Inspection on 17/12/09 for Charnwood Oaks

This inspection was carried out on 17th December 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Charnwood Oaks 12/08/10

Charnwood Oaks 10/02/09

Charnwood Oaks 06/11/08

Charnwood Oaks 05/08/08

Charnwood Oaks 27/02/08

Charnwood Oaks 22/10/07

Charnwood Oaks 07/11/06

Charnwood Oaks 08/08/06

Similar services:

Trevayler Residential Care Home

St Marys Nursing Home

Thornham Grove

Cheaney Court Care Home

Thistle Hill Hall

Chater Lodge

Conifer Lodge

Tixover Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Charnwood Oaks Sullington Road Shepshed Leicestershire LE12 9JG Lead Inspector Debbie Williams Key Unannounced Inspection 17th December 2009 04:17 DS0000066624.V378771.R01.S.do c Version 5.3 Page 1 This report is a review of the 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. 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 older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The 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. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.2 Page 2 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 Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charnwood Oaks Address Sullington Road Shepshed Leicestershire LE12 9JG 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) 01509 600500 01509 502128 charnwoodoaks@prime-life.co.uk info@prime-life.co.ukwww.prime-life.co.uk Prime Life Ltd Care Home 84 Category(ies) of Dementia (84), Dementia - over 65 years of age registration, with number (84), Mental disorder, excluding learning of places disability or dementia (84), Mental Disorder, excluding learning disability or dementia - over 65 years of age (84), Physical disability (12), Physical disability over 65 years of age (12) Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No persons falling within the categories DE or DE(E) to be accommodated at Charnwood Oaks when there are already 84 persons of those categories or combined categories accommodated at Charnwood Oaks No persons falling within the categories PD or PD(E) to be accommodated at Charnwood Oaks when there are already 12 persons of those categories or combined categories accommodated at Charnwood Oaks No persons falling within the categories MD (excluding Learning Disability or Dementia over the age of 50 years) or MD(E) to be accommodated at Charnwood Oaks when there are already 84 persons of those categories or combined categories accommodated at Charnwood Oaks The maximum number of persons to be accommodated at Charnwood Oaks is 84 10th February 2009 2. 3. 4. Date of last inspection Brief Description of the Service: Charnwood Oaks is a care home for older persons, providing nursing and personal care for up to 84 older people, some of who have mental health needs, dementia and/or physical disabilities. The home was purpose built in 2006 and is owned and managed by Prime Life Limited. The home is situated in the small town of Shepshed, Leicestershire. The home is close to the main road and is easily accessible by private or public transport. Accommodation can be found on two floors that can be accessed by either stairs or passenger lift. Charnwood Oaks is divided into four units. Each unit provides the residents with their own single ensuite bedroom and communal lounge and kitchen facilities are available. The dining room is situated on the first floor of the home and residents can choose whether to use this facility or not. Details of current charges are available at the home. Details of what additional charges residents can expect to pay can be found in the information pack, which is given to all residents either prior, or on arrival at Charnwood Oaks. A copy of the latest Inspection report is available at the home, or it can be accessed via the CQC website: www.cqc.org.uk. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.2 Page 5 Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection included a visit to the service. We visited the home on the 17th of December 2009. The main method of inspection used was case tracking which meant selecting four residents and tracking the quality of their care by checking records, discussion with them and with staff and observation of care practices. We checked all the standards which the Care Quality Commission has decided are key standards during this inspection. In some sections we have also checked additional standards; these will be detailed in the main report. The provider sent us their annual quality assurance assessment and this provided additional information about what has happened at the service since the last key inspection. What the service does well: Staff had a very good rapport with people living at Charnwood Oaks; people living there appeared relaxed around staff and were able to ask for what they needed. Staff ensured that people were safe and promoted peoples privacy and dignity at all times. Staff worked well as a team and the atmosphere at the home was relaxed and homely. When faced with confrontational behaviour, staff appeared skilled and experienced in managing this. The environment is furnished and decorated to a high standard. People were able to move around freely in the communal areas and in secure and pleasant outdoor space. The management team were approachable, people felt their concerns would be listened to and acted on appropriately. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.2 Page 8 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. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 9 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 Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 4. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents are provided with the information they need to make an informed decision before moving in. People have their needs assessed before moving in. EVIDENCE: People are provided with a statement of purpose and other information about the home before they move in. People have their needs assessed before moving in; this ensures that the service can meet their needs. We looked at assessment records and found these contained all the information required for Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 11 staff to understand people’s individual needs. A form known as ‘getting to know you’ is used to record people’s life history, significant events and personal preferences. Some of these documents contained minimal information and care staff we spoke with new very little about some people’s life history. Staff told us that plans were underway to develop people’s personal history records further and this could then be used as a form of reminiscence therapy. The home provides nursing care and is therefore staffed with qualified nurses at all times. Approximately half the staff employed had received training in caring for people with dementia and the management of challenging behaviour. Staff training and development in this area was ongoing. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Charnwood Oaks have their health and personal care needs met. EVIDENCE: We case tracked four people and this involved discussion with them, with staff, observation of care practice and looking at care records. Care records seen contained clear instruction to staff as to the actions they must take to meet people’s individual needs. Care records included risk assessments and these were frequently updated. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 13 We spoke with one visitor who told us they were always made very welcome at the home and that staff were very approachable and friendly. This person told us that there had been significant improvement to his wife’s wellbeing since moving into the home and they had been consulted about her care plan. The home provides nursing care so there are always qualified nurses on duty. Care records included risk assessments such as risk of falls and risk of developing pressure sores, risks are assessed on at least a monthly basis and appropriate action is taken where risk is identified. Where prevention of risk may result in deprivation of a person’s liberty, then a referral is made to the deprivation of liberty team to ensure action is only taken in the best interests of the resident. We looked at medication administration records and storage areas. Records seen were accurate and up to date. Medication is managed by qualified nurses. Nurses are supervised until assessed as competent by a senior nurse. Some people living at Charnwood Oaks were being given medication covertly, this means that medicine is hidden in their food or drink; this was only done with permission of the persons GP. Some nurses were crushing medication to give covertly; this is contrary to the provider’s medication policy and is not considered safe practice. We made a requirement that this practice must cease. Interactions observed between staff and residents were positive. Staff spoke with residents in a friendly and respectful way. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most people have their lifestyle needs and expectations met. People with advanced cognitive impairment have few opportunities to participate in activities that are meaningful to them. EVIDENCE: The service now employs a full time activities organiser who has received some training in providing activities for people with dementia. People are given the opportunity to take part in recreational activities outside of the home; there is a minibus for people to go out in. Staff have worked hard and have been innovative and creative in providing opportunities for meaningful activity for some people. However, there were some people with more advanced cognitive disability for whom little opportunities were available for meaningful activity. Some people were not engaged or occupied for the majority of the time and Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 15 interaction with staff was minimal. One person appeared anxious and agitated in the lounge area, staff offered some verbal reassurance but this was ineffective. When asked about this person, some staff knew nothing about this persons past or about their personal preferences. It is important that staff know as much as possible about people who have dementia as this information can aid interaction and communication and therefore meet peoples individual needs. Eventually, a member of staff offered to brush this person’s hair and then take them for a walk, this appeared to provide comfort and reassurance for this person. Information about people’s life history and personal preferences is included within peoples care records, in some instances, very limited information is available. The activities organiser told us that more work would be done to find out about peoples life history and that memory boxes would be introduced. Memory boxes contain significant objects and information from peoples past and provide a means of communication and interaction. It was evident that people, who were able to, could make choices about how to spend their time. People were free to move around the unit and to go outside. People living at Charnwood Oaks appeared relaxed and comfortable around the staff, interactions were positive and staff were helpful and respectful. Some people living at Charnwood Oaks had complex mental health needs and displayed behaviour that challenges, staff were experienced and skilled in managing potentially confrontational situations. Staff spoken with told us they were instructed to give people choice at all times. People, who were able to, asked staff for a variety of snacks and drinks throughout the morning and staff arranged to get people what they needed without question. We observed the lunchtime meal and this appeared appetizing and nutritious and people were offered a choice. Meals can be taken in the dining room, in the lounge area or in peoples own rooms. Nutritional risk assessments were undertaken on a monthly basis as was a record of any weight loss or gain. Evidence was seen of referrals being made to a dietician when nutritional risk was identified. We spoke with one visitor who told us they were always made very welcome at the home and that staff were very approachable and friendly. There was a range of activities available such as watching DVD’s, games and trips outside of the home. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected from abuse by complaints and safeguarding policies and staff awareness in this area. EVIDENCE: At least one staff member remains in the lounge areas at all time to supervise residents who may be at risk of falling or who may be unable to ask for assistance. People spoken with told us that staff and the management team were approachable and would listen to any concerns and take appropriate action. The provider has a complaints policy which is provided to all residents, this sets out the stages involved in a complaint investigation and provides details of who to contact if further investigation is required. There is also a suggestions book in the main reception. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 17 All staff receive training regarding safeguarding people form harm as part of their induction training, approximately half of all staff had also completed further training regarding this and had received training in the management of challenging behaviour. We recommended that some staff also attend the local authority’s safegurding training. Staff spoke with were aware of the correct procedures to follow in the event of suspected abuse. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20,21,23,25 and 26. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, comfortable and well maintained environment. EVIDENCE: The home is separated into four separate units, each with its own lounge and kitchenette. There is a separate dining area and two further lounges for communal use. All rooms are en suite. The home is decorated and furnished to a high standard and provides a comfortable well maintained environment which is suitable to meet the needs of people living there. People are free to Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 19 move around and have access to secure outside areas. The design and layout of the home is supportive for people with dementia or mental health needs. All areas of the home were extremely clean and people told us this was always the case. People private rooms were personalised with their own possessions. Staff had received training in infection control and this minimised the risk of cross infection for people living at Charnwood Oaks. The providers sent us their annual quality assurance assessment which stated that all routine maintenance and safety checks had been carried out. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are employed in sufficient numbers and are well trained and competent to meet the needs of people living at Charnwood Oaks. EVIDENCE: We looked at staffing rosters and spoke to staff and residents about staffing levels. Staff were deployed in sufficient numbers for the majority of the time. There is usually a qualified nurse on each unit during the morning and one qualified nurse over two units in the afternoon evening. One qualified nurse had called in sick on the morning of this inspection and this caused a shortage in staff. Staff spoken with told us that staffing levels had improved since the last inspection. There was always at least one member of staff in the lounge areas to supervise people who may otherwise be at risk. One visitor spoken with told us the home was very well staffed. We observed that staff appeared to work very well together as a team and people spoken with confirmed this. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 21 We looked at staff training records, all new staff receive induction training when they first commence employment. All mandatory health and safety training had been provided and was updated on an annual basis. Approximately half the staff employed had received additional training in caring for people with dementia and the safe management of challenging behaviour. The providers told us that further training in this area would be provided. The social activities co coordinator had recently completed further training in dementia care and this included the provision of meaningful activities. Approximately a third of all staff had either completed or were working towards National Vocational Qualifications in care. The provider’s recruitment policies and procedures minimise risk for people living at Charnwood Oaks. At least two references are obtained and Criminal Records Bureau check is completed before people commence employment. This ensures that people are suitable to work with vulnerable adults. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health safety and welfare of people living at Charnwood Oaks is promoted and the home is run in the best interests of people living there. EVIDENCE: Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 23 The providers sent us their annual quality assurance assessment which stated that all routine maintenance and safety checks had been carried out. Staff had received all mandatory health and safety training such as moving and handling people and this promotes safety for people living and working at Charnwood Oaks. The home is managed by a qualified nurse who was in the process of applying to be registered with the CQC as registered manager. It was evident that significant improvements had been made to the quality of care provided since the last key inspection and the home was being run in the best interests of people living there. Staff spoken with told us they felt supported by the management team. Staff worked well as a team, had a clear sense of direction and were motivated and enthusiastic. Quality assurance systems were in place and this included in house auditing and senior management audits. The manager holds a weekly surgery where she is available to address any issues or concerns, there is also a suggestions book in the reception area and resident and relative satisfaction questionnaires are sent out annually. Small amounts of money can be stored securely for people living at Charnwood Oaks if this is required. Records are maintained and audited regarding all transactions for peoples personal money, this minimises the risk of financial abuse. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 24 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 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 4 4 x 4 x 4 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 x x 3 Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13 Timescale for action Medication must only be given as 30/12/09 prescribed and must not be crushed. This to ensure that people receive their medication correctly and are protected from harm. Requirement 2. OP12 12 People living at Charnwood Oaks must be provided with opportunities for participating in meaningful activity that meets their individual needs and expectations. 20/01/10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000066624.V378771.R01.S.doc Version 5.3 Page 26 Charnwood Oaks 1. Standard OP18 It is recommended that staff attend the local authority safeguarding adults training. This is to ensure staff have up to date and best practice knowledge about how to protect people living in the home form abuse. Charnwood Oaks DS0000066624.V378771.R01.S.doc Version 5.3 Page 27 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) 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. 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