Inspection on 13/11/06 for Holly Lodge

This inspection was carried out on 13th November 2006.

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 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

Holly Lodge 03/04/07

Holly Lodge 02/03/06

Holly Lodge 05/09/05

Holly Lodge 03/03/05

Holly Lodge 08/09/04

Holly Lodge 04/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Holly Lodge 9 Rectory Road Oldswinford Stourbridge West Midlands DY8 2HA Lead Inspector Mrs Jean Edwards Unannounced Inspection 13th November 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holly Lodge DS0000024971.V315870.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. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Lodge Address 9 Rectory Road Oldswinford Stourbridge West Midlands DY8 2HA 01384 373306 01384 378160 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) Mr Mohammed Iftikhar Ali Mrs Paula Hubble Care Home 21 Category(ies) of Dementia (2), Mental disorder, excluding registration, with number learning disability or dementia (2), Old age, not of places falling within any other category (19) Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 2 DE, 2 MD and up to 19 OP Date of last inspection Brief Description of the Service: Holly Lodge is a residential home registered to provide 24-hour care for 21 people over the age of 65. It is located on a residential road just off the main Hagley Road in Oldswinford near to the church. It is accessible by public transport and close to local shops and public houses. The home has 19 single rooms and 1 double room, 2 lounges and a conservatory. There is a well-maintained garden to the front and rear and parking facilities at the side. Accommodation is provided over 3 floors accessible via passenger lifts or staircase. The level of fees for this home is currently between £388.00 and £415.00 per week, including a range of individual third party top up fees. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first unannounced key inspection visit for 2006 - 7, undertaken by an inspector from the Commission for Social Care Inspection (CSCI), starting at 8:30 am and finishing at 7:30 pm. All Key National Minimum Standards have been assessed at this visit. The range of inspection methods to make judgements and obtain evidence includes: discussions with deputy manager and staff on duty during the visit, examination of records and documents and discussions with residents, and relatives. Other information was gathered before this inspection visit from the pre inspection questionnaire submitted, and notification of incidents, accidents and events. Twenty service user surveys were sent to the home by the CSCI and an analysis of the fourteen survey forms returned is contained throughout this report. Comments have been generally positive, particularly about the environment and staff. There are currently 20 residents living at the home. During the visit the inspector has spoken to the majority of residents. Longer discussions have taken place with the residents whose care was looked at in depth. Relatives and other visitors have been asked for their views. Comments indicate that staff are friendly, helpful and welcoming. There has been a tour of the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents’ bedrooms, with their permission. What the service does well: Relatives, residents express high levels of satisfaction with the service provided. There is easy to read information available about the home, which helps people to make decisions about where to live. In answer to the questions on the CSCI service user survey forms all 14 responses indicate that have received satisfactory information to help them make decisions and have a contract / terms and conditions of residency from the home. A comment states, visited numerous times, always received a warm welcome. Holly Lodge continues to provide a high level of good quality care within a homely environment. Care staff are cheerful and committed to meeting each persons needs and ensuring they are treated with dignity and respect. The home continues to excel in the number and variety of activities it provides. Each residents birthday is made special for them, with celebrations at the home. There is good evidence that residents medical needs are met. In answer to the survey question: Do you receive the medical support you need? The responses Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 6 were: Always - 13, Usually - 1. With a comment, they always fetch the doctor, even when I have said not to bother. Visitors are warmly welcomed to the home and are offered refreshments, support and appropriate information, for example a daughter states, very happy with the care, staff are kind, considerate and nothing is too much trouble and there is good communication between shifts. There is a proactive approach towards any concerns or complaints, and efforts are made to listen and improve the service. A comment from the CSCI service users surveys states, Holly Lodge is warm, clean and homely. A comment from the CSCI service user survey states, My room is always clean and tidy with fresh bed linen. This inspection was conducted with full co-operation of the Deputy Manager, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspector would like to thank the deputy manager, staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection? What they could do better: The development of new care plans and fuller health care screening and assessments must be put in place to make sure that residents needs are not missed or overlooked. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 7 The homes system for the management and administration of residents medication needs improvement in a number of areas so that it is a safe as possible. Examples are that medication storage and records are reviewed and improved in accordance with advice. Whilst comments about food during the visit have been positive and the meals look appetising, the responses from the service user survey to the question: Do you like the meals at the home? Are as follows: Always - 5, Usually - 8, Sometimes - 1. The home needs to explore these results with the residents. Staffing levels at the home must be increased as a priority, with the managers hours separated and not counted as care hours. The registered manager must submit staffing proposals, demonstrating compliance with Department of Health guidance, to the CSCI office, Halesowen for consideration. To the question on the service user survey, are the staff available when you need them? Answers are - Always - 8; Usually - 4. The registered manager must also improve recruitment processes and staff personnel records as a priority. The registered persons must continue the progress to put in place a robust quality assurance system to measure and monitor the homes performance and the registered manager must be supported with her own professional development. The registered provider must take action to meet all requirements, especially in relation to the premises and staffing in a timely manner, failure to do so may affect the homes future quality rating. There are a number of records and areas of health and safety, which must be improved to safeguard the residents. For example the risks of Legionella and Asbestos in the home must be assessed with appropriate control measures put in place. 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. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 8 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 Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 9 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): 2, 3, 4, 5 Quality in this outcome area is good. The residents have a contract / terms and conditions of occupancy, the document this has the effect that residents and their advocates generally have sufficient information regarding their rights and entitlements, any agreed restrictions and how care will be provided. The home uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that care needs will be met. The home actively encourages introductory visits and there is verbal evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes statement of purpose, service user guide and recent inspection reports are available in the reception area. The service user guide is also Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 10 supplied in each residents bedroom. All 14 respondents to the CSCI service user surveys indicate that they have good information from the home, on which to make their decisions about choices of where to live. There is evidence from the CSCI service user survey and from a sample of case files that residents have been provided with a contract or statement of terms and conditions. It is positive that clear details of fees and third party top up arrangements are included in contracts / terms and conditions. Advice has been given about the recent revisions and additions to the Care Homes Regulation 5, and good practice guidance issued by The Office of Fair Trading, which needs to be incorporated into the next review of the homes contract / terms and conditions. Evidence from examination of residents records and discussions confirm that the assessment is conducted professionally and sensitively and has involved the family or representative of the resident. There is good evidence that individual care instructions and panel reports are obtained for residents funded by Social Services or the manager conducts a thorough documented assessment of each persons needs before agreeing the admission. Although the staff can explain that they are aware of residents needs, the home is not currently recording individual preferences such as rising, retiring, likes and dislikes, preferred gender of staff to give assistance with personal care, and there are risks in placing reliance on verbal communication between staff. There is written confirmation from the registered manager to confirm the persons admission to the home. From discussions it is evident that the home of offers introductory visits, and a prospective new residents visited the home during this inspection, confirming their wish to move in as soon as the bedroom is redecorated. A comment from the CSCI service user survey states, visited numerous times, always received a warm welcome. There are currently 20 residents accommodated at the home, and discussions with the deputy manager and assessment of the pre inspection information supplied by the home indicates that there is an awareness that the home may be accommodating residents who are outside the registration categories. The registered manager needs to seek medical clarification of diagnosed conditions to determine each persons primary needs. It is very positive that the registered manager contacted the CSCI for confirmation and support for her reluctant decision not to continue the service for someone in hospital with increased needs, which the home could not meet. Her decision was made in the persons best interests, despite considerable pressure from medical staff to readmit the resident. Discussions have been held about the possibility of requesting a variation to the homes registration categories. Information has been given about the Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 11 centralisation of the registration processes and contact details of the CSCI Regional Registration Team. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. The improved care planning and monitoring provides staff with the information they need to adequately meet residents needs. There is good multi disciplinary working taking place on a regular basis, which results in the health needs of residents being generally well met. The home is committed to make progress to improve the arrangements for administration of medication, which will reduce potential risks to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a care plan and the registered manager / deputy are continuing with the introduction of the new computerised formats. Assessment of two new care plan formats for two residents admitted recently show evidence of the good practice of involving residents and their relatives in the development and review of the plans, however signatures of residents or their representatives need to be obtained to indicate agreement. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 13 The plan in most cases includes essential basic information necessary to plan the individuals care and includes a risk assessment element. However medication regimes need to be fully recorded and plans do not always accurately reflect the current situation. The deputy manager acknowledges that it is difficult to progress the development of documentation and the priority has been to provide good practical care. Examples of missing areas from care plans are where residents have been prescribed antibiotics for chest or urinary tract infections and there are no short-term care plans in place. A recently admitted resident has been very unwell and though there is evidence of frequent visits from doctors and changes to medication, this is not accurately reflected in the care plan. There is a format for recording comprehensive care for people with diabetes, however the required information has not been completed. There are residents with occasional behaviours, which are described as outbursts of aggression and also one person is at risk from wandering and it is noted has no idea of danger. There are no documented risk assessments or risk management strategies to guide staff as to how to deal with these situations. All residents have good access to health care services to meet their assessed needs both within the home and in the local community. Some residents are able to choose their own GP within the limits of geographical borders and there is evidence of access to dentists, opticians, chiropodists and other community services, though these are not always documented. The home is currently not using nutritional screening assessments and there are at least two residents who may be nutritionally at risk. The home needs to implement procedures to ensure such residents are referred for advice from the community dietician and may be consider offering small frequent nutritious meals with increased calorific content. There is verbal evidence that each resident’s health is monitored with appropriate action taken. However there is insufficient documentary evidence in the sample of care plans examined of health care assessments, screening, treatment and intervention, such as use of nutritional tools and tissue viability and falls assessments. The home generally seeks professional advice on health care issues, acts upon it and is able to access the aids and equipment recommended. A resident has recently been reassessed by the occupational therapist and has been provided with a rollator to improve mobility. Observations and discussions show that pressure relieving equipment is in place or is under review with district nurse but this is not currently recorded. Similarly staff are able describe preventative measures such as legs elevated, changes of position or support for mobility but these measures are not recorded as part of each persons plan. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 14 The home has a medication policy which is accessible to staff. The medication policy and procedures must be expanded to reflect good practice guidance as discussed during this visit, such as risk assessments for use of any oxygen, CSCI notification of any drug errors and expanded homely remedies policy. Information has been sent to the home following the inspection visit. Medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. Observations of the administration of medication show that this is undertaken with sensitivity, however a member of staff tipped tablets into her hand to give to the resident, which is not good practice. Where medication systems are in need of action the management are wiling to work towards improvements. The example of areas to be improved include the improved monitoring and safety of medication stored in the domestic fridge in the main kitchen, improved practice of handwritten entries on MAR sheets and improved recording practice in the Controlled Drugs Register. From discussions it is evident that staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms as they wish. Discussions with residents indicate that are happy with the way that the staff deliver their care and show respect for them. A relative feels that there is good communication between shifts, and staff are aware of residents needs and follow up GP visits. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, 15 Quality in this outcome area is good. There are planned and spontaneous activities available on a regular basis, which give residents improved opportunities to take advantage of and develop socially stimulating activities. The majority of residents are able to maintain good contact with family and friends. Dietary needs of residents are generally catered for with a balanced and varied selection of food that meets residents tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents at Holly Lodge have the confidence to discuss what makes them happy and to comment where improvements can be made. The management and staff take residents feedback seriously and make changes where possible. Evidence from the service user survey forms indicate that staff listen to residents and make considerable effort to provide a flexible service, which enables them to enjoy a better quality of life. During the visit a relative states that she has brought concerns to the managers attention and they have been speedily rectified. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 16 The manager and care workers record residents preferences and use the information to plan activities, which residents will enjoy. There is a good understanding of the need to provide activities and access to social stimulation. There is evidence that some people prefer to spend their time on their own in their own bedrooms, with individual interests or in the quiet lounge. A small number of residents have chosen not to participate in the activities on the day of this visit. These decisions are well understood, respected and supported by staff at the home. The home has a system for displaying information and drawing attention to community events and activities in the reception area of the home. There is also a memory board, with the date and other special events, such as the November Remembrance Ceremonies. There is a monthly communion service at the home. Residents birthdays are noted, with their agreement; there are 6 in November 2006. The home has an independent activities organiser every Monday and Tuesday providing a range of activities and on alternate Thursdays there are armchair exercises . The home has recently had a bonfire night special, with no fireworks by request. The deputy manager states that an evaluation of the event shows that half of the residents enjoyed the event more and half missed the enjoyment of fireworks. Therefore more thought will go into how to stage this event next year. There is also going to be a fish & chip & tipple night and Sweet Assurance evening of singing 30 November 2006. A number of residents go out with their families; one person describes her enjoyment of a trip to Tewkesbury to the opening of her grandsons jewellery shop. Staff escort small groups of 5 or 6 residents on outings to garden centres, coffee shops and shopping centres. There have been a considerable number of visitors to the home during this inspection visit and it is evident that family and friends of the residents feel welcome and know they can visit the home at any reasonable time. Those spoken to have commented very positively about the care and attention provided by the home, stating nothing is too much trouble and the management and staff are always friendly and ready to listen and help. The visiting policy and visitors book is located in the reception area. All visitors are greeted and requested to sign in and out of the home for safety and security reasons. It has been indicated that staff always make time to talk to visitors and share information with the agreement of the resident. Residents are able to have personal possessions in their room, but may be not always be able to bring large items of furniture due to space or health and safety considerations. The registered manager must ensure that the inventories of residents personal possessions are maintained and updated and signed, dated by the member of staff and resident or their representative. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 17 Residents enjoy the flexibility of meal arrangements and are able to eat in their own room if they wish. It is particularly noticeable that regular drinks are offered and staff are always willing make drinks at any time and there are plentiful supplies of cool drinks, with easy access for residents, around the communal areas of the home. The food in the home is generally of good quality, well presented and generally meets the dietary needs of residents. The staff group including the cook are generally well experienced, consult with residents and try to meet the preferences and suggested dishes when preparing the menu. There is evidence that staff have received training to help those residents who need assistance when eating and are sensitive in their approach. However a care assistant, who did not quite understand one residents dietary or communication needs offered lunchtime options of faggots, mash and vegetables or minced beef and vegetables, which were not appropriate. At the intervention of the deputy manager and the daughter of the resident soup has been provided. The registered manager must seek advice from the community dietician regarding the nutritional content of menus and especially the use of appropriate high calorie alternatives. Records of daily food intake must be maintained for any residents assessed as being nutritionally at risk. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 18 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. There is evidence that any complaints and concerns are listened to and action is taken to look into them, and there are systems to record any investigations and outcomes. Arrangements for protecting residents are not yet satisfactory. Policies, procedures, guidance and staff training have not been fully implemented in order to provide residents with safeguards from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has complaints procedure displayed in various areas throughout the home. Information supplied as part of the pre-inspection questionnaire indicates that the home has not received any complaints since the last inspection in March 2006. It is stated that minor issues are dealt with at the time they are raised and recorded in each residents daily notes. This has been confirmed during discussions with relatives visiting the home during the inspection visit. From the results of the service users survey, some respondents indicated that they are aware of how to raise concerns and use the homes complaints procedure, though this was variable. It is recommended that the responses are discussed at the next residents meeting and that the complaints procedure be produced in alternative formats suitable for residents, such as large print. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 19 The home has not received any allegations relating to abuse of vulnerable residents. However it is stated that the home does not have a copy of the multi-agency procedures for the protection of vulnerable adults, Safeguard and Protect. Contact details for the protection of vulnerable adults manager based in Dudley Social Services Department have been given to the deputy manager so that a copy of the multi-agency procedure for the protection of vulnerable adults may be obtained. Currently there is no documentary evidence that all staff have been made aware and have been given time to read and understand procedures for the protection of vulnerable adults. Progress is being made to provide all staff with adult protection training. The registered manager must ensure that suitability and effective awareness of abuse and protection of vulnerable adult training, is provided for all staff. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 20 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, 21, 24, 25, 26 Quality in this outcome area is adequate. There continues to be significant and positive changes to the décor and furnishings. The incremental improvements contribute to creating a pleasing and pleasant environment for residents to live in. The grounds are maintained to provide a safe and pleasant outdoor environment for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Holly Lodge, which comprises of the Old House and the linked New House has a bright and cheerful interior and is homely and domestic in style. There are attractive, well-maintained gardens and garden furniture for the residents comfort and enjoyment. The tour of the building identified that a number of improvements have been made and a programme of redecoration and refurbishment is in progress. Residents bedrooms are well maintained and individually decorated providing pleasant personal living space. Some Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 21 bedrooms on the second floor have especially pleasing views across the countryside. The home has a part-time handyperson who has a reactive maintenance book. There is very positive evidence that he is very supportive and willing to work extra time to complete tasks and can also be called for out of hours assistance. The tour of the building identified some additional areas requiring work, which had not been documented maintenance programme, for example the threadbare stair carpet in the new house needs to be replaced as a priority, before it becomes a tripping hazard. It is noted that work was being undertaken on the heating systems on the day of this inspection visit. However there are a number of radiators, hot to the touch and unguarded. It has also been noticed that there are a number of areas of exposed hot water pipe work, mainly in bathing and en-suite facilities. The registered manager must undertake an audit of the home to identify all areas of exposed hot water pipe work accessible to residents, especially en suites, toilets and bathing facilities and ensure that they are guarded, boxed or covered appropriately. Although the decor throughout the home is generally of a high standard, there are several requirements for improvements to the premises, which are outstanding from the previous two inspection visits and work must now be completed within an identified timescale. It has also been noted that a jug and bar of used soap had been left in a bathroom and there is a risk that these items will be used communally, which compromises the homes infection control measures. The items have been removed during the visit. The carpets bathrooms and WCs do not allow effect infection control and appropriate replacement flooring must be scheduled into the maintenance and renewal programme. During discussion residents indicate that they are comfortable, the home is clean, warm, well ventilated, and well lit. There are two spacious lounges; a small quiet lounge and a dining room and residents are able to generally sit where they wish, though some people are protective about their own personal space. It is noted that the kitchen area is generally well organised, clean and tidy. The management have organised a deep clean for the kitchen the day following this inspection visit and the residents will be having a cooked meal of their choice from the local fish & chip shop. The Local Authority Environmental Services have recently inspected the main kitchen and the home has agreed to forward the report, when received, with any required actions to the CSCI office, Halesowen. There are plans to replace the Aga cooker and work surfaces as part of the annual development plan for 2007. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 22 The small laundry has recently been refurbished and improvements have been made to this area. The laundry procedure and infection control guidelines need to be displayed in this area to promote good infection control measures. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 23 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. Staff morale and confidence is good. The current staffing levels mean that there are insufficient dedicated care staff on at all times during the day, posing a risk that residents may not have all care, support and needs for stimulation met. The staff recruitment processes are not entirely satisfactory, which has the potential for residents to be exposed to risks of harm. The registered manager does not currently have sufficient time to demonstrate a commitment to staff training, support and development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The structure of the staff team is: registered proprietors, registered manager and deputy manager, 19 care staff and 2 ancillary staff. There are currently 20 residents (and one new admission imminent) accommodated, with a variety of dependency levels and diverse needs. There is no documentary evidence that the registered manager regularly reviews residents dependencies and occupancy levels, or reviews staffing levels, making appropriate adjustments, with the use of a recognised staffing tool, such as the Department of Health Residential Forum staffing Tool. Information has been provided to the home following the inspection visit. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 24 The assessment of staffing rotas, discussions and observations indicate that on the day of this inspection visit there are 5 care staff on duty from 08:00 till 12:00 and 3 carers until 16:00 hours. However one member of care staff undertakes on-going laundry duties and in addition one member of care staff is also undertaking catering duties for breakfast between 8:00 - 9:00 am. There are 3 care staff on duty from 4:00 until 10:00 pm. During the night there are 2 waking staff on duty. One senior carer undertakes administration tasks at times (for example wages from 2:00 - 4:00pm Mondays) and the registered manager and deputy manager have also recently undertaken a number of care shifts to make up numbers of care assistants, covering for vacancies and absences. It is stated that there are difficulties in recruiting appropriate candidates to fill care vacancies, especially at this time of year, in competition with retailers taking on temporary staff at higher rates of pay than the home is able to offer. There are cooks working on a rota basis from 09:00 to 3:00 pm to cover each day and domestic staff are employed to cover the whole week 08:00 till 12:00 MD (or 1:00pm). Members of care staff undertake catering and laundry duties during the afternoons, and this depletes dedicated care hours available for residents. The registered persons must have in place contingency measures to ensure that the home can provide adequate care hours, without over reliance on staff working excessive hours or depleting other essential tasks. Assessment of the pre-inspection questionnaire submitted, staff files and staffing rotas during the visit show that four staff have left the homes employ since the last inspection visit in March 2006. Assessment of a sample of staff personnel files at this visit indicates that staff recruitment processes are generally satisfactory. However the homes application forms do not request a full employment history with specific dates and this does not identify any gaps in employment. The personnel file of a recently appointed member of staff does not contain a recent photograph and there is no evidence of contracts / terms and conditions of employment or job descriptions. The registered manager does not have sufficient managerial time to supervise, monitor and provide staff development opportunities. The home currently has 45 of care staff qualified with an NVQ 2 award, which does not demonstrate compliance with the national standard of a minimum of a ratio of 50 of care staff with an NVQ 2 award by 2005. The homes training needs analysis and training plan and individual staff training profiles are incomplete at this visit and the manager has agreed to send completed documentary evidence to the CSCI office, Halesowen. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 25 During discussions there is verbal evidence that staff are knowledgeable about what residents needs are and how to meet them and there is a warm rapport with both residents and visitors. Staff spoken to generally feel that there is good team spirit and that they are aware of their responsibilities, what is expected from them. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 26 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, 37, 38 Quality in this outcome area is adequate. The registered manager does not currently have sufficient time to develop the service to its full potential. There are systems for resident consultation at Holly Lodge, and there is evidence that efforts are made to ensure that residents’ views are informally sought and acted upon. The standards of record keeping and health and safety compliance at this home are not entirely satisfactory to provide sufficient protection for residents from risks of harm. This judgement has been made using available evidence including a visit to this service. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 27 EVIDENCE: The registered manager is rotad off duty and has not been present during this inspection visit. The deputy manager has ably assisted during the inspection visit. Paula Hubble is the registered manager at Holly Lodge and has worked at Holly Lodge for more than 17 years. She has achieved the NVQ level 4 award in Management and Care. However she has not as yet achieved the RMA (Registered Managers Award). As previously highlighted in this inspection report the registered manager and deputy manager do not have sufficient time to develop the staff and service to meet and exceed the Legislative framework and National Minimum Standards. Though discussions it is evident that residents, relatives and staff feel the management at this home is open, approachable and helpful. The manager and deputy manager are striving to develop a revised quality assurance programme, which is based on monitoring the homes performance against the National Minimum Standards for Older People. The registered manager has devised an annual development plan, which is promising and has the potential to be further developed for the next year. Residents and relatives questionnaires have been used in July 2006 to seek their views the collated results are generally very positive, with the only area of weakness being the menus. The home has also issued questionnaires to obtain feedback from other stakeholders, such as district nurses, GPs and Social Workers but has not received any responses to date. The registered proprietor visits the home regularly and has provided Regulation 26 reports regarding the conduct of the home until August 2006; the outstanding reports have been faxed to the home during this inspection visit. Reports must be provided to the home in a timely manner. The home aims to hold residents meetings every three months and one set of undated notes are available. It is strongly recommended that the registered manager should devise and display a schedule of residents meetings, together with agendas and minutes of meetings to encourage participation. Although there are staff meetings, it is stated that they are irregular and there are no minutes available at this visit. The registered manager must aim to hold six meetings each year. It is stated that the home is not responsible for residents finances, though it does hold small amounts of monies on some residents behalf for temporary safekeeping. The funds are held individually in a secure location. The sample of records and balances examined are satisfactory with each transaction signed and witnessed by 2 staff and generally appropriate receipts. However the Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 28 independent chiropodist currently provides a general receipt for all residents treated at each visit and this does not comply with the Data Protection Act or good record keeping practice. There is evidence that the registered manager and deputy manager do not currently have sufficient time to develop a structured formal staff supervision system, with a minimum of 6 recorded one-to-one meetings with each member of staff, each year. There are some improvements to records, which include comprehensive preadmission proformas, better care plans, and daily records, though there are still records requiring further improvement such as risk assessments, nutritional screening assessments, medication records and staff records. The random assessment of a sample of health and safety and service maintenance records examined shows that they are generally satisfactory. The home does not currently have a Legionella or Asbestos risk assessment and water temperatures must be consistently maintained. It has been agreed that when actioned copies of these documents will be forward to the CSCI office, Halesowen. There is generally satisfactory evidence that mandatory training is being sourced and provided for all staff on an on-going basis. However there is not sufficient evidence that all staff have received two fire training sessions and participated in two fire drills in a twelve month period. There have been 46 recorded accidents involving residents since March 2006. The registered manager has a system for auditing accidents involving residents. However this must show effective analysis of any trends or high risk issues and an evaluation of control measures, and show that any additional controls have been implemented. Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X X 3 2 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 3 2 X 2 2 2 2 Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? 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 OP2 Regulation 5(1) Requirement To undertake a further review the contract / terms and conditions taking account of the revisions to the Care Homes Regulation 5 and the publication from the Office of Fair Trading relating to Contracts and terms & conditions in Care Homes Timescale for action 01/02/07 2 OP4 14(1) 01/01/07 To undertake a review of the residents primary needs and dependency levels, obtaining clinical diagnosis for any resident presenting with conditions, which may be outside the homes registration categories or conditions and request a variation condition from the CSCI Central Registration Team as necessary 1) Individual care plans must set out in detail what action was required to meet all the identified needs. (Timescale of 03/03/05 and 01/06/06 Not Fully Met) 2) Monthly reviews must be recorded and include signatures 01/02/07 3 OP7 14(1) 15(1) Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 31 from the people involved including the service user. (Timescale of 03/03/05 and 01/06/06 Not Fully Met) 3) More detail and specialist information is required for those people diagnosed with dementia. (Timescale of 03/03/05 and 01/06/06 Not Fully Met) 4 OP7 15(1) 1) To ensure all information is completed on new care planning formats 2) To complete care plans for short term care needs such as need for infections, antibiotics etc. 3) To ensure care plans contain short and long term goals 4) To ensure care plans are kept up to date and accurately reflect current situation, especially where there are changes when residents become unwell, have poor appetite or increased falls 5) To develop diabetic care plans with fuller detail of diet, foot care, skin care, oral care, eye care 6) To ensure all residents have a formal documented review of their care needs and care provision at least annually, more frequently where needs change and where possible involving other professionals and relatives 7) To devise and implement a comprehensive risk assessment and risk management strategy for the resident who may wander out of the home and is recorded Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 32 01/01/07 as having no idea of danger 5 OP8 13(4) To ensure that the following are documented as part of each residents case file / care plan 1) Risk assessment for safe moving and handling of residents, specifically new residents 2) Records of regular weight checks or use of other monitoring tool e.g. MUST (Malnutrition Universal Screening Tool) 3) Record of any pressure relieving equipment 4) Plan of any pressure relieving prevention, such as turns, change of position, mobilising 5) Nutritional screening assessment and referrals to GP and / or community dietician as needed 6) Daily records of food and fluid intake for residents with poor appetite or who are nutritionally at risk 7) Evidence of referral to community dietician for residents with poor appetite or who are nutritionally at risk, with documented outcomes 8) Records of personal care, baths, weights etc. must be individual in compliance with the Data Protection Act 1998 6 OP9 13(2) 1) To review and expand the homes medication policy and DS0000024971.V315870.R01.S.doc 01/01/07 01/01/07 Holly Lodge Version 5.2 Page 33 procedures, taking account of current guidance from the Royal Pharmaceutical Society of Great Britain, to include: fire precautions relating to any use of oxygen, covert medication, drug errors (always seek medical advice and Reg 37 notification to CSCI), homely remedies 2) To obtain a thermometer to record daily minimum and maximum temperatures to safely store significant amounts of medication currently held the homes domestic fridge and consider the provision of a drugs fridge if the current level of medication requiring refrigeration continues 3) To ensure staff signatures are obtained to demonstrate awareness and compliance with medication policy and procedures 4) To ensure that there is an up to date specimen signature list held with the Medication Administration Records 5) To ensure that there are individual photos of all residents on the medication system 6) To ensure that staff record variable dosages of medication administered on MAR sheets, for example one tablet or two 7) To ensure that any handwritten entries on MAR sheets are dated, signed and witnessed by 2 appropriately trained staff 8) To ensure that any Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 34 handwritten changes to instructions on MAR sheets are dated, signed and witnessed by 2 appropriately trained staff, with evidence of authority for the change, e.g. GP 9) To ensure the administration of creams, sprays etc are recorded on MAR sheets (or other appropriate recording system) or code entered for non administration 10) To define the code O when used 11) To ensure staff use a nontouch technique when administering medicines such as tablets 12) To record carried forward balances of medication on MAR sheets 13) To undertake regular documented internal audits of the medication system, recording any remedial actions taken 14) To ensure all short life medicines are labelled with date of opening, especially liquid medication 15) To use a separate page in the controlled drugs register for each resident for receipt, storage, administration and disposal of controlled drugs 7 OP10 12(1) 15(1) To ensure individual preferences for daily living activities are recorded as part of each residents plan such as rising, retiring, bathing, mealtimes etc. DS0000024971.V315870.R01.S.doc 01/01/07 Holly Lodge Version 5.2 Page 35 8 OP14 17(2) To ensure that all residents 01/12/06 property inventories property are fully completed on admission with clothing, furniture, valuables, hearing aids etc. and thereafter kept up to date, signed and dated by staff, resident and / or relative. 1) To develop and display menus in formats suitable to the residents capabilities 2) To include supper choices on menus and food records 01/02/07 9 OP15 17(2) Sch 4(13) 10 OP16 22 1) To produce the complaints procedure in alternative formats suited to residents needs and capabilities (large print etc.) 2) To discuss the collated results of the CSCI service user surveys in residents / relatives meetings to ensure awareness of the homes complaints procedure 01/02/07 11 OP18 13(6) 1) To obtain a copy of Dudley MBC multi-agency procedure for the protection of vulnerable adults Safeguard & Protect (contact details of the Adult Protection Manager given at visit) 2) To review the suitability and effectiveness of the protection of vulnerable adult awareness, making more robust arrangements as needed 01/01/07 12 OP19 13 16(2) 23(2) 1) Carpets required replacing / repair on the top floor landing. (Timescale of 03/03/05 and 01/06/06 Not Met) DS0000024971.V315870.R01.S.doc 01/02/07 Holly Lodge Version 5.2 Page 36 2) The bathroom in the old house requires a new floor. (Timescale of 03/03/05 and 01/06/06 Not Met) 3) Continue to repair or replace the loose or uneven flooring. (Timescale of 03/03/05 and 01/06/06 Not Fully Met) 4) Ensure all fire doors and closers are maintained, operating safely and door wedges are not used. (Timescale of 03/03/05 and 01/06/06 Not Fully Met) 5) Repair or replace the dining room furniture. (Timescale of 03/03/05 and 01/06/06 Not Fully Met) 13 OP19 23(2) To replace the threadbare stair carpet in the new house within an identified timescale 1) Proposed changes to the laundry room must be included in the renewal plan. (Timescale of 03/03/05 and 01/06/06 Not Fully Met) The homes policies and procedures must be updated to reflect practice and take into account health and safety guidelines. - Advice given regarding new DoH Infection Control Guidelines (Timescale of 03/03/05 and 01/06/06 Not Fully Met) 15 OP25 13(4) 1) To undertake a documented audit of the home to identify any radiators currently unguarded and any areas of exposed hot water pipe work accessible to residents, especially en suites, DS0000024971.V315870.R01.S.doc 01/03/07 14 OP26 23 01/01/07 01/12/06 Holly Lodge Version 5.2 Page 37 toilets and bathing facilities and ensure that they are guarded, boxed or covered appropriately 2) To implement written risk assessments for any areas where the work is incomplete as interim measures to protect residents from potential burns 1) To identify a timescale in the 01/01/07 refurbishment, renewal programme for the replace of carpets in bathing and toilet facilities with appropriate flooring for effective infection control 2) To provide hand washing signs in all communal bathing, toilet facilities and laundry facilities 3) To display copies of the homes laundry policy and infection control procedures in the laundry area 17 OP27 18(1)(a) 9(1) 1) The registered manager must submit to the CSCI Office, Halesowen formal staffing proposals, using a recognised staffing tool (such as DOH Residential Staffing Forum staffing tool for older people), taking account of current residents occupancy and dependency levels, with staff rotas, demonstrating that staffing levels are adequate to meet residents care needs (also detailing ancillary duties undertaken by care staff) 2) To increase the number of care staff to provide sufficient numbers of suitably qualified, competent and experienced care staff at all times that is: a minimum of five dedicated carers Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 38 16 OP26 13(4) 23(2) 01/12/06 (including a senior) 08:00 hrs 16:00 hours, and four carers (incl designated senior carer) 22:00 hrs - 08:00 hours (night hours) two wakeful care assistants, one of whom is designated as a senior carer. 3) In addition the registered manager be allocated appropriate full-time supernumerary managerial hours (minimum 35 hours per week). With immediate effect 4) To ensure staffing rotas include total care hours each week, clearly showing total of hours worked for each member of staff and in what capacity (i.e. ancillary duties, such as laundry and catering must be identified on each shift 18 OP29 19(1) 17(2) Sch 2&4 1) To devise and implement recruitment strategies to maintain staffing levels at all times, even if this is with the planned use of consistent agency workers (on short term contracts) 2) To ensure that all application forms are completed with a full employment history and any gaps in employment history are fully explored and reasons documented and checked wherever possible 3) To ensure that there is a recent photograph on each staff personnel file 4) To provide an accurate job description on each personnel file 01/12/06 Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 39 5) To ensure the contract of employment / terms & conditions accurately reflects the post identified on the staff rota (e.g. carer being used as a senior carer) 6) To ensure that there is a copy of the hairdressers and independent chiropodists POVA/CRB clearance on file 7) To ensure that there are copies of the private Chiropodists or other therapists qualifications, public liability insurance and POVA/CRB clearances 18 OP31 9(1) 1) To ensure that there are sufficient supernumerary managerial hours to develop and monitor practices to meet the National Minimum Standards for Older People 2) The registered provider must ensure that the registered manager has access to regular documented professional supervision, support and development 3) The registered manager must make a commitment to achieve the RMA (Registered Managers Award) within an agreed timescale 19 OP33 24 The home must introduce a quality assurance system. (Timescale of 03/03/05 and 01/06/06 In Progress - Not Fully Met) To forward copies the following to the CSCI office, Halesowen 01/03/07 01/12/06 20 OP33 24 01/01/07 Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 40 1) The collated results of the homes service user / relatives surveys 2) The collated results of the homes stakeholder surveys, when completed 3) An annual schedule of a minimum of 6 staff meetings, ensuring agendas and minutes are displayed in the home to encourage attendance To obtain individual receipts 01/12/07 from the independent chiropodist for each residents transaction, in compliance with the Data Protection Act 1998 1) To progress the implementation of the staff supervision system, ensuring that each member of staff has a minimum 6 formal recorded supervision sessions in each 12 months 2) To devise an annual schedule of supervision sessions, displayed to encourage participation 23 OP38 12,13 A 5-year electrical wiring certificate must be provided. (Timescale of 03/03/05 and 01/06/06 Not Met) 01/03/07 01/01/07 21 OP35 17(1) 22 OP36 18(1)(c) 24 OP38 13(4) 17(1)(2) 13(4) 17(1)(2) 25 OP38 1) Action must be taken to 01/01/07 ensure all staff attend two fire drills and receive fire training at least twice each year 1) To provide accredited / 01/03/07 approved risk management training for the registered manager and any other person undertaking risk assessment processes at the home or engage the services of a ‘competent’ DS0000024971.V315870.R01.S.doc Version 5.2 Page 41 Holly Lodge person to provide documented risk assessments, with control measures and risk management strategies. 2) To provide documentary evidence that approved risk assessment awareness training has been arranged for all staff to be delivered within an identified timescale. 26 OP38 13(4) 17(1)(2) To forward copies the following to the CSCI office, Halesowen 1) Asbestos risk assessment 2) Legionella risk assessment 3) Monthly records of water temperatures 01/01/07 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 Refer to Standard OP8 Good Practice Recommendations That small frequent nutritious meals are offered to residents with poor appetite, weight loss or nutritionally at risk That all medication in original containers is dated when opened so that accurate audits can be undertaken That staff signatures are obtained to demonstrate that they have read and have an awareness of the homes and the multi-agency procedures for the protection of vulnerable adults Safeguard & Protect The personal call alarm system, which is loud and piercing, DS0000024971.V315870.R01.S.doc Version 5.2 Page 42 2 3 OP9 OP18 4 OP19 Holly Lodge is replaced with a lower pitched repetitive sound in more frequent locations. NOT MET 5 OP30 6 OP33 That dates are entered onto the training matrix rather than ticks to demonstrate up-to-date training has been received That the registered manager should devise and display a schedule of residents meetings, together with agendas and minutes of meetings to encourage participation That the accident analysis is expanded to reference residents and highlight any trends or increased risks with details of remedial action or additional control measures 7 OP38 Holly Lodge DS0000024971.V315870.R01.S.doc Version 5.2 Page 43 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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