CARE HOMES FOR OLDER PEOPLE
Stokefield Care Home Stokefield Care Home St Johns Hill Road Woking Surrey GU21 1RG Lead Inspector
Lisa Johnson Unannounced Inspection 19th June 2007 09:45a 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 Stokefield Care Home DS0000036444.V339542.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. Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Stokefield Care Home Address Stokefield Care Home St Johns Hill Road Woking Surrey GU21 1RG 01483 761779 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) ann.duddridge@hanover.org.uk HanoverFriends Elizabeth Ann Duddridge Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 22nd September 2005 Brief Description of the Service: Stokefield care home is owned and managed by Hanover Friends. The service provides accommodation to 24 older people. The homes communal facilities are two sitting rooms and a dining room; the bedrooms are all single occupancy. Accommodation is provided over two floors, which is accessible by lift. The home has specialist bathing facilities and equipment. The care home is situated in close proximity to Woking town centre and local amenities can be accessed through the homes own transport or community transport. Parking facilities are provided at the front of the building The weekly fees range from £497-£634 Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over six and half hours commencing at nine forty five am and finishing at three fifteen pm. Mrs. L Johnson Regulation Inspector carried out the visit and Ms. A Duddridge Registered Manager represented the establishment. The inspector spoke to six people who live in the service to gain their views on the care provided. Six comment cards have been received from people using the service, one relative and two healthcare professional comment cards. These comments have been reflected in this report. Information was gained from the Annual Quality Assurance Assessment (AQAA) provided by the registered manager prior to this visit. During this visit a tour of the premises took place. Care plans, staff training records, staff personnel files and policies and procedures were sampled. The inspector spoke to three members of staff. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this visit What the service does well: What has improved since the last inspection?
Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 6 The procedures for recording and accounting of for the finances of people using the service have been reviewed. The outcomes of quality assurance audits have been published by the home and were seen on display in the homes reception. What they could do better: 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. Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 7 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 Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 8 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): 3 People who use the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that pre admission assessments are completed prior to admission to the home. The home does not support people for intermediate care. EVIDENCE: Pre-admission assessments were sampled for three people. It was evident that pre- admissions assessments were completed, which were detailed and comprehensive and included the health, personal, communication, social and spiritual needs of individuals. Community care assessments had also been obtained from care managers where this was required. Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 9 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each person is provided with an individual care plan, which details the individual’s health, personal, emotional and social needs and their health care needs are met. Residents are protected by the homes medication policy and procedures and are treated with respect and their right to privacy is respected. EVIDENCE: During this visit three care plans were sampled. Care plans were in place based on full needs assessments including health, personal, emotional, daily activities of living and social needs. The likes, dislikes and preferences of each individual were recorded including “how to attend to my personal care, medication, night support and daily routine. Care plans had been signed by people using the service and or their relatives. The home has also implemented summary care plans that were kept with the daily records. Plans are reviewed regularly, although one individuals plan had not been reviewed for three months and it was required that care plans must be reviewed monthly to ensure that the current or identified changes in need of people are being met.
Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 10 People living in the service are registered with a General Practitioner and a number of individuals have maintained contact with their own doctor. Care plans sampled indicated that a range of specialist health care professionals including district nursing, chiropody and ophthalmology support people living in the service with records being maintained of all health care appointments and consultations. All six people who completed surveys stated that they receive the medical support they require. Two health care professional surveys also state that the health care needs of individuals are met by the service. It was evident that a range of risk assessments had been conducted including for pressure areas, nutritional, moving and handling and plans for individuals identified at risk of falls, although an assessment had not been completed for one individual, therefore an immediate requirement was made that this was conducted for this individual ensuring their health, welfare and safety. Since this visit the manager has provided written confirmation to the inspector that this matter has now been completed. During this visit staff were observed to talk to people with courtesy and with respect. All bedrooms are single occupancy. Three people spoken with during this visit say that staff knock and wait before entering their rooms and each person has been provided with a key. Two individuals spoken with said that that they have their own telephones. Three health care professional comments state that staff respect peoples privacy and dignity with one person commenting. “We have always found the home great and a caring environment to work with”. A medication administration procedure was in place. Medication was stored appropriately including controlled medication maintained by the home with a register in place that was correctly recorded. A list of staff trained and authorised to administer medication was available. All medication administered was signed for and an audit and monitoring system was in place. Records were maintained for the disposal of medication and the manager stated that arrangements have been made for the pharmacy to visit and conduct an audit a date. Risk assessments had been completed for individuals who wished to self medicate. . Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 11 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, 15 & 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that people using the service have access to a range of recreational and leisure activities and maintain links with their family/friends and the local community. People are supported to make choices and individual preferences are respected and they receive well-presented and balanced meals. EVIDENCE: During this visit an activities timetable was observed on display and activities are provided for people if they wish to attend including card games, exercises, music, quizzes a shopping trip to the supermarket, library and pub lunches. The home has its own vehicle but is currently fundraising to purchase a more suitable vehicle and the home is arranging a barbecue as part of this event. The home is holding a cream tea event. The home holds social events including a cheese and wine party. One person told the inspector she likes to play the piano, which was seen in the dining room. Another individual told the inspector that they have their own car and some people were observed to be walking back from the local area. A hairdresser visits the home and a weekly church service is conducted. Some people like to visit the church of their own choice, which they attend. Six surveys received indicated that there are usually
Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 12 or sometimes are activities provided which meet their needs and preferences, although one person spoken with would like more opportunities to spend time out of the home for socialising, which was bought to the attention of the manager. A comment received from a health professional stated, “I think that the service does an excellent job on keeping residents motivated” The manager is currently interviewing for an activities coordinator and hopes to increase the variety and community activities. A survey received from a relative commented that staff make them feel welcome, they can visit their relative in private and that they are able to visit without restrictions. Two people spoke about their families and one individual said she visits her friend. A number of people have their own telephones to maintain links with family and friends. During this visit it was observed that people using the service are able to bring in their own furniture and possessions, which were seen on display in individuals bedrooms. Information was seen on display about access to advocacy services .The home provides a five weekly rotational menu. Choices of meals were clearly recorded on the menu, which were displayed on the dining room tables. The home employs a chef during the week and at weekends. The lunchtime meal provided was well balanced, nutritious and well presented. The inspector spoke with the chef who said that she visits people to gain their likes, dislikes and preferences. The home also caters for specialised diets. Surveys received indicate that three out of six people always enjoy their meals, two out of six say usually and one person said sometimes. During this visit most people were happy about the meals provided and comments included “good” and “Plenty to it” although some people commented stated that meals provided at the weekends could be improved. One comment received stated, “At weekends meals are not so good and portions have not been enough”. This issue was brought to the attention of the manager it was recommended that this matter be reviewed. Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 13 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service and their representatives have access to an effective complaints procedure and their views are listened to and acted upon. Policies and procedures are in place, which protects residents from abuse. EVIDENCE: The home provides a complaints procedure, which was seen on display. One complaint has been received by the home since the previous visit, which was actioned by the manager. The home maintains a complaints register, which was seen, in the main reception. All six comment cards received from people using the service stated that staff listen and act on what they say, they are aware of whom to approach if they had a concern and are aware of the homes complaints procedure. One individual commented, “ there is a complaints book and I know I can speak to the manager”. One relative survey received also indicated that they were aware of the homes complaint procedure”. Three people spoken with during this visited stated that were “happy and were satisfied with the care and support provided”. One-person said, “I am comfortable here”. The inspector spoke with one person who said that they would like more support at nighttime, which was bought to the attention of the manager. No referrals have been made under the local authority safeguarding adult from abuse procedures. The company has their own policy and a whistle blowing policy in place. Information was also seen on display as to how to contact
Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 14 agencies, although the manager could not locate the local authority procedure during this visit. It was required that this procedure is obtained and made available ensuring the health, safety and welfare of people using the service. Staff training records were sampled which concluded that staff were receiving appropriate training. The manager and senior carers have attended the local authority safeguarding adults from abuse training. Two members of staff spoken with during this visit confirmed their attendance at this training and were clear as to their responsibilities if they ever witnessed any abuse taking place. Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 15 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, 23 & 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. One matter was identified that needs attention ensuring that people living in the service a well-maintained, clean, comfortable, homely and safe environment. EVIDENCE: The home provides a safe, spacious and comfortable environment, which was well decorated and furnished. Since the previous visit a number of rooms have been refurbished to increase occupancy. Two bedrooms were viewed during this visit, which were decorated and furnished to a good standard and some rooms have a kitchenette. All bedrooms are provided with ensuite showers although one person spoken with said that she was unable to access her shower and this matter was discussed with the manager who said that the company is planning to covert these shower to wet areas as the present showers have a step leading in to them but did not know when this work is to
Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 16 be planned. It is required that the company responds to this matter ensuring that people using the service have accessible showers to use for their comfort. The home also provides three assisted bathrooms. There is well-maintained accessible garden for people to access to which had gazeboes and benches and the manager said plans are in place to purchase new garden furniture. The second floor is accessible by a lift and grab rails are installed. During this visit the home was cleaned to a good standard and no pervading odours were present. A separate utility is available and the laundry assistant stated that she had received training in infection control. Infection control procedures wee in place and staff were observed to be carrying hand disinfectant on their person. Five out of six surveys received stated that the home is always clean and fresh During this visit the inspector was informed that environmental health have visited where one recommendation was made. Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty were adequate to meet the needs of residents. Residents were protected by the homes recruitment policies and procedures and were in the safe hands of the staff that were competent and trained to do their jobs. EVIDENCE: During this visit there was a senior carer, three carers and the registered manager on duty. In the afternoon one senior and two carers are provided with two waking night staff available at nighttime. The inspector was informed that staffing levels would be increased in the afternoon when the home is fully occupied. The home also employs catering, ancillary, administration and a maintenance person. Five ot of six surveys received stated that staff are available when they are needed and one person said sometimes. During this visit three comments were received stating that the home would benefit from more staff, which was also reflected by a health care professional. During discussion with the manager it would appear that there are some staff vacancies including the temporary absence of the deputy manager and two seniors care staff vacancies, which the manager is currently recruiting to. This has resulted in service having to employ agency staff and the manager said she tries to maintain consistency by requesting staff that are familiar to the home. The home also employs staff on bank. Some comments received during this visit state that there does appear to be staff shortages although agreed
Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 18 levels have been maintained. Staff spoken with during this visit stated that the home would benefit from more permanent staff. The company is advised to monitor the staffing levels and to fill the vacant posts with attention being given to employing senior staff to support the manager. The General Social Care Code of conduct is bought to the attention of staff which was confirmed by one member of staff spoken with and was observed in the office. Training records were examined with detailed records and schedules being maintained of staff training that has been completed. This included mandatory training such as first aid, moving and handling, safeguarding adults, infection control and food hygiene the company has a trainer who conducts this training. The home has accessed the district nurses to conduct training in diabetes awareness and is planning training in stoma care. Due to some staff vacancies the home does not presently have fifty percent of staff holding National Vocational Qualifications although the manager provided evidence that a number of staff are being supported accessing the course. Two members of staff spoken with during this visit told the inspector about the training that they have received. New staff receive induction based on the skills for care guidance. A health care professional commented, “the team work well together and professionally”. Staff recruitment is conducted using an equal opportunities policy. The personnel files were sampled for three members of staff. All files contained the required information. The company conducts POVA first checks and obtains enhanced Criminal Record Bureau checks, which were seen on individual’s files. Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 19 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, 33, 35 & 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is able to demonstrate that she has the appropriate qualifications and experience to manage the home, which is run in the best interest of people using the service and their financial interests are protected. The health, welfare and safety of people is using the service is mainly protected with one matter identified needing attention. EVIDENCE: The manager has worked in the service for a number of years and has the appropriate experience and skills to manage the home. The manager has recently completed the Registered Managers Award. There was an open atmosphere and during this visit the manager was observed to make herself accessible. Staff spoken with during this visit felt supported by the manager. One person living in the service commented, “the manager is very
Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 20 approachable” and another comment received stated, “the manager works tirelessly on everyone’s behalf “. The home conducts quality assurance questionnaires, which have been updated and the company also conducts six monthly audits. Outcomes of these audits are published and were seen on display in the reception. The manager stated that the outcomes of the surveys are discussed during resident meetings which are` held regularly. The inspector was informed that the company also carries out audits looking at care plans and medication. The responsible individual completes monthly quality visits and these were available for viewing. The home has a range of policies and procedures, although some are in need of updating and the manager stated that work is in process to address this matter. One member of staff spoken with stated that policies and procedures are brought to their attention. A copy of the Commission for Social Care inspection report was also seen on display for people to be able to view. The home has a policy in place for the protection of resident’s finances. The arrangements for records that are in place were discussed. Monies held on behalf of people were stored securely in a safe with only the manager and office administrator holding the key for access. Expenditure was recorded and receipts maintained with two signatures present and the balance sampled for one individual was correct. During this visit some records and certificates were sampled which identified systems are in place for routine service and maintenance arrangements for the environment. Records sampled included the gas safety certificate, the insurance certificate and records for water temperature monitoring, which is regularly checked and recorded. During a tour of the service substances hazardous to health were appropriately stored and locked away safely and the inspector was informed that an inspection has been conducted by environmental health where one recommendation was made which has been completed. Fire records were examined and it was observed that weekly alarms checks are recorded and fire fighting equipment had been serviced, although It was observed that a fire drill had not be carried out recently. The manager stated that fire training is being carried out shortly and the inspector required that advice be sought from the fire officer about the frequency of fire drills that are to be conducted ensuring the health, welfare and safety of people using the service. Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 21 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 2 X 3 X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP18 Regulation 15(2)(b) 13(6) Requirement Timescale for action 19/07/07 3 OP21 23(2j&n) 4 OP38 16(4)(e) All individual care plans must be reviewed on a monthly basis A copy of the local authority 29/06/07 multi- agency safeguarding adults from abuse policy must be acquired. The company must ensure that 19/07/07 the showers provided in a number of bedrooms which are inaccessible to people be reviewed. A copy of the review and action to be taken with timescales to address this matter must to be forwarded to the CSCI. Guidance must be obtained from 29/06/07 the fire officer as to the frequency of fire drills to be conducted in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations
DS0000036444.V339542.R01.S.doc Version 5.2 Page 23 Stokefield Care Home 1 Standard OP15 It is recommended that the manager reviews the quality of meals provided at weekends Stokefield Care Home DS0000036444.V339542.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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
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