Inspection on 21/02/08 for The Friendly Inn

This inspection was carried out on 21st February 2008.

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

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

Other inspections for this house

The Friendly Inn 29/10/09

The Friendly Inn 06/07/09

The Friendly Inn 19/02/09

The Friendly Inn 17/12/08

The Friendly Inn 31/05/07

The Friendly Inn 15/11/06

The Friendly Inn 26/06/06

The Friendly Inn 14/03/06

The Friendly Inn 16/08/05

The Friendly Inn 08/03/05

The Friendly Inn 24/09/04

The Friendly Inn 17/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Friendly Inn Gloucester Way Chelmsley Wood Birmingham West Midlands B37 5PE Lead Inspector Yvette Delaney Unannounced Inspection 21st February 2008 09:00 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 The Friendly Inn DS0000004561.V356492.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. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Friendly Inn Address Gloucester Way Chelmsley Wood Birmingham West Midlands B37 5PE 0121 779 5128 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) TheFriendlyInnCH@aol.com Mr Michael John Goss Mrs Joanne Shaw Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2007 Brief Description of the Service: The Friendly Inn Care Home is a converted public house. There have been several major extensions to the home over a number of years. The home is registered to accept up to 30 residents in the category of old age requiring personal care. Accommodation is provided over two floors. The home has 30 single bedrooms, of which 29 have en-suite facilities. The Friendly Inn is located in Chelmsley Wood and is readily accessible to amenities such as shops, places of worship and public transport. The home has a number of aids and adaptations to assist any frail residents including, emergency call system, shaft lift, hand and grab rails, a mobile hoist and assisted toilet and bathing facilities. There is a well-maintained garden area at the rear of the building. Parking facilities are available at the front of the building and on-road parking is readily available outside of the home. The Acting Manager advised that the weekly fees for living in the home is £344, top up fees are no longer payable. Additional items such as the services of a hairdresser, newspapers and toiletries are paid for separately. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this home is 1 star. This means that the overall outcomes for residents in this home are adequate based on the information gained during the inspection process. The focus of inspections undertaken by us is upon outcomes for the residents and their views of the service provided. This process considers the capacity of the service to meet the regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. This was the second Key unannounced inspection of this year, which examines all essential aspects of operating a care home. This type of inspection seeks to establish evidence showing continued safety and positive outcomes for residents. The unannounced inspection took place over two days between the hours of 09:15 and 18:30 hours. Since the last inspection in July 2007, a random inspection was undertaken in November 2007. Some evidence of improvement was found during the random inspection. This key inspection visit, showed some further improvement in a number of areas. It was evident that the manager had made some progress in addressing the requirements made at the previous inspections. Further improvements are needed if the home is to meet regulations and national minimum standards recommending good practice. Before the inspection the manager for the home was asked to complete an Annual Quality Assurance Assessment (AQAA) detailing information about the services, care and management of the home. Following receipt of the AQAA, a number of questionnaires were sent out to people who live in the home and their families to ask their views about the home. Twenty questionnaires were sent out to residents and twenty to family members or their relatives. The return was poor and only two relatives returned their questionnaire. Information contained within the AQAA and questionnaires is detailed in this report where appropriate. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 6 Two people living in the home were identified for close examination by reading their care plans, risk assessment, daily records and other relevant information. This is part of a process known as case tracking and where evidence of the care provided is matched to outcomes for the residents. Other records examined during this inspection, include staff recruitment records, training records, social activity records, staff duty rotas, health and safety records and medication records. The homes manager was present throughout the inspection and the inspector was able to tour the home, spend time speaking with residents, six visitors and staff. An ‘expert by experience’ accompanied the inspector on part of this visit. This is someone who has experience of care services themselves. The expert by experience takes the opportunity on the inspection visit to talk to residents, visiting families and staff. Findings in this report are also based on the persons’ observation of the interaction between people who live in the home and staff. Their findings are also included in this report and used as evidence when deciding on the quality of service provided at the home. What the service does well: Comments received in questionnaires from family members and speaking to residents in the home expressed what they felt that the home does well. These include: “Provides a happy and safe environment for people unable to live in their own home. The residents are also treated with the utmost dignity and the carers seem to be very supportive of each other.” “This home in my opinion gives an excellent service to the residents. It is staffed by hardworking dedicated people who are always willing to listen.” “I never thought that I would see my relative in a care home and so well settled.” The care files showed us that a full pre-admission assessment was undertaken and the needs of each person were recorded. Each person also had a social service assessment and initial care plan. This is good practice and shows that individuals wishing to use this service are assessed before being offered a place in the home. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Although improvements are being made in this home, there remains a lot of work to do to maintain standards in the home by ensuring that all requirements are addressed. Care plans show some improvement but progress is slow. To ensure that they are sufficiently detailed and updated to reflect the current care needs of people living in the home in a timely manner the following need to be done: • The acting manager with support from the provider must put a system in place, which will help to quickly update all the care plans of residents living in the home. This will ensure that all staff have information available to them, which will support them in providing appropriate care to all residents. Staff should be trained on how to develop a care plan and keep it updated. This will ensure that people who live in the home have an updated care plan at all times and receive timely and appropriate care, which reflects their current care needs. • Risk assessment documentation used in the home need to be reviewed to ensure that the criteria used will allow staff to make an appropriate The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 8 judgement of the level of risk a resident could be exposed and the action staff need to take if any to reduce the risk of harm. Areas related to the risk of cross infection need to improve. Areas to be addressed are the poor standards maintained in the kitchen and laundry areas of the home so the residents are not at risk of cross contamination. Staffing levels should be reviewed to ensure that sufficient numbers are on duty at all times. Attention should be given to peak times of activity in the home, which includes mealtimes and where two members of staff are required to meet a residents’ care needs using appropriate and safe practice. This will ensure that residents care needs can be met safely at all times. 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. The Friendly Inn DS0000004561.V356492.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 The Friendly Inn DS0000004561.V356492.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 and 3. Standard 6 does not apply, as the home does not admit residents who require intermediate care. Quality in this outcome area is adequate. People do not have current up to date information about the services offered by the home, so they can make an informed choice about moving into the home. People who are considering moving into the home benefit from having their care needs assessed so that they can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the Statement of Purpose and Service User’s Guide. Some residents or their relative have a copy of the document. The documents were examined and found to need updating. The document still contains the name of a manager who has not managed the home for some years. The details provided on the number of senior care staff working in the home and the number of stated to be on duty for some of the shift patterns is incorrect. These observations are based on information received in the AQAA and records examined in the home. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 11 A comment from a relative in a questionnaire received by us they state that: “This (Complaint Procedure) was explained to us before…(Resident) went into the home. The manager called upon us to explain everything and also left us with a brochure about the home and everything that we needed to know.” Each resident has a copy of the terms and conditions for living in the home; these are signed and dated by residents. Signing this document confirm that the resident and/or their representative accept the terms and conditions for living in the home. Two care files for people using this service were examined to determine if the information required to ensure that the service can meet their needs is carried out. The care files showed us that a full pre-admission assessment was undertaken and the needs of each person were recorded. Each person also had a social service assessment and initial care plan. This is good practice and shows that individuals wishing to use this service are assessed before being offered a place in the home. The expert by experience who visited the home with the inspector asked several residents about their choice of home and why they chose the Friendly Inn. Three residents said they did not have a choice as they came straight from hospital, one said she had been at the Friendly Inn for respite care and liked it so she decided to live in the home on a permanent basis. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 Quality in this outcome area is adequate. Care plans for some residents show improvement and provide staff with guidance on aspects of resident’s care needs this should result in appropriate care being given, but not for all residents. The privacy and dignity of residents are not maintained at all times, which could affect their quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection, there were 26 elderly male and female people living in the home. Two residents were identified to be involved in the care tracking process. The quality of the written care plans shows some improvement. The manager is making a lot of effort to update and improve care plans for each person living in the home. However, one person reviewing and updating the care files and plans for all the people living in the home is making this a slow process. This will not ensure that the care plans are at the stage where they can be updated as and when changes occur, which for some residents may be more than monthly. Getting the care plans to this stage will make sure that they reflect each residents current care needs and will support care staff to provide appropriate and safe care. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 13 The two care plans examined had been updated to contain more detail to tell staff what action they need to take to meet the needs of each person. The care plan of one person recently admitted to the home was examined; the contents showed that they had a pre-admission assessment carried out in hospital before being admitted to the home. The information was used to help write their plan of care. The care plan detailed the level of support the resident needed to help them meet their care needs. For example, the plan identified that the support of one carer was needed to help the resident meet their personal hygiene needs. The information detailed what the resident is able to do for themselves and whether prompting or encouragement was need. The pre-admission assessment for the same resident had identified that the they were unable to mobilise independently. Reading the care plan it was evident that the residents’ mobility had improved and they were now able to mobilise around the home unaided. The risk assessment and care plan had not been updated to show this change in the residents’ ability and therefore a change in their care needs and how the staff should meet these needs. Another resident was receiving oxygen, needed to support them in their daily life. The care plan identified that the resident knew how to use the oxygen equipment. The care plan was informative but did not provide information for staff on ensuring the safe use of the equipment. For example, there were no details about the need to keep the oxygen equipment and tubing clean to prevent the risk of infection. The resident had two portable oxygen cylinders; both were in use, which would mean that there would not be a spare cylinder in case of an emergency. Risk assessments, which include assessing risks, related to pressure areas, falls, mobility and nutrition were available for both people. The risk assessment forms used did not in all cases contain suitable criteria to ensure that a full and appropriate risk assessment is completed. For example, this includes the assessment for determining the residents’ risk of falling. If risk assessment are not fully completed and the criteria used for the assessment is not comprehensive the home cannot be sure that all staff respond in the same way to reduce the risk of residents being injured or harmed. Entries in the resident health records and comments by people living in the home confirmed that they are supported in getting access to relevant health care professionals when needed. This includes access to GP, Chiropodist, Community Psychiatric Nurse and Optician. Family members confirmed that they are kept up to date about anything that affects their relative. “…(Resident) was taken into hospital after a fall…. I received a phone call immediately …(Resident) had left in the ambulance.” “ I am always contacted immediately day or night.” The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 14 The Expert by experience observed and talked to residents about the care they received in the home and reported. A hairdresser comes once a week and the ladies enjoyed this opportunity to have their hair done. Most of the ladies and gentlemen, living in the home, there are three gentlemen and twenty-three ladies looked generally clean and well cared for. One lady’s clothes however, were not clean. The residents blouse looked grubby and there were signs of food stains on the front, the collar also looked dirty. Many of the ladies were in need of having their fingernails cut, several had broken and dirty nails. One resident told the ‘Expert by Experience’ that they had been living in the home since December and that their relative came and gave them a shower and washed their hair. The resident was asked if staff did this and they said “only twice since I have been here”. This information had not been included in the residents care plan as part of their personal care routine. The inclusion of this information in the care plan would show that it had been discussed with the family and resident and a choice that they had made. It was observed by the expert by experience that a resident eating their lunch in the lounge was using a suitable low-level table, but was having difficulty eating without dropping food down their clothes. Staff had not provided any protection for their clothes. Helping the resident to place a napkin may have helped to prevent this and support the resident to maintain their dignity and keep clean. The Expert by Experience said that staff were friendly and respectful; to residents and staff appeared happy in their work. Staff were seen to speak to residents in a friendly way but they did not appear to have time to sit and ‘chat’. A comment received from a family member about the care their relative receives said: “I feel my …(Resident) is very well cared for and is in safe and comfortable surroundings.” The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. Open visiting arrangements encourage regular contact with relatives and friends. The food is not well prepared or cooked to maintain its nutritional content. Social and recreational activities do not occur often enough to meet the full needs of all residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Expert by Experience spent 4½ hours at the home and was able to meet and speak to four visitors, who were all very pleased with the standard of care their relatives were receiving. Observations during the day, information and records examined provided a picture of the daily life for residents living in the home. There was no evidence of activities for the residents only the TV and hairdressing and once a month a gentleman visits to engage the residents in a singsong session. Supporting the residents to get involved in activities is part of the role of care staff. It was evident from the number of staff on duty and from duty rotas, that there are insufficient care staff to take this role on. A resident spoken with able to talk about some of the activities and events which The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 16 take place in the home but she said that there was not ‘much’. A relative commented on the Christmas 2007 festivities in the home, saying, “The Xmas festivities laid on (family included) were spectacular. The Xmas decorations including 6 Xmas trees (large) the best I have seen.” A number of residents are supported to continue their involvement in the community. Talking to residents the expert by experience was told that one person attends a day centre locally and enjoys this; another person goes out to a bingo club once a week. Most of the ladies and gentlemen were observed to be reasonably able. An increase in activities could be a welcome change for them, giving both mental and physical stimulation, especially if they were encouraged to pursue hobbies or new interests. One of the lounges in the home is rarely used. This area would make an excellent activities room if there was better lighting. Activities such as ‘film nights’ could be suitable to take place in this room. The use of this room was discussed with the manager. Some of the garden area has been used for extending the Home, with building work on going, the weather on the day of the inspection made it is difficult to confirm how much garden will be available once the work has finished. A patio area was furnished with wooden furniture ready for the summer months. Family members commented in questionnaires received by us that the home helps their relative to keep in touch with them. “I normally visit every day but on the rare occasion that I don’t, on of the staff will phone me if requested to do so by my…(Resident).” “My…(Resident) has a mobile phone by…(Resident) bed and I am able to communicate with...(Resident) even after visits. One of the carers always makes sure…phone is charged. … (Resident can also phone me or my husband with their (Staff) help.” The main meal on the day of inspection was roast chicken, cabbage, carrots, mashed potatoes and gravy, or two thick slices of corn beef (cold) with cabbage, carrots mashed potatoes and gravy. All meals were served with gravy residents were not given a choice. The pudding was sponge with custard. The expert by experience viewed the kitchen during her visit and found the cabbage already cooked at around 11am and was informed that the chicken was cooked first thing that morning and had been cut up ready to serve. The lunch was not served until 12.30/1.00pm. The main complaint received from residents about food was that there was too much. Other concerns about the meal were that the cabbage had been cooked for so long it had lost its entire colour. Gravy put on cold corn beef did not look appetising and the plates were piled high with food. Cooking and leaving the food for so long before the meal is served, means that it will have to be reheated and encourages the risk of bacteria. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 17 In the dining room some of the dining room tables are placed against a wall, the chairs are on one side, which means that residents using these tables are looking at a wall whilst eating their meal. This does not encourage social interaction between residents at mealtimes. However, this may be a temporary arrangement due to the main office being out of action and part of the dining area being used for an office. Chairs in the dining room are wooden and most residents have a cushion to sit on. The cushions are not suitable and these slip and slide, which could cause a resident to slip off chair. A menu board is not available care staff said that they go around all residents each day and ask them what they would like to eat. There are two choices for lunch on most days, except Sundays and Wednesdays when only a roast dinner is provided. Fresh fruit was offered to residents in the afternoon. The dining room tables are very good but there were no table clothes or napkins used to improve and enhance the social environment. Plastic mugs were used for cold drinks with lunch, these can be seen as not age appropriate and institutionalise the atmosphere and life in the home. Assessments did not show that residents had been assessed as only able to use plastic cups. Crockery available was a mix of patterns and type and looked well used, cutlery was very mixed and nothing matched. On the day of inspection there were seven residents eating their lunch in their bedroom, this was their choice. The expert by experience visited one of the residents. One of the staff asked the resident if they wanted their meal on a small low table near their chair or on their lap. The resident chose to have their meal on their lap. Several tables are available in the home that can be used to go up to an armchair, or a suitable lap tray could have been used. A cold drink for this resident was placed on the small table; this was not easy for the resident to reach. The member of staff had not taken into consideration that this was a hot meal; the bottom of the plate could be too warm or if the meal was spilt could harm the resident. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. People have access to the information they need to complain and know who to talk to if they have any concerns. The adult protection procedure and staff awareness of the procedures reduces the risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed in the reception area of the home. Copies are also available in the Service User Guide. Residents and relatives spoken with said that they were aware of how to complain and whom to complain to. Comments made include: “I have never had the need to raise a concern.” The manager confirmed that one formal complaint has been received by the home since the last inspection. The concerns raised in the complaint were about the state of the bedroom that was allocated to resident being admitted to the home for respite care. Some of the concerns raised by the complainant related to the state of the room includes: “The room was filthy. The carpets were very marked and dirty, the walls were dirty, light switches had not been cleaned and the bathroom was not clean.” The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 19 The complainant went on to describe other concerns about the alternative room offered and the poor attitude of staff on duty at the time of admission.” The resident only stayed in the home for one night and did not complete their full stay. The records for this complaint were examined and showed that it had been appropriately investigated. We have received a number of complaints related to care, the environment and daily life in the home. These issues have been examined during the inspection year. The complaints received have been anonymous, which makes it difficult to confirm the events and prove or disprove them. The policy and procedure detailing the action to be taken by staff to ensure the protection of vulnerable adults were examined. The information guides staff on the procedures to follow if they saw or suspected evidence of abuse Staff were able to confirm that they had attended training related to the protection of vulnerable adults. Two members of staff were able to explain the action they would take if they saw abuse. Both answered appropriately. Training records examined indicates that protection of vulnerable adults training had been received by staff in 2007. There have been no incidents referred to the adult protection team for further investigation. The expert by experience reported that she had not seen any evidence of abuse, verbal or otherwise on the day of inspection. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22,23, 24, 25 and 26 Quality in this outcome area is poor. The standard of the environment is not consistently well maintained to provide a safe and homely place for people to live. Practices do not ensure that the standards of hygiene are maintained and that people living in the home are cared for in a safe and clean environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The tour provided the expert by experience and the inspector with the opportunity to view the home and see whether any changes had been made to improve the environment. A number of the views expressed below are as seen through the eyes of the expert by experience the outcomes were observed by the manager for the home and us. We noted the following: The Friendly Inn is a converted Public House, there have been several major extensions carried out over a number of years. The extension being carried The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 21 out is to enlarge the office and bedrooms. It was evident that every effort is being made to ensure residents are not disturbed more than is necessary. Some of the rooms are near completion and were viewed these look suitable and would give good additional space for residents occupying these bedrooms. One resident who would benefit from the addition of the extension was looking forward to the changes. The home was mainly clean and fresh but two bedrooms visited had a strong smell of urine, which could affect the wellbeing, privacy and dignity of residents if action is not taken to control the odour. Some bedrooms were not well presented. Bed linen looked as if it had not been ironed. This made rooms look untidy. One of the bedrooms visited was furbished with some of the resident’s own possessions. This person had brought in their own bedspread, which helped to make the room look homely, tidy and well presented. Some bedroom doors were left open even if residents were not in them. One resident said that they locked their bedroom door and was seen to do this when going to the lounge or dining room. Several of the bedrooms visited had curtains were hooks had come undone and pelmet hooks required fixing. This made the rooms look untidy. In two bedrooms visited, the toilets had not been flushed. These were en-suite, which mostly comprised of hand basin and toilet; some have showers but these do not provide level access. This means that residents are not able to walk straight into the shower but have to step up. Part of the building work presently taking place in the home includes building a shower room/wet room on the first floor of the building. The home is lit using low energy bulbs, but using these, many of these are not suitable for the lampshades in use. The bulbs were too big for the lampshades and this made the lighting very poor. Handrails have been installed on most corridors. There is only one banister rail on the stairs. If residents are walking down the stairs, there is no rail for them to hold onto. The banister rail available is approximately six inches wide and not easy for residents to grip. There is a good size lift with a hold button for staff to use in an emergency. The inside of the lift was clean and fresh. There are two lounges, the main lounge is bright and pleasant, and there is a pet bird in a nice cage, which several of the residents enjoy talking to. This is clean with no mess on the floor. A small area leading off the main lounge has a large fish tank containing tropical fish, this area does not appear to be used, there is a library of books and two armchairs where a couple of residents could sit quietly. This area would not be very comfortable as the area is used to store wheelchairs. Armchairs are in reasonable condition, some residents use cushions to make them more comfortable. There are several folding type small tables, which do The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 22 not appear very substantial, and two wooden glass topped coffee tables, which are not in good condition and one wooden table. The outlook from this lounge is pleasant, and residents used this lounge during the inspection in preference to other areas. The second lounge looks comfortable and is located in the newest part of the building but is rarely used. The lounge is furnished; some chairs looking well used others new. There is an organ and a music centre in a wooden cabinet, which is well worn. The lighting in this room is very attractive but there is only one window area and the level of lighting makes for a very dark room. There is a very large flat screen TV, a round table, and four wooden chairs. The carpets throughout the home appear in good condition. The floor in the kitchen, laundry room and sluice room as described below are either dirty or badly worn. There is a small room near the laundry room; dirty washing bowls and commode pots were stored on the floor. The sink was not clean and it has a worn wooden edge, which means that it, is open to bacteria. Care staff do the laundry in the home and as previously discussed there are not sufficient staff on duty at any one time to undertake additional duties. The time available would not allow staff to ensure that the laundry was completed to a high standard. The laundry room is small; two washers with tumble driers above. The room was not clean and organised. There was dirty washing on the floor and clothes that have no number or name in are pushed in a corner at the side of the tumble drier. Some of the clothes are sorted, washed and put into small baskets, which have the room number or name on the front. Clothes that have been ironed or require to be hung up are put onto a clothes rail. There was evidence of a cardigan having been washed at the wrong temperature and as a result had shrunk. The floor in the laundry is not very clean and in badly worn in places. There were insufficient washing baskets to put dirty washing in and to put items not marked in. The ironing board cover was worn and burnt, the sink was not clean and two worn and dirty scrubbing brushes were in the sink. As noted in the kitchen there was a large bin in the laundry for rubbish, which did not have a lid. Observations made in the kitchen by the expert by experience noted that pots and pans, frying pans and a roasting tin were well worn, one roasting tin had years of baked on grease. The coating on frying pans, which had been nonstick, was worn away. Crockery available was a mix of patterns and type and looked well used, cutlery was very mixed and nothing matched. A bin in the kitchen was used for rubbish and had no lid on it. The draw front in one of the kitchen units was missing another draw was piled high with The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 23 cooking utensils and cupboards were in need of being washed down, some looked marked. The kitchen floor had several taped areas because of the damage to the floor. A number of dishes were stored at the side of the oven on the floor. Kitchen staff said that these were used for buffet meals. These dishes also looked old and well worn. These practices and the state of kitchen equipment and utensils in the home do not support good food hygiene in the home. The owner of the home advised that he does plan to refurbish the kitchen. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 24 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 and 30 Quality in this outcome area is adequate. The number of staff on duty is not sufficient to meet the needs of people living in the home at all times of the day. The majority of staff are qualified and have attended Mandatory training, however, staff have not received up to date training related to the care needs of people living in the home. Residents cannot be sure that care provided will meet their assessed care needs. Staff recruitment procedures are robust to ensure residents are protected from the risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection, there were 26 residents living in the home each with varying levels of dependency. There was 3 staff on duty to meet the care needs of residents. Two care staff and a senior carer, who was also responsible for administering resident’s medication. The acting manager was also on duty. The owner of the home was present in the home. There was not sufficient staff on duty on the day to provide the level of care needed and undertake other duties such as the laundry and activities for residents. Staff working in the home were observed to be caring and supportive to residents and positive comments were made about staff these include: The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 25 “Have found the staff at Friendly to be very co-operative in every aspect. Nothing is to much trouble.” Information in the AQAA and records examine showed that 67 of the care staff employed in the home have completed a National Vocational Qualification (NVQ) level 2 or above in care. Training records were available for examination. These showed that staff had received some training in 2007. Training received by staff includes moving and handling training, fire and protection of vulnerable adults. Staff spoken with were able to confirm that they had attended some training mainly related to mandatory training requirements. Evidence that staff have been able to access training related to the care required by the people living in the home, such as care of people on oxygen, diabetes, dementia was not available. Information available on the induction process shows that it is linked to the common induction standards developed by the Skills for Care Council. A review of three staff files confirmed that recruitment practices for the home have improved. Staff files contained evidence of protection of vulnerable adults (PoVA) checks and Criminal Records (CRB) checks and appropriate references are on file. This is good practice, which will help to ensure that staff employed in the home are considered safe to work with vulnerable elderly people living in the home. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. A person who has the required experience manages the home. The welfare and well being of people living in the home are not consistently protected and safeguarded, which could result in risk from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager has been working in the home for sometime, she knows the home well due to working in the home as a carer. The acting manager has completed a National Vocational Qualification level 3 in care and is experienced in the care of the elderly. She is currently undertaking the ‘Registered Manager’s Award’ and has completed and application with us to be the Registered Manager for the home. It is not known she will officially be given the title of manager. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 27 The acting manager has started to put in place systems to monitor the quality of the service provided by the home. Questionnaires have been developed to determine the views and opinions of residents and relatives. A number f the completed questionnaires were seen and read. Most of the information was positive but there was no evidence to show that the questionnaires had been analysed and the outcome used to make changes for the benefit of residents. The owner of the home who is also the registered responsible individual confirmed in a report read that he visits the home most days. A record is maintained of the dates he visits but there is no evidence of conversations held with residents, relatives or staff. This will help the provider to monitor the services provided in the home and determine whether the home is run in the best interests of the residents. Systems for the safe keeping of monies to safeguard residents’ financial interests are good. Records seen are appropriate and receipts and written records of transactions are kept. Information included in the AQAA and records examined on the day of the inspection evidenced that maintenance and servicing work is carried out in the home. Records were accessible and had been maintained, since the last inspection visit. Records examined for checking the safety of electrical equipment used in the home showed that they have been tested. Water temperatures in resident areas have been checked. Chlorination of water and testing for the prevention of Legionnaires has been an outstanding requirement from previous inspections; this work has now been carried out and a copy of the report shared with us. Safe practices were not observed at all times in the home. These practices have been discussed in this report and are related to care, the environment and health and safety issues these include: • Wheelchairs in use in the home had not been maintained to ensure they are suitable and safe for residents use. There was only one wheelchair seen with footrests in place. One wheelchair had worn arm pads and residents needing wheelchairs to assist their mobility where moved about the home without footrests. Several of the residents had Zimmer frames or walkers that were in reasonable order. Footrests for wheelchairs were found stored in an area of the home. Residents’ personal care needs were not thoroughly completed to ensure their fingernails are clean. This increases the risk of cross infection, which could affect the health and wellbeing of people living in the home. Oxygen equipment in use was not clean. This increases the risk of cross infection, which could affect the health and wellbeing of people living in the home. DS0000004561.V356492.R01.S.doc Version 5.2 Page 28 • • The Friendly Inn • • Electric cables were trailed across a bedroom floor presenting the risk of someone falling through tripping over the cables. Low energy light bulbs in use in residents’ bedrooms were not suitable for the lampshades. The bulbs were too big and touching the lampshade, which could present a fire hazard. The standards of cleanliness and maintenance in areas of the home, which includes the kitchen and laundry, were not good. This presents a risk to resident’s wellbeing. • Disinfectant and washing products were stored on the floor in the laundry and not locked away, which could present a risk of harm to residents living in the home. A full size electric scooter belonging to one of the residents is stored in a recess by the stairs, with some wheelchairs. There was a bundle of what looked liked dirty sheets left in this area. The very early preparation and cooking of the meal planned for lunch meant that it was over cooked, left standing and needed to be re-heated. This practice puts the food at risk of contamination and puts residents at risk of cross infection. Observations made in the kitchen by the expert by experience noted that pots and pans, frying pans and a roasting tin were well worn, one roasting tin had years of baked on grease. The coating on frying pans, which had been non-stick, was worn away. A bin in the kitchen was used for rubbish and had no lid on it. The draw front in one of the kitchen units was missing another draw was piled high with cooking utensils and cupboards were in need of being washed down, some looked marked. The kitchen floor had several taped areas because of the damage to the floor. A number of dishes were stored at the side of the oven and on the floor. Kitchen staff said that these were used for buffet meals. The dishes also looked old and well worn. • • • These practices and the state of kitchen equipment and utensils in the home do not support good food hygiene practices. This could affect the wellbeing of residents and lead to the spread of infection throughout the home. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 2 3 2 2 1 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 30 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 OP7 Regulation 15 Requirement Each person living in the home must have a plan of care, which is sufficiently detailed and updated to reflect his or her current care needs. This will ensure that they receive person centred and appropriate care, which meets their needs. Care plans must provide staff with information on how to meet the care needs of people living in the home. This will ensure that people receive person centered care. Care plans must support any changes made to prescribed medication. This will ensure that people who live in the home receive person centred care. Not assessed, at this inspection previous date 26/06/07. Risk assessment documentation used in the home must be reviewed to ensure that the DS0000004561.V356492.R01.S.doc Timescale for action 30/06/08 2 OP7 15 30/06/08 3 OP7 15 30/06/08 4 OP8 13(4) 30/06/08 The Friendly Inn Version 5.2 Page 31 criteria used will allow staff to make an appropriate judgement of the level of risk a resident could be exposed to and the action staff need to take if any to reduce the risk of harm: • Particular attention must be given to risk assessment used to determine the risk of residents falling. The home can then be sure that any action necessary to reduce the risks to residents of harm is taken. The home must install a quality 30/06/08 assurance system to assess and confirm staff competence in medicine management. This will ensure the safety of people using the service. Not assessed, previous date 26/06/07. 30/06/08 Systems must be further reviewed to ensure that all new medication is safely received into the home. The systems must include two members of staff receiving and receiving all medication received in the home. This will ensure that people living in the home are not put at risk from harm. Not assessed, previous date 26/06/07. A second member of staff must 30/06/08 check all directions hand written on the medicine chart. This will ensure the accuracy of the directions recorded on medicine charts and the safety of people living in the home. Not assessed, previous date 26/06/07. All Controlled Drug (CD) transactions must be recorded in the CD register and witnessed by DS0000004561.V356492.R01.S.doc 5 OP9 13(2) 6 OP9 13(2) 7 OP9 13(2) 8 OP9 13(2) 30/06/08 The Friendly Inn Version 5.2 Page 32 9 OP9 13(2) 10 OP15 13(3) 11 OP25 13 12 OP38 13(5) a second member of staff. This will ensure that people living in the home are not put at risk from harm. Not assessed, previous date 26/06/07. People living in the home who wish to administer their own medicines must be suitably risk assessed as able and all compliance checks documented. This will ensure the safety of the residents from the risk of harm. Not assessed, previous date 26/06/07. Resident’s meals must not be cooked so far in advance of the planned mealtime so that the food is left standing for a long period before it is ready to be served. This will help to prevent the risk of infection due to the contamination of food. All light fittings must be checked to ensure that light bulbs are safely fitted in resident’s bedrooms and the lampshade used is appropriate for use. This will protect residents from the risk of harm. Safe care practices related to moving and handling must be used at all times. This includes: • Residents must be transferred in wheelchairs safely. Footplates must be fitted to wheelchairs. • Risk assessments should be completed for residents who request not use footplates when using a wheelchair. These practices could result in injury to residents if not carried out appropriately and safely. The flooring in the kitchen and laundry must be reviewed and risk assessed to ensure it does DS0000004561.V356492.R01.S.doc 30/06/08 28/02/08 28/02/08 28/02/08 13 OP38 13 31/05/08 The Friendly Inn Version 5.2 Page 33 14 OP38 13 not present a health and safety risk to staff working in there or residents who may enter the kitchen. The standards of health and safety management within the home must be improved. This must include: • Disinfectant and washing products must be stored in a locked cupboard/room. The standards of health and safety management within the home must be improved. This must include: • Dirty laundry must not be put on the laundry floor or placed in inappropriate areas around the home. Appropriate bins with lids should be used in the laundry and kitchen areas of the home to prevent the risk of infection from contaminated material. Suitable kitchen equipment, utensils and crockery must be available for use by residents to prevent the risk of cross infection. Utensils and crockery used in the kitchen must be appropriately stored to prevent the risk of cross infection. All areas of the home must be kept clean. Areas to be addressed include the kitchen and laundry areas of the home. 28/02/08 15 OP38 13(3) 28/02/08 • • • • This will ensure that people who The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 34 use the services live in a clean home and have their health, safety and welfare protected. 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 and Service User Guide should be updated and available in alternative formats. This will ensure prospective residents have all necessary current information to enable them to make an informed decision about using the home. To support the quick and timely update of care plans consideration should be given to the resources required to support the staff to undertake this task. This should include: Additional support for the manager. Accessing training for all staff on how to develop and write a care plan and keep the plan up to date. This will ensure that people who live in the home have an updated care plan at all times and receive timely and appropriate care, which reflects their current care needs. The support needed by residents at mealtimes should be assessed so that the need for any additional equipment or aids to help them eat their meal in a way, that maintains their dignity is identified. The use of discreet and suitable napkins should be reviewed. Care and attention should be given to residents clothing and fingernails to ensure that they are clean. This will protect residents from the risk of cross infection and support them to maintain their dignity. Residents should be consulted about a programme of activities that takes into account individual and group needs. Records of social and therapeutic activities should include the residents’ views on the activity and whether they enjoyed this or were satisfied with the outcome. This will ensure mental and physical stimulation is provided, which meets resident’s individual needs. Evidence should be available to show how residents are supported to exercise choice in their day-to-day life. This should include choice of meal, gravy and other condiments DS0000004561.V356492.R01.S.doc Version 5.2 Page 35 2 OP7 3 OP10 4 OP10 5 OP12 6 OP14 The Friendly Inn 7 OP14 8 OP15 9 10 OP15 OP15 11 OP15 12 OP19 13 OP20 14 OP21 15 16 OP22 OP22 available on the table and the chose of activities. This will support residents to maintain their independence. The home should consider if forming a relatives/residents forum would be in the best interests of people living in the home. The forum would provide feedback on positive comments or concerns to the management team. The support needed by residents at mealtimes should be assessed so that the need for any additional equipment or aids to help them eat their meal safely and in a way is identified. The use of suitable armchair level tables should be reviewed. Menu’s should be planned to ensure that residents are offered nutritious and suitable meals at all times, which will help to promote their wellbeing. Dining tables should be dressed at mealtimes with suitable table clothes and napkins, this will help to promote residents comfort, appetite and social interaction in a relaxed setting. The cooking ability of the cook should be reviewed to ensure that they practice safely and are able to cook a nutritious, appetising and tasty meal which is well balanced and based on the needs of the residents. Training should be provided if needed. This will help to improve the quality of life for people living in the home. Details and plans for ongoing refurbishment in the fabric of the home, updating of the décor and replacement of furniture should be maintained in the home. This will ensure that residents are living in a homely, attractive and well-maintained home environment. All furniture in communal areas should be fit for purpose and in a good state of repair. This should include a review to check the suitability of the chairs provided for residents in the dining room. To ensure that residents are able to sit comfortably and are not in danger of slipping off the chair. A review of the bathing facilities should be added to the ongoing maintenance and refurbishment programme for the home. This will ensure that there are suitable bathroom and shower facilities on each floor, which are easily accessible by people living in the home. Suitable banisters should be fitted along the stairs, to assist all residents to be able to hold and grip the banister safely if they are able when going up or down the stairs. An ongoing programme for the regular maintenance and servicing of wheelchairs used in the home should be implemented. This will help to ensure that wheelchairs are safe to use at all times. DS0000004561.V356492.R01.S.doc Version 5.2 Page 36 The Friendly Inn 17 OP24 18 OP26 19 OP26 20 OP26 21 OP26 22 23 OP26 OP26 24 OP27 25 OP30 26 OP31 Support should be given to help residents maintain tidy, clean and well-presented bedrooms. Bed linen should be suitable laundered so they are not creased. Curtains and blinds should be hung correctly. This will help to improve residents’ quality of life and promote a sense of wellbeing. The condition of the kitchen should be reviewed with a view to a complete refurbishment. This will promote the wellbeing of residents protect them from risk of harm and so increase their quality of life while living in the home. A review should be carried out of kitchen equipment, the crockery, plastic cups, kitchen utensils, pots and pans to ensure that they are suitable and in good condition to be used for the preparation and serving of food and promotes the health and wellbeing of people who live in the home. Practices carried out in the laundry and kitchen areas of the home should be monitored and audited to ensure that safe practices are maintained at all times. This will ensure that residents are living in a clean and healthy environment, which promotes their health and wellbeing. A review should be carried out of the organisation, procedures and equipment used in the laundry to ensure that safe practices can be maintained by care staff when undertaking laundry duty. This will help to ensure residents’ clothes are appropriately laundered, promoting their wellbeing and that residents are living in a clean, safe and healthy environment. Procedures should be in place to control unpleasant odours in the home. This will promote the quality of life for residents living in the home. A washing machine with a sluice cycle should be purchased when the existing washing machine in the home needs to be replaced. This will ensure safe cross infection procedures are maintained. Staffing levels should be reviewed to ensure that sufficient numbers are on duty at all times. Attention should be given to peak times of activity in the home, which includes mealtimes, and the involvement of staff in domestic duties. This will ensure that residents care needs can be met safely at all times. All staff must receive training appropriate to the health; personal and health care needs of the people in their care. For example: Management of residents who are dying. Dementia care and Food hygiene. This will ensure the safety of people who live in the care home, that staff are trained, and competent to meet their care needs. The Registered Manager must ensure that practises and procedures carried out in the home are monitored. This will promote and support the health, safety and wellbeing DS0000004561.V356492.R01.S.doc Version 5.2 Page 37 The Friendly Inn 27 OP33 28 OP33 29 OP33 of residents living in the home. When seeking the views of people living in the home on the services provided, the manager should consider using advocacy services to support residents to complete questionnaires. The registered provider should document details of the outcome of his visits to the home, which show evidence of monitoring the quality of service provided and confirms that the home is run in the best interests of the residents. An action plan should be produced from the outcome of any survey results produced in the home. The results of service user surveys should be shared with people who use the service. This will support improving the service delivered to people using the home. The Friendly Inn DS0000004561.V356492.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection West Midlands Office 3rd Floor 77 Paradise Circus Queensway Birmingham B1 2DT 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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