Inspection on 30/07/07 for Maesknoll

This inspection was carried out on 30th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Maesknoll 01/12/08

Maesknoll 18/12/07

Maesknoll 03/08/06

Maesknoll 14/01/06

Maesknoll 21/07/05

Maesknoll 28/03/05

Maesknoll 05/10/04

Maesknoll 25/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Maesknoll 101 Bamfield Whitchurch Bristol BS14 0SA Lead Inspector Sandra Garrett Key Unannounced Inspection 09:30 30th & 31st July 2007 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 Maesknoll DS0000035910.V338203.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. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maesknoll Address 101 Bamfield Whitchurch Bristol BS14 0SA 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) 0117 3772690 0117 3772691 maesknoll@bristol-city.gov.uk Bristol City Council Lesley Irene Edmonds Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate one named service user aged 58 years of age. Home will revert when named person leaves. 3rd August 2006 Date of last inspection Brief Description of the Service: Maesknoll is a care home registered with the Commission for Social Care Inspection to provide accommodation and personal care to forty people aged 65 years and over. The home is owned and run by Bristol City Council Adult Community Care and situated in the residential area of Whitchurch. Maesknoll is arranged over two floors with lift access. There is a small patio and large areas of lawn surrounding the outside of the home. The fee for living at the home, in common with all other City Council care homes (excluding those for people with dementia), is £460 per week. People funded through the Local Authority have a financial assessment carried out in accordance with Fair Access to Care Services procedures. Local Authority fees payable are determined by individual need and circumstances. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk http:/www.oft.gov.uk An old, outdated copy of an inspection report dated 2005 was pinned up on the wall in the entrance hall. The manager was advised to replace it with the last key inspection report. Other notices stated that if anyone wanted to read the last report they should ask at the office. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key or main inspection took place over two days. The manager Mrs Lesley Edmonds was present for most of that time and was welcoming and open to the inspection process. A relief assistant manager was also on duty for part of the time to cover for another assistant manager who was unavoidably absent. Five people living at the home were spoken with together with the majority of the care staff team over the two days. A range of records was looked at closely, including: Care records, complaints, activities, fire safety, supervision and training records. At a pre-inspection visit people living at the home had filled in eleven of our surveys that asks them about life in the home. Comments from these are used throughout this report. The home had also just had its own quality assurance survey done and the report had been sent to us just before this visit. Findings and comments from this are therefore also included. The previous key inspection was done in August 2006. A follow up random (or short) inspection was done in January ’07. The manager has been in post for the last eighteen months after being re-deployed from another local authority home that had closed. She is a manager of thirty years experience and her main aim is to put people living at the home first. She tries to cultivate a sense of ‘family’ at the home and this has been apparent throughout. However, Maesknoll is home of division and tension i.e. between management, between management and staff and between staff and people living there. There are clear divisions within the management team that have not been sorted out despite requirements and good practice recommendations made at previous inspections. These divisions have split the staff group, within which there are factions supporting some of the management team and some supporting the manager herself. These divisions have been clear to us for the last three to five years (before the current manager took up her post). The registered provider has been made aware of the situation yet from evidence gained at this visit has failed to effectively support the current manager or take clear and decisive action. This situation cannot continue and must urgently be resolved. The divisions negatively affect people getting care and result in poor quality of life for those that are aware of what’s going on. Some people living at the home that are more able to be independent are very aware of the situation and feel it has affected their lives. It has made it an uncomfortable place for them to live. One person told us at the random inspection in January ‘its like a snakepit here’. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 6 Sadly little had changed at this visit despite the manager’s attempts to improve the situation. People told us that if they are able to do things for themselves, they don’t get the care they need when they need it. They also complained of staff not speaking with them, even to greet them. They told us they felt that key time had been cancelled as they rarely get opportunities for it that would enable them to get some respite from the atmosphere. What the service does well: What has improved since the last inspection? Four out of seven requirements made at the last visit in January ‘07 or carried over from August ’06 were met: Care plans showed that they were being looked at regularly and changed where necessary so that peoples changing needs are picked up and met. People spoken with showed good knowledge of their care plans and whether their needs were being met that showed they had been consulted. Copies of care plans were seen in peoples rooms that give them ownership of them. However whilst the home may have the information, do reviews and update care plans there is good evidence that needs are not met. Improvement in recording individuals’ weight was also seen. Regular weighing now takes place and the results recorded. This makes sure that peoples changing health needs are picked up early through regular checks. The smoking lounge had now been put back to where it was needed away from the main communal area of the home. The bar area that was being used by smokers now smelled fresh and pleasant and non-smokers are not at risk of the effects of passive inhalation. Regular fire drills had now taken place and were properly recorded. This shows that people living at the home are kept safe and protected from risk of harm by staff that are trained and clear about fire safety. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 7 Two out of four good practice recommendations had been adopted: both of these were about improving care recording. Care records had got much better and were more person-centred (putting the person at the centre of all that is done for them and acting from their own choice and viewpoint). Good records were seen that gave clear indications of peoples lives at the home. What they could do better: The Statement of Purpose and service users guide must both be changed to make sure they are up to date and include all the information that people moving into the home need, in order to make a clear choice about it and to know what services are on offer. Further, the revised Statement of Purpose must include information about how the particular needs of people from different groups in society can be met. Also the service users guide should include clear details of the overall fee payable and the arrangements for paying it. Further, contracts must be signed. They must include the person’s room number and give information about the fees payable so that people are clear about their rights and responsibilities. Where new people move into the home, they must have a care plan started or an Adult Community Care plan brought in so that staff know what their needs are and can confirm that they are able to meet them. Other requirements were made that focus on trying to improve the situation at the home for people living there: Each person living at the home must be treated with dignity and respect by staff at all times even if staff are under pressure. The home must be run for the sake of the people living there, not for the staff. Regular key or one to one time must be re-started so that people living at the home have more chance of better social time and for staff to re-build relationships with them. Whilst a previous requirement made at the August 2006 inspection about a review of agency staff had been done, this had not gone far enough to improve the staffing situation that negatively affects people living at the home. A complete review of staffing levels must therefore be done by matching each person’s needs against staff hours available. The review must include an action plan of how to increase staff permanently – not simply continuing to rely on agency staff that don’t know people living there or their needs. A report of the review must be sent to The Commission for Social Care Inspection within 28 days of it being done. Two named staff members that have been working at the home since 2005 must do training in safeguarding adults from abuse. This will make sure that people living at the home are protected from risk of harm or abuse. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 8 Further a requirement made at the January ’07 visit about training for staff in managing behaviours that challenge them, wasn’t fully met. Short sessions had been held with staff from a local community mental health team but these weren’t detailed enough to help staff understand and meet peoples needs. Team building sessions facilitated by someone independent from the home and with experience in doing so, must be put in place as soon as possible to improve the atmosphere and the quality of life for people living there. Further, a report on the progress of sessions must be sent to the Commission within one month of the first one taking place. The sessions should be ongoing and focus on improving relationships between management and staff so that peoples anxieties about the tensions are reduced. Frequency of care staff supervision sessions hadn’t been increased in line with the City Council’s own policy. Ways must be found of making sure supervision happens more regularly and focuses on discussion of issues about improving the quality of life for people living at the home. As this has been a repeated requirement from three previous inspections, a statutory requirement notice under Regulation 43 of the Care Homes Regulations 2001 will be issued. Care records must be written at least once a week to show that people living at the home are getting the care as well as the quality of life that they need. 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. Maesknoll DS0000035910.V338203.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 Maesknoll DS0000035910.V338203.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 & 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Out of date information doesn’t keep people fully informed. Further, people from minority groups may not feel welcome at the home without positive information available about this. People living at the home aren’t made aware enough of clear information about their rights and responsibilities and the amount of money they have to pay for living there. Satisfactory arrangements for people coming into the home make sure their needs are met. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 11 EVIDENCE: Both the Statement of Purpose and service users guide were looked at. People have a copy of the Statement of Purpose in a file in their room. The service users guide is simply a sheet with details of services available at the home and doesn’t meet National Minimum Standards guidelines and regulations. The Statement of Purpose had the present manager’s name and details on it but other aspects hadn’t been looked at or changed in some time. Of our surveys eight people said they had received enough information about the home before they moved in. However three people said no to this question. Comments included: ‘Given a tour & shown all aspects of care provided’, ‘I was given information but this was the only place available at the time’, ‘I came here from another home’, ‘Someone came to see me to see if I was satisfactory to come here & I was fortunate to be able to come here a week later’ and: ‘Someone brought me here to look around & I looked at others but I chose here’. The responsible individual (the person named by the provider to make sure legal responsibilities under the Care Homes Regulations are met) had issued recent guidance to all local authority care homes. This was following an admission to another home that broke down and caused distress to the person concerned and other people living there. The guidance states that the Statement of Purpose has been revised and it: ‘does allow us to provide care to people that have a level of dementia that is manageable providing the primary and presenting needs are concerned with their physical care and not their dementia’. The Statement seen in the home didn’t fully reflect this and was unclear about admission of people with dementia. Further, neither the Statement of Purpose nor the service users guide (copies of which were seen in peoples rooms) included any information about meeting specialist needs of people from diverse groups such as black or minority ethnic, sexual diversity, gender, disability or religion. (The Statement of Purpose is one that is the same for each Council home. Therefore each home’s Statement of Purpose should contain the same information). A long stay contract was seen in the file of a person who wasn’t staying permanently at the home. The contract had the room number but no information about fees other than that s/he is responsible for them. One person had a blank copy of contract in her/his room but nothing was filled in on it and it wasn’t signed. Other contracts were seen that had all the information on them and were signed. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 12 The manager said she is going through each person’s contract to make sure they have the up to date one. From our survey only three people said that they had received a contract whilst seven said no to this question. Comments included: ‘I can’t remember’ (2 people), ‘I signed a contract’ and: ‘I remember signing something’. Assessments done by social workers before people move into the home were seen in individual files. These gave background information about the person’s life at home or in hospital before coming to the home and included a care plan that is used at first to help staff meet needs. Information from the assessments is then used to help develop the home’s care plan for that person. One person who had come into the home as an emergency, had lots of preadmission information about her/his personal circumstances, but no care plan. The person was able to say what care needs s/he had and was relatively independent. The assessment gave clear details of what the person needed to keep her/him safe but this information wasn’t being used to form a care plan (See Standard 7 below for more information on this). The manager hadn’t received the Annual Quality Assurance Assessment that we send out to homes once a year. Another one had been sent and the manager said she was halfway through filling it in. Therefore we couldn’t use the information from it. The Assessment asks homes’ managers a range of questions about the home. Some of these questions are about meeting the needs of different groups in society from which people may come into the home. The manager said that no Black people or people from ethnic groups were living at the home at this visit. No information about other groups was available apart from age. A condition of registration about the home having a person under 65yrs of age living there is no longer needed as the person had moved into independent accommodation. Maesknoll DS0000035910.V338203.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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements in looking at care plans and recording peoples weight regularly, makes sure peoples changing needs are picked up and met. People living at the home are looked after well in respect of healthcare needs but they aren’t all treated with dignity and respect. EVIDENCE: Five peoples care records were closely looked at. Some of these had personal profiles at the front of the file that gave information on the person and their past life. The records showed the person’s likes and dislikes, daily routines and information about relatives as well as a past history that helps staff know more about them. This is good practice but wasn’t seen for each person. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 14 Care plans were on the whole thorough and detailed with clear information about individual peoples needs. Care plans included information on: Mobility Dressing Diet Washing and bathing Continence Chiropody Sight Family and friends Memory Hearing Dental Emotional needs. For one person the section on diet showed that s/he needed small portions and cooks confirmed that they were aware of peoples individual needs for the right portion size. However in another care plan under ‘Dental’: it said ‘needs assistance with mouth care’ but no actions were recorded on the plan for this. Another person’s care records were looked at but didn’t have any past history. The care plan was very detailed and well written from a person centred approach (i.e. putting the person and their needs at the centre of the plan). The plan stated that: (the person)’has been told to ask for any assistance that (s/he) may need’. (The person) ‘says s/he feels unwanted if not offered help’. However when spoken with the person said that s/he doesn’t get the help s/he needs as staff don’t have the time and believe s/he is capable of meeting her own needs more often than not. Handwritten updates were seen as and when things changed for the person. S/he also had emotional needs that from discussion with both her/him and staff were not being met. An action was recorded: ‘staff must try to find time to speak to (the person) – not just leave to her/himself’. Staff admitted that they don’t have time to speak with everyone and more than one person said that staff don’t even say hallo to them. The care plan had been updated in April ’07 but didn’t have any signatures to show it had been discussed and agreed. A third person’s records were looked at. The social work assessment clearly detailed the circumstances and reason for emergency admission to the home that’s for a short stay until permanent accommodation is found. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 15 No care plan, either by Adult Community Care or the home, was seen. The person was spoken with and was able to describe her/his needs. The manager said that the person had only been at the home three weeks so was still within the four-week trial period. However as there was no other document to show what needs the person has and how they are to be met, the manager must make sure one is done immediately so that staff are aware of her/his needs. A requirement made at the visit in January ’07 was partly met. Most of the care plans showed that they had been checked monthly and records were seen of this. For one person monthly reviews were seen from March ’07 to July and comments included. For another the care plan done in Feb ’07 was fully reviewed in July with no changes. The plan showed staff know the person’s needs well. The keyworker had signed it but not the person or her/his relative that attended the review. For a third person monthly review sheets were seen that were all done each month in 2006 up to June 07. However for one person the monthly review was last done in July ’06 and nothing was seen recorded since then. A requirement also made at the January visit about checking peoples weight where necessary was met. Weights are recorded on a form that records such things as bathing, chiropody and dental appointments among others. For one person who was frail and said s/he felt poorly, weight was being recorded regularly. This showed that her/his weight had remained stable although low. Another person had lost weight and this was recorded with evidence of regular checking. The person that had come in for short stay had been weighed within two weeks and this was recorded. The manager showed us a sheet she had done that is a checklist for making sure peoples weights, care plan review meetings and monthly reviews are done. The sheet included dates of when the reviews had been done and when they are due to be done again. The manager had starred in red where actions needed to be taken so that staff would know what to do. This is good practice. The district nurse visiting the home was spoken with on the second day of inspection. She was visiting five people and doing different things such as dressings and a catheter change. The district nurse spoke warmly of the home and praised the staff who she said were hardworking and helpful. She was visiting one of the people we case-tracked. However, actions she was taking weren’t seen recorded in the person’s care plans. Both the home’s doctor and a consultant psychiatrist were also seen visiting people in the home over the two days of inspection. Moving and handling risk assessments were seen for all the people whose records were looked at. Further, individual risk assessments were seen e.g. for smoking, plus use of oxygen and use of a toaster. Assessments showed the level of risk and the likelihood of it happening and were dated. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 16 Medication wasn’t looked at as our pharmacy inspector will be doing her own inspection shortly. The manager was seen giving out medication at lunchtime. She said she had made sure a staff member is always present in the dining room to help people and answer any questions, rather than the person giving out the medicines being distracted. This is good practice. Staff were observed giving care to some people whilst we were at the home. Where this was observed staff were kind, patient and helpful and treated people with respect. Call bells were answered promptly. However some of the more able people living at the home told us that staff don’t always say hallo to them and they are frequently told staff have no time to give them. One person’s bed remained unmade late in the morning and the person said the sheets were due to be changed. However when s/he asked about this s/he was told to ask her/his key worker to do it when she came on duty. Comments about getting the care and support they need were mixed: ‘Sometimes I have to wait one or two weeks between my baths’, ‘sometimes tablets are left for residents to take of their own accord but sometimes these aren’t taken due to mental health problems’. However comments were mainly positive: ’I get on with them all’ and: I don’t think you could get anywhere better’. However another person commented that ‘The staff didn’t listen to me at all and I was told to stop complaining about things’. From the home’s own quality assurance survey done just before our visit, again comments were mixed. 78 of people felt satisfied with the management and staff. However some comments were of concern i.e. ‘ We can’t say anything – we’re not allowed to’ and: ‘sometimes we get told off – e.g. ‘if you shut up and stop talking you’ll hear the telly’’. Further from the home’s own quality assurance survey a general comment was made: ‘don’t always get treated with the respect you should. I see others not always being treated with respect, especially if not compus mentis’ These comments reflect the overall concern that there are not enough staff on duty to meet the needs of every person and that divisions within the home lead to a lack of respect for people living there. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 17 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. Activities and lifestyle choices don’t fully meet the needs or wishes of everyone living at the home. The location of the home doesn’t enable much community contact for people living there. Meals at the home are well managed and provide daily variation, good nutrition and social contact for people. EVIDENCE: From looking at records, talking with people living at the home, plus the manager and staff, from comments in both the home’s and our surveys, it’s clear that activities are a challenge to provide. People have mixed views about whether they want to join in with activities, what type of activities they want and how often. The manager and staff said that there’s a small yet regular group of people who join in with and enjoy activities. Others told us they were unaware of any although we saw notices about them pinned up outside the dining room. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 18 Comments from our surveys were very mixed. To the question: ‘Are there activities arranged by the home that you can take part in? Eight people said ‘always’, one person said ‘usually’, one person said ‘sometimes’ and one person said ‘never’! Comments in our survey included: ‘I haven’t done anything up till now & haven’t heard about anything either’; ‘There are activities but I’m in my 70’s & most of them are 80 & 90. It’s all too old for me’; ‘There is but I don’t take part in them’; ‘I’ve heard them doing things here’. ‘There was a singing evening that I went to & bingo yesterday which I didn’t bother with because I don’t enjoy it.’ ‘There are activities but it’s not for me, I do have a game of bingo now & again’ and: ‘I like singing & I used to be a dancer’. Records looked at showed a mix of activities in the home that included: A Hawaiian dancer A Chicken supper Fresh crusty bread suppers (a regular occurrence that the manager said includes different types of meats and cheeses for people to try) Mothering Sunday family tea A 90th birthday party A fish and chip supper A night of singing and dancing with an entertainer. However it is noticeable that many of the activities centre on food and eating rather than a clear mix of non-food related ones. Peoples enjoyment of the food-based activities may also show dissatisfaction with menus that should be looked at closely. All the events were written about and included comments to show that people had enjoyed themselves e.g. a person living at the home ‘got up and took to the floor with myself and others for a couple of waltzes’ and: ‘I was pleased so many mentioned that they had enjoyed the evening (it was the fish and chip supper). ‘Next Saturday we’re having Bingo’. The manager is committed to giving people the kind of activities that they want and said that they really love the crusty bread suppers that she buys all the food for. In the home’s own quality assurance survey activities scored the lowest at 65 compared to an average score of about 80 for the other sections. It was clear from the answers that people talked about the daily living routines of the home e.g. ‘have made friends in the home’, ‘enjoy socialising’, ‘own choice of paper delivered to my room’ and: ‘have organised a knitting circle for charity’. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 19 Some negative answers were given however, especially about the opportunity to go out of the home e.g. ‘very few trips out – too expensive’ (six comments),’they get the money for trips but say it’s a staff problem’, ‘anything to break the monotony’ and: ‘bingo stopped’. The biggest issue however was key time (one to one time with key workers that is more social rather than simply focussing on doing care tasks for people). People told us when we visited to do the surveys: ‘We don’t go out, it’s been stopped by social services. I think it’s disgusting & unfair, I used to love going out & now I feel like a caged animal’ and: ‘There is no key time anymore. I was going out on my own but now I haven’t been out since Christmas’. We contacted the responsible individual about these comments who said that key time hasn’t been stopped. He went on to say that: ‘what has happened is that when the pressures are on staff, dedicated key time is often the aspect of care that goes by the board’. He went on to say that he has ‘thrown out the challenge to staff for a second time to think about the routines of the home and come up with some ways to improve efficiency and create some time that can be dedicated to residents’. Please see Standards 27 – 30 for more about this issue. Relatives were also asked to fill in the home’s quality assurance survey forms and their comments were included in the report. Comments from relatives about activities included; ‘my relative has dementia and finds the home quite a lonely place’ and: ‘many residents seem to have little contact with the outside world’. The manager said that community contact is reduced although a ‘Good News’ religious group comes in regularly and holds services that people enjoy. Relatives are able to visit freely and were seen taking people out to the shops and to their homes. The home is located in a residential area of Bristol that isn’t close to shops, pubs or other amenities. Therefore people have to rely on family members to take them out or wait for staff to have the time to do so. From comments throughout this report it’s clear about some of the choices people living at the home have. They are able to move about the home freely, are able to stay in their rooms or sit in the lounges, can take part in activities or not, have a choice of different food at each meal and can go out if they are able, either on their own or with relatives. However other choices such as choosing to get up when they like or go to bed when they want are questionable. Staff said that because of pressures on them in the morning there is little time to help everyone get up when they come on duty. They said that the manager is clear about letting people stay in bed if they wish but other members of the management team wanted people to be got up earlier. One comment was also seen in the home’s survey about finding their relative ready for bed in the early afternoon and the curtains pulled. It wasn’t clear if this was a choice or not. However no-one commented to us about this particular issue. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 20 The two cooks on duty during this visit were spoken with. They said that they work hard to try and make sure people have a good menu and that meals are what people want. However they were aware that they couldn’t always please everyone. They said that they try new or different dishes but people living at the home like the more traditional English food. In one person’s care plan it said that s/he likes curries and lasagne and that cooks are to make sure they are available. Cooks confirmed this although the dishes didn’t appear on the menus seen. They said that they had ‘done a curry in the past but it didn’t go down very well’. Menus showed a good variety of meal choices with often a vegetarian choice at lunchtime. Salads are always on offer and choice of a hot teatime meal or sandwiches is given every day. From our survey five people said they ‘always’ like the meals, whilst one person said ‘usually’, one person said ‘sometimes’ and one person said ‘never’. Comments included: ‘The meals at Maesknoll are no different from one week to the next. Also my daughter always brings food in so I can have something different each day’. ‘The food is fine’; ‘not bad’; ‘I eat almost anything; I’ve never been fussy’. ‘It’s very bland; abroad every thing has a lot more taste’ and: ‘Yes we get food & we can always have seconds’. We sampled a meal with people on the first day of the visit. The choice was of faggots, chips and peas or egg, chips and peas with several choices of dessert. The meal was hot and tasty and people were seen enjoying it. One person told us on the second day that the meal she had had was lovely – the best she had had for a long time. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 21 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 poor. This judgement has been made using available evidence including a visit to this service. Improvement in staff relationships needs to happen if people living at the home are to feel confident in raising concerns about any aspect of their care. The way abuse issues are handled keeps people protected from risk of harm or abuse happening to them. However improvements in staff training in the subject is needed to keep people safe. EVIDENCE: Copies of the City Council’s complaints leaflet were seen in individual peoples rooms. The leaflet has all the information necessary for people to be able to make a complaint, although the first line of contact is usually the registered manager. From our survey eight people said they ‘always’ know how to make a complaint although two said ‘usually’ and one said ‘never’. People again gave mixed answers to the question i.e. ‘Ive made some complaints & they’ve always been dealt with promptly. I don’t recall seeing the leaflet’ and: ‘yes but I haven’t been unhappy though’. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 22 However others said: ‘I do know (how to complain) but I don’t think anything would be done’; ‘I do know but I wouldn’t make one unless it was really serious, I wouldn’t want to make trouble for myself’ and: ‘I would go down to the office but what’s the point, nothing gets done’. To the question ‘do you know who to speak to if you’re not happy?’ one person had said: ‘if they listen to me’. Another said: ‘Not really because they’ve changed hands. I would speak to the nurse because it would be private with her’. These comments particularly are of concern as they imply that people don’t feel confident that any concerns they have will be taken seriously, acted on quickly and kept confidential. They also show that the divisions in the staff team are clearly having an effect on peoples confidence about raising concerns. The complaints log was looked at. Since the last key inspection in August 2006, four complaints were made – all by peoples relatives. This bears out peoples comments in the surveys. The complaints were about care practice, discharge procedures, missing clothes and the smell of the home. The log showed clear information about the complaints and how they were dealt with, including responding to the person complaining within twenty-eight days and whether upheld, partly upheld or not upheld. Three of the four complaints were upheld and one disputed by a staff member involved. On one person’s care plan details of an incident of abuse that the person had been subject to was recorded and gave details of the physical support s/he needed in order to keep her/him safe. Further the reporting of the incident had been done quickly and all relevant agencies contacted including Adult Community Care, the safeguarding adults co-ordinator and ourselves. A letter from the Care Direct team manager was seen that praised the manager’s ‘quick and efficient actions’ that kept the person and other residents safe. From staff training records looked at, almost all of the staff have done training in safeguarding adults from abuse between 2004–6. No plan for updating training for those that did it in 2004 was seen. Further, two staff had started work in 2005 but no evidence of any safeguarding adults training was seen in their records. Please also see Standards 27 – 30 for more information about training. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 23 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from living in a comfortable, clean, safe standard of accommodation that is well decorated and kept up, physically accessible and meets their needs. EVIDENCE: From the home’s quality assurance survey lots of positive comments were seen about the environment of the home e.g. ‘Clean and comfortable, safe and secure’ (two similar comments); ‘light and airy – like home from home’; ‘opening windows – nice view’ and: ‘sufficient for one – quite all right’. Relatives also commented on the freshness and brightness of the home, the comfortable, homely bedrooms and good security. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 24 Work has been done to make the home more accessible to disabled people and visitors. There are accessible toilets with raised seating and grab rails. The front entrance has been made self-opening. There is a lift to the first floor for those who cannot manage stairs. From our survey to the question ‘is the home fresh and clean’, nine people said ‘always’ and two said ‘usually’. Comments included: ‘Cannot fault the cleanliness of the home, the staff are always on the go’ and: ‘It’s spotlessly clean’ although one person said ‘I suppose they call it clean’. Rooms seen were of good size and nicely decorated with homely furnishings. The home looked and smelled fresh and clean and domestic staff were seen working in all areas of the home. The manager had been able to get some extra funding that would be used to refurbish parts of the home and to improve the garden. A new patio area at the front of the home together with new planting will make it a pleasant place for people to sit in good weather. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 25 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 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Low staffing levels and inadequate management of staff time fails to make sure people living at the home get the service they are entitled to expect. Proper checks on staff before they come into the job keeps people living at the home safe and protected. Insufficient training in mental health, dealing with behaviours that challenge and dementia awareness fails to make sure peoples needs for support with these issues is met. EVIDENCE: Comments from our survey about the question: ‘are the staff available when you need them?’, were mixed i.e. ‘Yes I think so’ and ‘It’s not too bad’, although others were clear about the lack of staff: ‘There isn’t enough staff especially at weekends’; ‘They’ve got their work cut out for them; they could definitely do with some more staff. They try & do as much as they can’; ‘Some days there are more here than others and: ‘I think they should have more because they work so hard’. However to the question ‘is there anything else you’d like to tell us?’ one person said: ‘Sometimes the staff at Maesknoll EPH are not very helpful & do not listen to what people are saying’. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 26 Staff spoken with also felt that there aren’t enough staff on duty, especially in the mornings when the workload is busy. At this visit there were five care staff on duty in the morning but staff said that was unusual as mostly there are only three. They also said that if agency staff are on duty this also affects staff ability to do their work and meet peoples needs as the agency staff don’t always know what peoples needs are and need a lot of guidance from permanent staff. Rotas were looked at and showed differing numbers of staff on each day. These ranged from 3 – 6 each morning but the average was between three and four. The manager said there were still staff vacancies that were being interviewed for within the next two weeks. These were three care staff posts of fifteen, sixteen and seventeen hours respectively. Staff said that the reason they can’t give key time to people is that with so few staff most of their time is taken up with doing tasks such as bathing or housekeeping. They said that sometimes they don’t even get time to do many baths for people and this had been seen in comments from relatives in the home’s own survey. Staff further said that the dependency levels in the home (peoples needs for extra help because of their frailty or health conditions) are greater now yet there are fewer staff. Staff acknowledged that people who are more independent don’t get time spent with them but felt powerless to do anything about it with so few staff on duty. When we asked what would help them they said that if they had a staff member just to do the laundry and nothing else that would take pressure off them and stop things from going missing. Staff denied that there were any other ways they could manage their time in spite of the challenge put to them by the responsible individual. However we recommend that time management should be looked at closely, particularly when doing tasks and fitting in meal and rest breaks. Training records were looked at closely. From these basic standard training such as moving and handling, fire safety and basic food hygiene had been done for each person. Some staff had done training in person-centred care recording. However a requirement made at the January ’07 visit had not been properly met. Staff said that they had had sessions with members of the InReach team that visits each home to offer support around peoples mental health needs. Staff said that whilst they enjoyed these sessions they would like more focussed training for longer sessions e.g. a day at a time. Their training records showed that mental health training had been done by a number of staff in 2006 but the sessions were short – 1-2hrs only once in the year. In 2007 they had had training in dementia but the sessions were for 45 minutes only. The requirement is therefore continued with a short timescale. Training in dementia and mental health issues e.g. managing behaviours that challenge should be given by a recognised training provider as frequently and in as much detail as to be beneficial to all staff. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 27 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, 35, 36, 37 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A trained and experienced manager is prevented from making her mark on the home because of staff attitudes that aren’t moving forward. Peoples cash held at the home is protected and kept safe for their benefit. Improved daily records show quality of care given to people living at the home, but further improvement is still needed to make sure they are written regularly. Improved fire safety makes sure everyone at the home is kept safe from the risk of fire. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 28 EVIDENCE: The manager Mrs Lesley Edmonds was on duty at this visit and was welcoming and open to the inspection process. It’s clear that Mrs Edmonds’ main aim is to make sure people living at the home are happy and able to enjoy activities that they like. However, some staff spoken with said that communication wasn’t good and that there was a lack of organisation in the home, although this wasn’t apparent at the visit. The manager and relief officer on duty were seen talking with staff and giving information. The manager had a meeting with the cooks on the second day that discussed changing teatime menus. Instructions about writing care records were seen displayed and the manager answered numerous enquiries from people living at the home, relatives, contractors and staff during the two days of the visit. It‘s therefore hard to see how communication could be improved or what this concern really means. However, people living at the home told us that staff talk about tensions between the management team to them that should be kept confidential. It’s been noticeable that there are divisions within the home over the last few years and we have commented on this in previous inspection reports. Good practice recommendations about team building for management staff have been adopted but little improvement noted. People told us that tensions and disagreements within the management team have been talked about in front of them so that they are aware and become anxious about it. Further, they also said that they felt staff know and talk about peoples own confidential and personal information and they were unsure how this happens, which increases their anxiety. People living at the home are very aware of the atmosphere that they feel hasn’t changed from each visit we have made. Staff also made us aware of the divisions that have been apparent each time we’ve talked to them both as a group and individually. The manager hasn’t been clearly supported since she took up post and staff are reluctant to change entrenched patterns of working and move forward. This, together with their perception of having too few staff, is damaging to people living at the home. The responsible individual as representative of the registered provider has been made aware of our concerns but has failed to support the manager or put in place the actions needed to turn the home around. From this visit it wasn’t clear that the home is run in the best interests of people living there - rather that it’s run to suit the staff. It was very disappointing to note that a good practice recommendation made at the January ’07 visit to find ways to improve the situation by team-building sessions for the whole staff team had been ignored. The manager said she is going on a six-day leadership course in September-November ‘07 and details of this were looked at. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 29 However until staff attitudes to the management of the home change, the home cannot develop and improve enough to give people living there the care they’re entitled to expect. The registered provider must therefore take responsibility for making sure the situation improves. A check of peoples cash kept at the home for them was done. Several records were looked at and cash checked against balance sheets. All amounts tallied with the sheets and where money is given out to people they had signed for it. Regular balance checks are done and a note in the home’s communication book about an assistant manager picking up an error in someone’s records showed good practice. A repeated requirement made at the August 2006 inspection about supervision, again wasn’t met. Twenty staff records were closely looked at. From these it was clear that care staff aren’t getting opportunities to discuss their work regularly enough. One person had six supervisions done over a period of eighteen months rather than the recommended one year. The sessions included the yearly performance review that each staff member has. For six other staff only one session in the year had been recorded and staff spoken with confirmed this. Supervision records were also patchy i.e. some good, clear records of discussion about meeting peoples needs plus any training needs were seen. Others were brief and gave little detail of the content of sessions. Five staff had had two sessions in a year, six had had three sessions and one person had had four sessions. Whilst it’s accepted that management time is under further pressure at the moment because of unavoidable absences, the divisions within the home mean that staff need more not less supervision. Therefore ways must be found of making this happen e.g. by group supervision sessions that have a team–building focus built in. Failure to meet the requirement will lead to enforcement action being taken. Two good practice recommendations had been adopted about writing respectful daily records from the person’s own viewpoint and with less frequent mention of bodily functions. A notice was seen on the wall in care files/medication room from the manager about the last inspection picking up poor recording. Further it reminded staff to keep records updated regularly – although this was clearly not happening. Daily records were much improved generally. They were good, detailed and gave information about e.g. hospital appointments, daily life, assistance given and family visits. The abusive incident towards one person had been written up and reported. However, a further good practice recommendation about making sure records are written at least weekly hadn’t been adopted. There were still lots of gaps seen e.g. for one person from 1/07/07 then not again until 28/07/07. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 30 For another a long gap from 26 May ‘07 until 21 July ’07 was seen. Staff said they were under pressure to do other things such as bathing and activities and had little time to write the records. Whilst this is partly accepted, care records must be written regularly to make sure important events are recorded and to show that people living at the home are getting the care and social stimulation they need. Similarly key time records were better – e.g. a good record of helping a person put her make-up on was seen. All key time sessions for this person had been well written and showed the good relationship between the person and her keyworker. The person had told her keyworker that she didn’t see her as often as she would like and this was also recorded. In another person’s records more information about enjoyment e.g. of bathing was seen. More detail of actions taken was seen especially as the person was unwell. However keytime sessions again weren’t happening or recorded often enough and long gaps were seen e.g. March ‘07 then not again until May ‘07, then not again until July’07 - although then twice more on 21/07/07 and 22/07/07. Fire safety records were looked at following a requirement made at the August ’06 key inspection. Since then six drills had been done. Some of these were actual incidents of the fire alarm being set off, whilst others were proper drills. All drills were well written up and attended by between five to thirteen staff including members of the management team. Notes of drills included actions taken to protect people and other issues picked up e.g. the visitors book being checked to show that everyone could be accounted for. Records of regular fire safety training were seen in staff training files, together with completed questionnaires on the subject. Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 31 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 2 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 18 3 X X 3 X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 1 1 X 3 1 3 3 X 2 Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 32 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 6(a) Timescale for action The Statement of Purpose must 31/12/07 be reviewed and amended to make sure it is up to date and gives clear information about the types of needs the home can meet and the circumstances in which people are admitted. This will make sure that people considering a move to the home will get the information they need. The service users guide must 31/12/07 be amended to include all details as set out in the Care Homes regulations (as amended 01/09/06) This will make sure people are given clear information about the home at the time they come to live there. People’s individual contracts 01/11/07 must be signed by them or a person able to sign on their behalf, contain their room number and details about fees payable. Requirement 2. OP1 5(1)(a-bd) 3. OP2 5(1)(c) Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 33 4. OP7 15 (1) Care plans must be done for 07/09/07 each person staying at the home for longer than four weeks. Further, copies of the Adult Community Care care plans must be obtained so that staff are aware of care needs on admission. This will make sure that peoples care needs are picked up and met whilst living at the home. Every person living at the home must be treated with dignity and respect by all staff at all times. This will make sure that people living at the home feel that they are important and that the home is run in their best interests. People living at the home must be given more opportunity to have regular, meaningful one to one time with key staff. This will give people better social stimulation and help re-build their relationships with staff. Two named staff members that have been in post since 2005 must have safeguarding adults from abuse training. This will make sure that people living at the home are protected from risk of harm or abuse. A complete review of staffing must be done to make sure that staff numbers match the dependency levels of people living at the home and the continuity of care is maintained for everyone. A report of the outcome of the review must be sent to Commission for Social Care Inspection by the due date. 5. OP10 12(4)(a) 07/09/07 6. OP12 12(5)(b) 01/11/07 7. OP18 18(1)(c)(i) 01/10/07 8. OP27 18(1)(a) 07/09/07 Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 34 9. OP30 18(1)(c) (i) 10. OP33 24(2), (4) All staff must receive, from a 01/11/07 recognised training provider, training in caring for older people with behaviours that challenge from a person-centred perspective. (Timescale not met from January ’07 inspection) Team building sessions for the 01/11/07 whole staff team facilitated by an independent person must be put in place as soon as possible to improve the quality of care for people living at the home. Further, a report on the progress of sessions must be sent to the Commission within one month of the sessions taking place. This will make sure that the atmosphere at the home improves so that people living there have positive outcomes for their care and quality of life. Care records must be written 07/09/07 regularly (at least once a week) to make sure important events are recorded and to show that people living at the home are getting the care and social stimulation they need. 11. OP37 17(3)(a) Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 35 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 OP1 Good Practice Recommendations The Statement of Purpose should be amended to show how people from different groups in society e.g. black or minority ethnic, sexual diversity, gender, disability and different religions can be cared for. Further, the service users guide should be amended to have clear details of the total fee payable and the arrangements for paying the fee. A way of showing how many people from different groups in society live at the home and how their specialist needs can be met should be put in place. The activities programme should be looked at and a mix of different ones chosen by people living at the home should be put in place. Further where food-based activities give enjoyment these should form part of the overall menu. The manager should seek to raise confidence among people living at the home about making complaints and make sure that complaints are kept confidential. A review of care staff time management should be done to make sure that all necessary tasks for people living at the home are done i.e. activities, key time, personal care and daily recording. Sensitive or personal information about either people living at the home or staff should be kept confidential and not discussed openly. Team building sessions should be regular and ongoing until relationships between management and staff have improved. This will benefit people living at the home and reduce their anxieties. 2. 3. OP4 OP12 4. 5. OP16 OP27 6. 7. OP32 OP33 Maesknoll DS0000035910.V338203.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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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