Inspection on 02/08/07 for Elmwood

This inspection was carried out on 2nd August 2007.

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

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

Other inspections for this house

Elmwood 26/03/07

Elmwood 13/06/06

Elmwood 20/03/06

Elmwood 19/01/06

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Elmwood 42-46 Southborough Road Bickley Kent BR1 2EW Lead Inspector Wendy Owen 2 nd Unannounced Inspection & 7 August 2007 10:00 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000066220.V343045.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000066220.V343045.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmwood Address 42-46 Southborough Road Bickley Kent BR1 2EW 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) 020 8249 1904 020 8249 4117 Mission Care Care Home 67 Category(ies) of Old age, not falling within any other category registration, with number (66), Physical disability (1) of places DS0000066220.V343045.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 place registered for service user category PD for named service user only. 26th March 2007 Date of last inspection Brief Description of the Service: Elmwood is a purpose-built facility providing accommodation for up to sixtyseven residents in the category of older persons. It is located over three floors with a large reception area on the ground floor. The Manager’s office is also located in this area. There are additional facilities by way of a cinema and coffee lounge on the first and second floor. Each floor has a dedicated dining/sitting area. The middle floor is dedicated to intermediate care where the beds are funded through the Primary Care Trust. The maximum stay in this unit is six weeks. A multi disciplinary team of staff work intensively with residents to facilitate a move back to their own homes. The two other floors are for those residents in the category of older persons. These two floors provide long-term care and occasionally respite. Staff are allocated to specific floors to promote team working and provide a consistency of care. Each floor has a senior qualified nurse leading the team with support and ancillary staff. The organisation has recently recruited a qualified nurse to manage the home. Information is available to prospective residents and their relatives in the form of a residents’ guide and a resident and visitor’s guide. Contracts are provided for those who are privately funded through the organisation whilst those placed by the Local Authority (LA) are expected to have the Local Authority Placement agreement. Fees range from £586.44 to £861. These fees are different for those whose arrangements have been made by the LA and for those funding arrangements privately. DS0000066220.V343045.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection included a site visit and was undertaken by two inspectors for one day and a further two half days by two inspectors. In producing this report the inspector took into consideration information held by the Commission, information provided by the Manager in the form of Annual Quality Assurance Assessment and information held by other agencies. Written surveys were sent out to residents and relatives of which the Commission received 14 completed from residents and eight from relatives. The inspector also received verbal feedback from a Care Manager and Reviewing Officer in Bromley Social Services and two relatives. During the visit to the home the inspectors had discussions with residents, relatives, staff and management. The GP also briefly discussed the care. Records were viewed and practices were also observed. One inspector undertook a short observation in the second floor lounge to experience what it is like for those living there. What the service does well: Mission Care have developed information packs for people wanting to understand what the service has to offer. The home also ensures that information is obtained on all prospective people who may wish to use the service. Many residents are provided with contracts or placement agreements informing them about the care they should receive. Elmwood is a purpose built home and is built to a high specification. It is located in a residential area of Bromley. It is well maintained and equipped to a good standard with café, chapel cinema all on site for the benefit of those living there. Administration is well organised with records of monies spent on behalf of the residents fully documented and receipted. DS0000066220.V343045.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Information provided to those who wish to use the service needs to be more comprehensive and contain specific information on what the home can provide. This includes providing terms and conditions to those who are placed in the home by the Local Authority as well as those who are funding care privately. There has been some improvement in the care plans and supporting risk assessments. However, the lack of information in some areas still means that individual needs may not be met. It also means that care is not individual to the person using the service. This together with some basic training skills still required by some staff means that residents care needs are not being fully addressed. The health care needs of residents are not currently being addressed due to the medication practices and issues around pressure care. It is clear from the inspection that residents are reliant on the activity coordinator to provide the stimulation they need. Without this, particularly on weekends and when she is on annual leave there is little stimulation and interaction between residents and staff with residents placed in the lounge with the TV on for most of the day. “there appears to be no rapport between staff and residents, and staff and relatives/visitors.” Wrote a relative. It is clear through the feedback that there are issues around language, communication and culture. This seriously impacts on the quality of care and is a barrier to improvement. Staff must be provided with training or instruction on how to communicate effectively and on the culture of those they are caring for along with how to respond appropriately when people need their support. DS0000066220.V343045.R01.S.doc Version 5.2 Page 7 A resident wrote: “They are rough when handling you and I would find more clarity of speech helpful-so both sides know where they stand i.e. patient and carer.” Whilst another said: “A few of the carers are rather abrupt and appear not interested.” The feedback on the quality of food provided was also mixed. The feedback on the day showed there to be differing views on the lunches and supper meals and observations showed routines to be fixed and not supportive of individuals actual needs. The manager assures to a degree that she maintains the health and safety of those living in the home. However, staff practice of not ensuring call bells are in reach places residents safety at risk, as does the lack of monitoring on the units to ensure residents are supervised. One resident said: “staff are quite caring. Pressure of work sometimes causes delay in response to call-generally satisfactory. The communal areas of the home were clean and generally fresh. However, more attention must be paid to individual accommodation. “Individual rooms are kept clean but individual rooms are not kept fresh and clean.” Said one survey. The Commission and the Providers agreed staffing levels on registration. There have been occasions where these have not been met, particularly at night where full RGN cover has not been in place. Agreed levels must be maintained to ensure residents receive adequate nursing care and support. It is also necessary to ensure that confidentiality is maintained through appropriate communication at key times and therefore the home must ensure handovers do not take place in communal areas. Improvements have been made in the way the organisation recruits new staff. However, it is also crucial that the full checks be made to ensure systems vulnerable individuals living in the home are protected. It is positive to note the recruitment of a new manager that has provided some good leadership and support of staff. However, there has not been adequate time to implement systems such as regular formal supervision of staff, ensuring complaints are dealt with effectively and ensuring staff are aware of how to respond appropriately to peoples concerns when raised with them. In order to support the service the organisation must implement an effective system for monitoring and reviewing the quality of care in the home in order to effect improvements. Part of this is to improve the way in which the monthly visits are arranged and reported upon. DS0000066220.V343045.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000066220.V343045.R01.S.doc Version 5.2 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 DS0000066220.V343045.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some information is provided to ensure prospective residents are aware of what the service can offer them. Prior to admission residents are assessed to ensure staff have the information they need to provide the required support for individuals. EVIDENCE: The home has produced a Residents’ Guide and a Guide for relative and visitors. These provide information for prospective residents and relatives. A copy of the “Guide” is kept in residents’ rooms. These need some amendment to ensure they provide the information required by the Statement of Purpose and Service Users Guide e.g.-details of the manager, provider and numbers and qualifications of staff etc. The Guide should also include a template of the DS0000066220.V343045.R01.S.doc Version 5.2 Page 11 contract between residents and the Provider. The information would also benefit from making it explicit to readers about the different services e.g. nursing/residential and, in particular, the rehabilitation unit, detailing how the admissions and assessment differ between the units. It is clear from the surveys that the provision of information is not consistent and should be provided for all residents. The administrator has overall responsibility for co-ordinating referrals, assessments and admissions and she has developed a checklist to ensure procedures have been implemented. Information is sent out to protective residents, except for details of the contract and letters are sent where assessments have taken place to confirm the home can meet the individuals’ needs. The system is different on the rehabilitation unit where the PCT are responsible for co-ordinating and ensuring the individual is appropriately placed. The home receive a very detailed level of assessment from “CART” to ensure staff aware of needs prior to admission (although some people are only informed they are going to ICU on the day they were admitted – so there no opportunity to visit prior to admission) and to maximise independence during 6 week placement. There is no choice in the home where they are to receive rehabilitative care there is very little information provided about where they would be staying. The manager should investigate how information about the unit could be made available at the hospital for prospective residents. (See requirement) The feedback from the residents’ surveys provided mixed feedback on the question if they were in receipt of contracts. Viewing of files showed that there was evidence of Placement Agreements between the Authority and the resident, providing information on fees. These had been regularly updated. In these cases residents do not receive a copy of the terms and conditions from the Provider. Those who are privately funded are, however, in receipt of contracts. These provide satisfactory information on the terms and conditions of the service. All prospective residents should be provided with a copy of the terms and conditions as part of the pre-admission information and as stated earlier the terms and conditions should be included in pre-admission information. (See recommendation) Three files viewed showed evidence of the initial referral; relatives visiting to view the home, contracts or agreements and, in recent months letters, confirming the home is able to meet the needs of the individual. The inspector noted that whilst the Provider notified residents in advance of any increase in fees the month’s notice was only just met. Two residents spoken to and a number of the surveys completed identified that few prospective residents visit the home prior to admission mainly due to the poor health of the person entering residential care. The inspector also viewed three files to ensure the pre-admission procedures had been followed in respect of assessments. In one case the individual came DS0000066220.V343045.R01.S.doc Version 5.2 Page 12 from a distance and a care manager’s assessment had been obtained with the home confirming the assessment by telephone rather than visit the person in hospital. It is noted that the Guide states all prospective residents would be assessed by the home; this statement may need reviewing if this is not the case. In the two other cases the assessments had been completed by home but it was unclear as to whether they were pre-admission assessments or the nursing assessments that are part of the care plan. There were some gaps in the information, especially as stated in previous reports, a lack of signatures and dates. This makes it difficult to decide whether the assessment was prior to admission or after. DS0000066220.V343045.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were in place for residents, however these did not fully reflect identified needs and therefore staff do not have the full information required to support the residents in their personal, physical and social care needs. The healthcare needs of residents are not being met with the potential risks to their health, safety and well-being. EVIDENCE: The three inspectors spent time on one unit each to observe practices, talk to residents, staff and, where possible, relatives. The written and verbal feedback received showed that the quality of care is variable on the units with care improving in some units more than others. For example, the rehabilitation unit now has a stronger leader who is focussing on improving the care and collaborating jointly with the PCT staff. New systems have been implemented DS0000066220.V343045.R01.S.doc Version 5.2 Page 14 such as joint handovers three times a week and combined care plans. Staff are keen to implement the training provided by PCT staff. Three people using the service were spoken to on this unit and records case tracked. There was good evidence of assessment from the PCT, who fax treatment plans to home, Elmwood staff then complete in-house care plan. This is a rather basic format, and comprises of a pre printed format, which contains some useful information but is generally confined to nursing care needs. It does not include social needs in any detail, or allow scope for individuality, nor reflect changing needs, or how staff should proceed when they have changed, even though case notes do highlight where changes have occurred. The plans include specialist input and are reviewed and reassessed throughout stay. Feedback from physiotherapist on this unit confirms that the quality of care has improved considerably in last three months The feedback on the other two units is much more mixed. On the ground floor nursing unit the inspector spoke to three residents and one relative and on the third floor unit, two residents and one relative. Feedback shows that, for some, basic care is just being met, whilst, for others, the care provided is satisfactory. Attention to detail is lacking for a number, including the lack of appropriate grooming such as shaving, hair and fingernails being attended to and clothing. It was a concern to one visitor that staff may undertake personal care but will fail to replace items, such as call bell and magazines etc. This causes problems as their relative is paralysed and cannot stretch for objects. Staff need to be sensitive to this. Another relative said that their husband had not been dressed appropriately to respect his dignity nor had he been shaved by staff or bathed since admission. It is also clear from the surveys that many residents would prefer a bath to a shower although this does not happen regularly. It may also be made more difficult with the reductions in bathroom space in the future. Relatives wrote: “ I expect more than we are receiving apart from stimulation there is a lack of attentiveness and lack of initiative on the part of the staff. “Mum is always clean and well-fed.” Of staff one relative wrote: “they are very loving and always have a smile. My mother is very happy in her own way. She is on the whole well cared for.” However. the latter two comments were only two of a very small number expressing good care in the home. Other concerns revolved around the language and” communication forming a barrier to improvements and affecting overall quality of care. Older people DS0000066220.V343045.R01.S.doc Version 5.2 Page 15 living there who have hearing or vision problems or some confusion rely on tone and facial expression as well as actual language. A number of relatives and residents spoke of some staff being abrupt and a few relatives felt that they were ignored by staff when they raised concerns. This may be about culture. On the ground floor a number of residents spoke highly of one member of staff in particular who was always ready with a smile, chatting to residents and generally making them feel good. Previous to the inspection the inspector had received a concern regarding male carers performing personal care on female residents and how personal care was not respecting privacy and dignity. This was not identified as an issue on this inspection, although the care plans should record preferences of individuals. Verbal feedback also showed that the staff close doors and curtains when providing personal care. One visitor raised the issue that their relative had not had a bath in the year since they were in the home, only a bed-bath. This may be an issue with the resident relating to the use of hoists etc but this should be dealt with sensitively and the resident encouraged if that is the case. It was also clear from the written feedback that a number of residents would prefer a bath rather than a shower. The inspector is concerned in light of the possible changes to the bathrooms that there may not be enough bathrooms to ensure residents bath according to their preferences. One relative spoke of her concern over the grooming and personal care of their relative. Shaving appears to be left for days with the relative often having to undertake this to ensure her husband looked well cared for. Feedback from care managers have identified improvements in the service over recent months. This is positive. Three care plans were viewed on the ground floor nursing unit and two on the third floor nursing unit. The care planning information consists of a nursing assessment, care plan and risk assessments. The nursing assessments contained comprehensive information about the needs of the person and risk assessments identified where there were risks in tissue viability, nutrition, falls and mobility. Care plans are then developed to ensure staff take appropriate action to support the person where the identified needs recorded. These contained basic information with dates of review entered regularly. However, there were a number of gaps in those viewed and this shows that they were not reflective of the current situation, had not detailed some of the core needs and had focussed on the physical needs of the person. Key information was missed, especially around spiritual, social and financial needs. Staff completing the plans need to ensure they are reflective of the actual needs: for example one person is refusing personal care and medication but this had not been identified. It also appears care plans are set around the routines of the home rather than the individual Personal care traditionally takes place in the early morning when, for some it may be preferred late morning or afternoon. In another the staff had identified possible depression or neurosis DS0000066220.V343045.R01.S.doc Version 5.2 Page 16 but there were not corresponding care plan entries as to how staff would support the individual. Another did not have the individuals routines as far as activities were concerned e.g. day centre. Staff were not fully aware of this either. The inspector spoke to the newly appointed lead person. She intended to review all of the care plans to ensure “they told the story” of the individual. Both of the plans that looked at had been audited at the end of March and were reviewed monthly. Most of the records viewed contained supporting risk assessments in core areas with evidence of corresponding entries in the care plan of the action staff are to take. The inspector spent time viewing the records of two residents with pressure sores and considered information held regarding pressure sores in the home. The consultant physiotherapist on the rehabilitation unit told the inspector that there has been some improvement with staff now recognising when to involve the tissue viability nurse. This is not the case on the other units. The two care plans viewed contained risk assessments regarding pressures sores and some information on wound care. One of the resident’s records identified that they had two pressure sores that were healing well or healed. However, this resident has subsequently transferred to another home (within two weeks) and the inspector has been informed that the individual on arrival was noted to have a grade four and grade three pressure sore. No information had been supplied to the home and on assessment they were told the wounds were healing or healed, as documented in the paperwork. In another case the inspector was informed that a resident has developed a grade four pressure sore whilst in the home. This demonstrates that staff are not acting appropriately and seeking advice of the professionals in ensuring pressure sores are treated. It is also of concern that the Elmwood had not advised the home of the resident’s care needs or pressure sores and that staff appeared not to be aware of the transfer. During a tour of the units it was evident that pressure-relieving equipment was in place for a number of residents. However, one resident who is currently recovering in bed and therefore at risk of skin breakdown was provided with a pressure relieving mattress but had blankets under her feet (with heels resting on them) increasing the risk of skin breakdown in that area. Mixed feedback was also received about the medical support provided. Some relatives felt that the home communicated quite well, although for others, the quality of the communication was poor. There has been concerns raised by the relatives and residents about the system for seeing the GP. For some they felt staff ignored their needs to see the GP or they didn’t recognise when the GP should be contacted. Others spoke of the system for having a GP from a distance may be affecting this. (See requirements and recommendations) “I have very little contact with the GP with whom I am registered (as authorised by the home). Luckily at present my medical needs seems to be DS0000066220.V343045.R01.S.doc Version 5.2 Page 17 catered for. I would however, appreciate more personal contact by the GP and more time for personal talk.” Another resident said about receipt of medical support: “Unless seriously unwell 999/Emdoc would be applied-medical support indifferent.” The medication practices and records were viewed on the ground and second floor. The inspector is aware of issues regarding a resident where the home had run out of stock for one resident on the rehabilitation unit and issues with the correct administration and dosage. Medication records on the ground floor were found to be satisfactorily completed, with photographs in place for most of the residents and allergies, in the main recorded. When auditing on the ground floor the inspector found controlled drugs (liquid) with name of the person prescribed crossed out and another name in their place. If medication is prescribed for one person and administered to another this is in effect theft. Another prescribed medication was also kept stored even through the person was not there anymore. Controlled drugs had been appropriately recorded although there was little evidence in the CD or the returns book of their disposal. It was noted hand transcriptions did not always have two signatures i.e. counter signed and that in some cases pharmacy labels had been placed on the record. The use of labels has been halted as their placement may cover details on the medication record. The complaints file showed issues raised by the GP with medication records pertaining to them not being up to date-brought. On viewing one resident’s medication they had been prescribed diazapam but this had not been entered on the medication record On the second floor medication records in respect of one of the latest admissions showed that they had been hand written and been counter signed. All of the sheets had been signed with no gaps; some medication had been stopped by the doctor and replaced by another one. The doctor had changed the sheet but she had not signed the changes. This is recommended. The changes where tracked in the medication book. The medication was not blistered and one was packed in tubes that arrived boxed four tubes in a box, individual tubes were not labelled but they were left out of the box in the medication trolley and would not be able to be identified unless staff knew whose they were. Staff returned them to the labelled box and undertook to dispense them from the box. The second record viewed had all of the medication recorded appropriately and all but one was properly recorded with no gaps, except for one of the pills had not been signed for five days. On viewing the medication pack the medication was not present. Neither the staff nurse on duty or the floor manager could explain why the sheet had not been completed or the mistake noticed for several days. An investigation was being undertaken on leaving the unit. DS0000066220.V343045.R01.S.doc Version 5.2 Page 18 Medication is administered by RGNs only. Lunchtime medication administration was observed on both floors and it appeared to be done appropriately. (See requirement) DS0000066220.V343045.R01.S.doc Version 5.2 Page 19 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide a stimulating environment for many of those living there with a lack of interaction affecting the overall wellbeing of residents. The meals provided are often lacking in variety and residents are not supported to enjoy their meals in a way that ensures their nutritional needs are met. EVIDENCE: The activity co-ordinator was on annual leave during the inspection and therefore planned activities had not taken place. It is clear from records and from discussions with some relatives and residents that actviities do take place. The inspectors have also observed activities on previous occassions. However, this inspection has highlighted that, unless the actvitiy co-ordinator is working, activities and stimulation for residents is severely affected. Throughout the day the inspectors saw little evidence of any activities or stimulation of residents. There has been, in the past, evidence of activities taking place. DS0000066220.V343045.R01.S.doc Version 5.2 Page 20 The home has an activity room, café, chapel and cinema. None of these were in use by residents or relatives. It is clear from the feedback that activities are offered and residents choosing whether or not they participate. However, many residents spend their days in their room and, for those, there is very little going on. It was clear from observation on both nursing units and feedback from some relatives, that residents were placed in the lounge with the TV or radio on and left there, often without providing TV magazines or any way of deciding what to watch, if anything. There was little effort of staff trying to chat with residents or encouraging them to communicate with each other. Only one staff member on the ground floor initiated conversation. It appears to the inspector that staff believe the role of providing a stimulation environment is the sole responsibility of the activity co-ordinator and they do not understand that they play a key role in this. A few spoken words, smiles and gestures would improve the quality of life for many and spending time chatting on a one to one or a group is invaluable in the over wellbeing of the individual. It may be that the language is a barrier to staff becoming involved in this way and sticking to the practical tasks at hand. One relative wrote: “I think the home meets practical needs, but I cannot see much is provided in way of stimulation. There seems little engagement with the residents.” The main issues arise around communication and interaction. One resident was also concerned at the lack of supervision in the lounges. People can be left for long periods with no staff within range to be called for help, the call buttons are on the other side of the room to the chairs and can not be reached unless the person is mobile. While the inspector was in the room observing, a man who should use a zimmer frame wanted to go out to the balcony to smoke, he had trouble getting past another resident so he parked the frame in front of the resident blocking her way and proceeded without it, this really upset many of the Residents who were worried for his welfare, they tried to persuade him to get the frame or to sit down and to wait for a staff member to come, he proceeded with difficulty, holding onto other residents and chairs on his way to the balcony. Despite the commotion in the lounge area no one came to see what was going on until I went and found a staff member and asked her to offer assistance. A relative also spoke of having to attract staff attention for a resident who needed their help without this staff would not have known the resident needed help as they were not supervising the area. A Care Manager also wrote: “I did have a slight concern on one occasion when a gentleman in the lounge had had an accident and needed changing that the carer at the time was doing the tea round and said that she was on her own as the others were in training and the trained nurse was with the doctor at the time. the nurse didnt think to ring downstairs for assistance.” DS0000066220.V343045.R01.S.doc Version 5.2 Page 21 One inspector sat in the main lounge of the second floor for 50 minutes during the morning observing three residents and experiencing for a short time what it was like to be living in the home. The overall experience was that there was very little staff interaction and what interaction there was did not have a positive outcome for those observed. The staff delivering the drink did not interact with any of the residents unless to wake them up if sleeping. She did not ask if they wanted a drink or sugar and they were not offered an alternative to tea. Only one lady was given coffee after she had specifically asked for it and the carer left the trolley to fetch it. They were then offered biscuits from a tin or given two if they were unable to help themselves, also with minimal interaction. This further demonstrates staff perceiving their role to be one of being task driven. The feedback on the quality of meals provided was, once again, very mixed. Therefore part of the inspection time focussed on the lunchtime meal and the routines on the three units. The home has a four -week menu and staff ask residents the day before what residents would like to choose for their meals the following day. Choices are recorded by staff. In all units the dining tables were well presented and laid with condiments. Residents had the option of being seated at the dining table, seated in comfy chairs with small tables or taking the meal in their room. On the ground floor there was some delay in providing lunch to those in their bedrooms. Three meals had been plated up and it was some time before it was taken to the resident in their room. Three residents were without a meal, one of whom was a vegetarian. This had been forgotten and no meal ordered. One relative told the inspector she was not confident that her mother would have a meal if she wasn’t there to assist her. One day she came in and the meal had been placed on the table without her mother able to eat due to her paralysis. Observing the routines the inspector found some differences on the units. On the ground floor staff poured gravy on the main meal and cream on the dessert without asking the residents, whilst on the second floor staff asked each resident. There was no choice of dessert (except for a diabetic lady) and the alternative main course was quiche, which very few individuals opted for. The food was presented pleasantly and in good portions. One man complained he had been given too much, his plate was removed and another smaller meal served. Two of the residents had told me that the food was alright but sometimes they could not make real choices, they were given spaghetti rings with for example sausage rolls, they didn’t like it but could not have one without the other. So the meal was ruined. One resident who required assistance a carer sat next to him and did not interact at all. Another resident was promised assistance but had been very late in coming, although the resident managed themselves. It was observed that the staff discussed who needed “feeding” in loud voices. This was less then respectful of the individual’s dignity. There was also an absence of adapted crockery and cutlery available. One resident who spent all the time in DS0000066220.V343045.R01.S.doc Version 5.2 Page 22 her room kept knocking her jug of water off the table as she had poor vision. She also found it difficult to eat, as the plates were white and the food blended together. She would find it easier to have a coloured jug and a plate that was dark in colour to help her. One lady who needed support to eat waited a long time before she was given her food, 45 minutes in fact. When the food was taken to her I felt the plate and it was still hot. The staff sat on a chair close to her and mixed the pureed food together before feeding her. I asked why she had waited so long and the carer said he had waited until everyone else had been served so he could take his time, as this resident could not be rushed. The resident was not aware that the meal was being served and did not appear to be distressed at not getting her meal with everyone else. Two alternative drinks of squash had been offered just before the food was served, in a way that people where able to make a positive choice, the staff member who did this spoke to everyone in a positive and genial manner, she woke people up gently before talking to them and made comments and made conversation as she poured out the drinks, everyone reacted in a positive way to her. The meal was probed for temperature by the kitchen staff as it was being served and the temperature was recorded. I asked if the last meal served was checked and I was told they did not have enough probes but they were ordered so it could be done. (See requirements and recommendations) It is clear from feedback and from observations that visitors are welcomed into the home and can spend as much time as they wish with their relative. There are rooms available for privacy e.g. café or bedrooms. Previous comments have shown that for some visitors there are some issues around staff acknowledging their concerns about their relatives. DS0000066220.V343045.R01.S.doc Version 5.2 Page 23 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The way in with complaints and concerns are being dealt with is improving although for may they still do not feel that they are listened to in a way which makes them feel valued and respected. EVIDENCE: Mission Care have a complaints procedure which is available within the home and in information provided to residents. The Commission is aware of some concerns that have been raised though relatives and other agencies. In the past the organisation have been slow in investigating and reporting on the concerns or complaints raised. Improvement is still required in this area. However, the Inspector feels confident that, with a new manager in post, this has the potential to improve. Feedback from residents show that they are aware of the new manager and that they find her approachable, willing to listen and deal with their concerns. This does not; however, appear to be true of the staff working the floor. One relative spoke of being ignored when trying to raise a concern. All staff must be made aware of DS0000066220.V343045.R01.S.doc Version 5.2 Page 24 what action to take when someone wishes to raise a complaint or concern to ensure these issues are resolved to the satisfaction of the complainant. Otherwise the culture will be that of “what is the point in complaining as staff don’t listen or do anything about it” stated by one relative. The inspector viewed the complaints log and it appeared that most complaints had been logged, with the exception of one of the recent adult protection investigations. Mission Care also have an adult protection procedure and Whistle-blowing policy. Since the last inspection it is clear that a number of staff have had training in this area, although this was not fully discussed with staff. The manager is also looking to make some members of staff responsible for adult protection in the home i.e. providing information and guidance to staff and looking at practices. If used appropriately this would be beneficial. There have been two adult protection allegations requiring investigation. One investigation has been completed, whilst the other is a little more complex and requires further time. The completed investigation has identified the need to address certain practices in the home and to ensure the skills; practices and competency of the qualified staff are monitored. The investigation demonstrates that the manager is able to investigate objectively and robustly to ensure the outcome is one based on evidence. However, it is of a concern to the inspector that, incidents such as pressure sore deterioration, is not addressed as part of the protection from neglect. (See requirements and recommendation) DS0000066220.V343045.R01.S.doc Version 5.2 Page 25 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Elmwood provides residents’ with a good standard of communal and individual bedroom accommodation, although storage space is limited and impacts on the rest of the home. Residents benefit from various equipment, that is generally maintained to ensure they are in safe hands. The home is generally clean and fresh satisfactory but improvements in the cleanliness of individual accommodation could be improved for many residents. EVIDENCE: Elmwood is a purpose-built home providing accommodation for up to sixtyseven older persons. It consists of three units located over three floors with a large reception area on the ground floor. The Manager’s office and DS0000066220.V343045.R01.S.doc Version 5.2 Page 26 administrative office is also located here. There are additional facilities including a cinema, chapel and coffee lounge. Each floor has a dedicated dining/sitting area. The last inspections identified a lack of storage throughout the home with stairwells, bathrooms and corridors used as storage for hoists and wheelchairs etc. The use of the stairwell is potentially hazardous and still used for this purpose. The manager spoke of plans to adapt one bathroom on the first and second floor plans to provide storage and staff WC. The manager must ensure that consideration be given to the needs of residents as regards bathing rather than showering and to ensure there will be appropriate numbers of bathrooms on each floor for this purpose. (Please see standards 7-11) (See requirement) A tour of the units showed bedrooms to be overall, personalised, except for the rehabilitation unit and those residents spoken to felt their rooms generally met their needs. Residents were noted to have TV, radios etc in their rooms and beds were generally positioned to meet the needs of the individual. Call bells were in place in all areas, although for some they were not positioned to enable the resident to reach. Comments have also been made about the timescale for staff to attend to the call bell. “Sometimes a bit slow responding to the buzzer, up to fifteen minutes to 20, not good in an emergency” Many residents benefited from pressure relieving equipment and this was seen to be used appropriately. Hoists had been serviced, although the recent service was being undertaken outside of the six month required. This must be monitored in future to ensure six monthly servicing is maintained. (See requirement) Whilst the overall feedback stated the home was generally clean and odour free a number of people responded that the bedrooms were not cleaned to the standard of the communal areas. One resident told the inspector that furniture was rarely moved to clean the carpets and dusting was “rare”. The inspector noted when visiting some bedrooms that shelves were dusty and the area around furniture was not as clean as other areas. (See recommendation) A number of people are MRSA positive and there are infection control procedures in place with some rooms having clinical waste bins, soluble bags for laundry and hand wash in bathrooms as well as gels located around the home. On the ground floor a trolley was located outside of one room with a supply of gloves and aprons. However, there was not consistency in their availability around the home. DS0000066220.V343045.R01.S.doc Version 5.2 Page 27 The hot water temperature was sampled in two bathrooms on the ground floor and was found to be satisfactory. It is a concern that the “handover” on the ground floor was undertaken in the reception area. This is not confidential at all with people walking through, some waiting for the lift and, as was the case on the day, visiting dentists also sitting in the area and so could overhear discussion regarding residents. (See requirement) DS0000066220.V343045.R01.S.doc Version 5.2 Page 28 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing numbers are not always appropriate to ensure residents’ needs are being met and to ensure their health and safety. The improvements in the training mean that some progress is being made in a number of areas. However, there are issues around communication and language that are a barrier to further improvements being made to ensure residents’ overall well-being. EVIDENCE: Staffing levels in the home were agreed at registration and require a RGN to be on duty on each floor during the day and night. Staff are then supported on the ground and second floor by four or five carers. On the second floor the unit also benefits from PCT staff to provide the rehabilitative aspect of the care. Since the last inspection registration of the home there have been concerns over the quality of care and leadership. It is positive to note that the organisation now have some staff who are able to lead and guide others to ensure care standards can be reached and further improve. The feedback from the rehabilitation unit is that they are able to work together positively with the DS0000066220.V343045.R01.S.doc Version 5.2 Page 29 clinical lead on this unit and staff are more motivated to improve their skills and therefore the care provided. There is also a new clinical lead on the second floor unit, although only recently recruited and therefore time is required to see the results of the new leadership. The inspector is aware that the home, at times does not meet the full RGN staffing level that was agreed with the Commission, particularly at night. Subsequent to the inspection we were notified by two separate staff who reported a shortage of RGNs on one unit during the previous night. Discussions with the manager showed that this had occurred and it was not an isolated occurrence. The manager was reminded of the levels agreed at registration and that these must be maintained. If, for any reasons these are reduced the Commission must be informed through the Regulation 37 notifications. (See requirement) The records of three newly appointed staff were viewed and the inspector had discussions with two members of staff regarding their employment. There was evidence of the home obtaining the required checks, including Criminal records Bureau checks (CRB), proof of identity and references. The quality of the references must be further looked at to ensure they are from reliable sources and not friends etc. The organisation must also rigorously apply the regulations in respect of verification of previous employment in care and reasons for leaving that employment. There was good evidence of the recruitment procedures with application forms, interview schedules and letters offering posts. The application forms would benefit from further scrutiny including exploration of gaps in employment. Discussions with the three staff confirmed appropriate application and interviewing processes and that they provided the documents required prior to commencing work. Two new care staff also told the inspector of the comprehensive induction training where they received one weeks training on various core areas before working on the units for the second week for their practical training. They were assigned to staff for this period to observe care practices. Both confirmed that they are have induction booklets containing Mission care handbook and the induction training units to be completed. Both staff confirmed that they have been placed on various training and are paid for this. The inspector had sight of an induction booklet noting it is the induction developed by Skills Sector Council containing the Common Induction standards as well as the organisations’ policies and procedures and Codes of Conduct. (See requirements) Training in the Mission Care homes is arranged through the training department with the majority of training provided by the training officer. The organisation should ensure that they provide the trainer with the skills and knowledge to ensure they are competent in providing the training. The training records of four staff were also viewed and it is evident that the organisation has been working hard to provide training in key areas such as adult protection, infection control, food hygiene, health and safety and induction for DS0000066220.V343045.R01.S.doc Version 5.2 Page 30 new staff. There is also some evidence of more specific training including malnutrition, needs of older people, risk management and medication administration. However, it is clear from the feedback and observations that the organisation needs to focus on basic care tasks, pressure care and communication and cultural issues. (See previous comments regarding communication, language and culture). The inspector also noted that a number of staff have not received moving and handling training by a competent person or training has expired (this must also be addressed in the induction training). The organisation has now trained staff in the sister home to provide training to staff and therefore this is due to be addressed in the next few months. No requirement has been raised on this occasion as the home has a plan of action. However, this will be monitored at the next inspection to ensure training has taken place and note taken of one resident who felt that many staff “rough handled”. The files viewed also provided little evidence of formal supervision of staff. Supervision records that were viewed were also limited and the Manager agreed that this was an area requiring improvement. (See requirement) The home is still working towards ensuring 50 of staff have achieved the NVQ 2 or above. DS0000066220.V343045.R01.S.doc Version 5.2 Page 31 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. With the appointment of a manager who has good leadership skills the home has the capacity to improve, given adequate time and with the organisation ensuring that there are systems in place for monitoring and reviewing the quality of care to plan for continued improvement. Whilst the manager ensures the health and safety in a number of areas the lack of fire drills and regular fire instruction could lead to potential dangers. EVIDENCE: DS0000066220.V343045.R01.S.doc Version 5.2 Page 32 It is positive news that Mission Care have appointed a new manager who has now been in place since June 07. She is an RGN with up to date PIN, BSc; PGCE and is currently undertaking an MBA at present. She has relevant previous experience in healthcare and management position in residential care. She is applying for CRB and then to apply for registration with CSCI. Feedback from staff on the units has been positive with one PCT staff member stating care on the rehabilitation unit “improved considerably” over last three months. The Manager provides a strong lead supporting other senior staff in the home to ensure the quality of care is improved. Feedback from residents and outside agencies show that the quality of care is improving due to the strong management and an understanding of what good care is. The inspector is of the view that the home now has the capacity to improve further given the management and if quality assurance systems are implemented and complaints responded too appropriately. The lack of quality assurance systems impacts on the quality of care provided. However, Mission Care has recently appointed a quality assurance manager and so systems are due to be implemented, including a review of the regulation 26 visits and corresponding reports. This is much needed as the previous inspections identified the lack of monitoring and few reports being received by the Commission. The last inspection report commented that Mission Care had undertaken a survey of the care with the inspector requiring the results to be evaluated and report sent to the Commission. It is now evident that this was not a survey of residents but for staff and focussed on the Christian ethos of the home. Whilst the inspector is pleased that staff surveys have taken place there is a need to focus on the quality of care experienced by residents to ensure improvements are made, as required by the Regulations. It is positive to note that meetings are held regularly between the home and residents and the home and relatives to try and gather feedback. (See requirement) The health and safety of the home is maintained to a satisfactory level although the storage continues to be potentially hazardous. Many of the fire extinguishers were left on the corridor floor. Mainly due to them obstructing the hoist movement as they are brought from the stairways on some unit and staff had broken the extinguisher mountings. The handyman said that he had contacted the fire officer who was coming to the home to advise on the best way to deal with the problem and that it would be sorted out soon. Records showed that there has been a lack of regular fire instruction for staff and fire drills with the fire log showing only one fire drill dated 13/7/07. Other checks have been made including the equipment used, servicing of the alarm and the weekly check on the fire alarm. (See requirement) DS0000066220.V343045.R01.S.doc Version 5.2 Page 33 It is positive the core training is taking place and that the home has implemented the Skills Sector Common Induction Standards for new staff and that a moving and handling trainer (Homefield) is to commence moving and handling training for Elmwood staff. An audit of a sample of residents’ monies showed there to be good systems in place with accurate records. DS0000066220.V343045.R01.S.doc Version 5.2 Page 34 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 2 3 3 X 2 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 2 3 3 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 2 X 2 DS0000066220.V343045.R01.S.doc Version 5.2 Page 35 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 Requirement Timescale for action 01/11/07 2 OP7 15 Full Information must be provided to prospective residents and their representatives to ensure they are able to make a considered decision on whether the home is able to meet the needs of the person wishing to stay in the home. 01/11/07 The Manager must ensure that care plans are reflective of needs, kept under review and have supporting risk assessments in place. All supporting records must be fully completed. Previous timeframe for action 28/02/06 and 30/06/07. This remains outstanding. There must be systems in place for ensuring those individuals with pressures have the details recorded, interventions detailed and monitored to ensure appropriate treatment for improvement. Residents must have their personal care and grooming DS0000066220.V343045.R01.S.doc 3 OP8 12 01/11/07 4 OP7 12 01/11/07 Version 5.2 Page 36 5 OP9 13 6 OP30 12 (5) 7 OP15 16 8. OP16 22 attended. This must be done in a way that is individual to them and according to their preferences. The medication practices must be improved. Specifically, • medication must only be given to the individual prescribed for • handwritten transcriptions must be countersigned • all medication given must be signed for • medication must be stored appropriately in the original containers with details of the person prescribed for The manager must investigate how communication, interaction and language can be improved to improve the quality of care for people living in the home. The quality of food must be improved together with the support provided by staff to ensure residents receive a healthy, nutritious diet. The Manager must ensure that complaints are responded to within given timeframes and that evidence of the complaint, the investigation and the outcome are retained. Staff must also be given instruction in how to deal with complaints and concerns to ensure people feel listened to. 01/11/07 01/01/08 01/12/07 01/11/07 9 OP38 23 10 OP10 12 Call bells must be placed within 01/10/07 reach of the individual and responded to within an appropriate timescale to ensure the safety of residents. The manager must ensure staff 01/10/07 handovers take place in an area which respects the confidentiality DS0000066220.V343045.R01.S.doc Version 5.2 Page 37 11 OP27 18 12 OP29 17 13 OP36 18 14 OP33 26 15 OP19 13(4)(a) 16 OP33 24 17 OP38 23 of the people using the service. Staffing levels within the home must not be decreased, any reductions may place the residents at risk. Recruitment procedures must ensure applicants previous employment in care is verified; gaps in employment checked and references are received from reliable sources. The formal supervision of staff must take place more regularly for all care staff to ensure practices are monitored and quality of care improved. The Responsible Individual must submit Regulation 26 reports to the CSCI arising out of the monthly unannounced visits. This requirement remains unmet with the timescale of 30/6/07 expired. The Responsible Individual must identify and provide additional storage to allow residents to be able to use the bathroom safely. This requirement has been partly met with the home locating possible storage space. Please provide the action plan for providing the storage space required. Mission Care must implement a system for monitoring and reviewing the quality of care provided at Elmwood. Any review must involve a survey of residents. Fire drills and training must take place as required by the authority. 01/10/07 01/11/07 01/01/08 01/11/07 01/11/07 01/12/07 01/11/07 DS0000066220.V343045.R01.S.doc Version 5.2 Page 38 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP2 OP30 OP30 OP38 OP26 Good Practice Recommendations Terms and conditions should be provided for those residents whose placements are funded by the Local Authority. Staff should be provided with more in depth training in the basic care needs of residents. Culture and diversity training should be provided for all staff There should be adequate supervision of residents on the units Individual’s private accommodation should be cleaned more thoroughly. DS0000066220.V343045.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000066220.V343045.R01.S.doc Version 5.2 Page 40 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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