responsibilites in ensuring that people living at the home are protected. 14 24 23 Fire exits must be kept clear 04/01/2010 at all times. To ensure the safety of the residents and everybody present in the home 15 24 13 The unguarded radiators must be covered or low surface temperature radiators fitted. 29/01/2010 04/01/2010 04/01/2010 Care Homes for Adults (18-65 years) Page 38 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To reduce the risk of accidental burning. 16 24 23 The remaining bedrooms must be redecorated and refurbished. For the well being and comfort of the residents. 17 24 23 Adequate lighting must be provided. To ensure that the residents are able to live in comfortable and homely. surroundings. 18 24 13 Risk assessments must be in 04/01/2010 place for those radiators that are close to the residents beds. To reduce the risk of accidental burning 19 24 16 The lounge furniture must be thoroughly cleaned or replaced. To ensure the comfort of residents. 20 24 23 Adequate heating must be provided. To ensure the comfort and well being of the residents. 21 24 23 The home must be kept secure. 04/01/2010 04/01/2010 04/01/2010 04/01/2010 29/01/2010 Care Homes for Adults (18-65 years) Page 39 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To protect the residents and staff from harm 22 24 23 An extractor fan must be fitted to the designated smoking lounge. To ensure the comfort and well being of the residents. 23 24 23 The exterior of the home needs to be cleared of rubbish and the garden and rear yard kept tidy. So that the residents are able to enjoy the facilities. 24 26 16 Adequate bed linen must be provided. To ensure the comfort and well being of the residents. 25 27 23 The shower tray must be fitted in the shower room. To ensure that the residents are provided with a safe showering facility. 26 27 23 The upstairs bathrooms must be redecorated and refurbished. So that they provide comfortable, safe and clean facilities for people to use. 04/01/2010 04/01/2010 04/01/2010 04/01/2010 04/01/2010 Care Homes for Adults (18-65 years) Page 40 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 27 28 13 People must smoke in the 04/01/2010 designated smoking area only and risk assessments in relation to smoking must be undertaken. To reduce the risk of fire and protect the health and safety of the people in the home. 28 33 18 Adequate staff must be provided. To ensure that the assessed needs of the residents are met at all times. 04/01/2010 29 35 18 Management must 04/01/2010 demonstrate to us that all staff are to be provided with all mandatory training and training specific to the needs of the residents. To ensure that the staff have the knowledge,skills and competencies needed to support and care for the residents safely. 30 37 12 The registered person must 04/01/2010 ensure that the care home is conducted in such a way as to promote and make proper provision for the health and welfare of the residents. To ensure their safety, protection and well being. Care Homes for Adults (18-65 years) Page 41 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 31 42 37 Any incidents which may affect the well being of the residents must be reported to us. To show that the appropriate action has been taken. 04/01/2010 32 42 23 Fire checks must be undertaken and recorded in accordance with the requirements of the Fire Precautions Act 1971 and Fire Precautions regulations 1997. To protect the safety and wellbeing of the residents,staff and people visiting the home 04/01/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 People should be properly assessed by the staff at the home, to ensure that the staff at the home can meet the residents needs. Care records should always be dated and signed. This will show an accurate and up to date record of the residents condition at any one time. To enhance the lifestyle of the residents, more opportunites should be available for them, in and out of the home, to participate in activities, education, training and employment. Where a resident manages their own medical condition Page 42 of 44 2 6 3 13 4 19 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations there should be information in their care plan to show how this is managed. 5 19 So that there is an accurate record of a residents access to support services staff should ensure that visits to all healthcare services are recorded in the residents care file. The senior person on duty should have access to the safe key so that the residents can access their money at any time. Consideration needs to be given to providing a call bell system in the home if the needs of the residents change and they need to summons assistance. Waste bins, preferably with a pedal to reduce the spread of infection, should be provided in the bathrooms and toilets. The manager should ensure that staff undertake the NVQ training in care so that they have the skills and competencies needed to care for and support the residents. To ensure the safety of the residents, the water temperatures should be checked and recorded on a regular basis to ensure that the thermostatic control valves are working correctly. 6 23 7 24 8 9 30 32 10 42 Care Homes for Adults (18-65 years) Page 43 of 44 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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