Inspection on 13/05/05 for Tregothnan Retirement Home

This inspection was carried out on 13th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Tregothnan Retirement Home 05/11/09

Tregothnan Retirement Home 29/12/08

Tregothnan Retirement Home 15/11/06

Tregothnan Retirement Home 24/11/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Tregothnan Retirement Home 112 Balmoral Road Morecambe Lancashire LA3 1ST Lead Inspector Joy Howson-Booth Unannounced 13th May 2005 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 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. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Tregothnon Retirement Home Address 112 Balmoral Road, Morecambe, Lancashire, LA3 1ST Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01524 412259 Thackray Care Services Ltd Mr Robert Thackray CRH Care Home 13 Category(ies) of OP Old Age 13 registration, with number of places Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The organization must at all times employ a suitably qualified & experienced manager who is registered with the Commission for Social Care Inspection. 2. The registered manager must achieve the Registered Managers Award by 2005. 3. Radiator covers must be installed on all radiators in the home by 31 March 2005. 4. The home is registered for a maximum of 13 service in the category OP (Older Persons). Date of last inspection 7.10.04 Brief Description of the Service: Tregothnan Residential Home is situated on one of the main roads leading into the West End of Morecambe in a fairly quiet residential area, close to local shops and amenities. There is a ramp leading up to the side of the front door for use by wheelchair users, but there is still a small step to enter the front door. The home is a Victorian terrace built over three floors, accessible by a passenger lift. Four of the bedrooms have an ensuite facility and, for the remainder, a bathroom/toilet is within easy reach. There are communal areas including a small roof terrace, dining room and lounge. There are toilets on all floors, accessible by residents. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over two days by two inspectors from the Commission who inspected against the National Minimum Standards. There were 13 residents in the home, and, as well as speaking with a number of these residents, the three staff on duty throughout the day and the registered manager were also spoken with. Three care plans were examined, along with other documentation including medication administration records and healthcare records. Staff records were also examined. Two comment cards were received. All the residents spoken with or who responded via the comment cards said that they liked living at the home and felt well cared for, with the staff treating them well and providing care with privacy and respect. From discussions with the members of staff on duty it was found that they feel supported and the home is well managed. The inspection lasted for approximately 8 hours. What the service does well: Tregothnan is a small home, run as a family business with friendly and caring staff that are managed by a dedicated and experienced manager. The home has achieved the Investors in People Award. A number of staff have worked at the home for sometime and know the residents well. The manager is very keen to ensure that the residents know this is “their home” and responds to individual needs and requests. There was a very good atmosphere in the home with the residents and staff seeming to get on well together. Residents are able to maintain their own lifestyles and routines with support being provided in a sensitive and positive manner. Comments from the residents included “we have very good care”, “if anyone has any complaints then they are wrong”. Staff continue to receive support and leadership, with a positive approach to doing training, particularly the National Vocational Training. National Vocational Training enables staff to be provided with formal training in a range of care practices and at the same time their level of capability in these areas assessed. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 6 The owner/manager is expecting to achieve the Registered Managers Award by the Autumn of this year. The Registered Managers Award is a formal training programme which teaches a range of management skills – for example, the recruitment of staff, how to do financial budgets. What has improved since the last inspection? What they could do better: Information needed before anyone is admitted to the home needs to be more detailed, particularly for emergency admissions, so that the home can make sure they are able to meet the residents needs. The care plans which provide information over the care needs of individual residents need to give more details, particularly over social, personal and employment histories, religious and last wishes, interests and activities and any other information which enables staff to give care based on the individual residents needs and wishes. Generally residents were happy with the quality and quantity of the meals provided but it may be helpful for the manager to talk with them to see if they have any ideas or suggestions. Residents said that the home does not provide any outings which is something that should be developed. Activities that the residents enjoy should be recorded so that the manager can see if he can improve these in any way. Some improvements to the medication administration and recording systems have been recommended. The manager has also been provided with clear information over the requirements for Criminal Record Bureau checks for prospective staff as it is a legal requirement for all staff to have a CRB disclosure prior to starting to work Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 7 at the home. The CRB check means that soon-to-be staff have been checked against a National Register and are safe to work with people who are vulnerable. Staff need to have update training in some important areas, including the fire procedure for the home. The manager is on-hand during the working day and he is always around to talk with residents in the home. This is very good practice and means that any issues or problems can be sorted out quickly. 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. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 5 and 6 Pre admission visits and trial periods are available, but residents assessments are not comprehensive. This means that full information is not provided or sought by the home to ensure people are able to make informed choices or to enable the home to make an informed judgement as to whether or not the individuals needs can be met. EVIDENCE: Three residents files were examined and although a pre-admission assessment had been completed by the named Social Worker for two, for one resident admitted privately there was no pre-admission information on file. The registered manager confirmed that there had been two emergency admissions and information on these people had been obtained after their admission to the home. One newly admitted resident was on short-term care and was aware that she was at the home for a short time prior to a return to her own home. Confirmation has already been provided that prospective residents are free to visit the home to assess its suitability and a trial period of 4 weeks is available. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 10 The home does not provide an intermediate care facility. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Whilst care plans are not comprehensively detailed the healthcare needs of residents are well met with evidence of appropriate interventions on a regular basis. The systems of administration of medication are generally good which means residents medication needs are being met, although some improvements have been recommended by the Pharmacist Inspector. EVIDENCE: For the three care plans examined it was found that two contained comprehensive information over the individual care needs of the residents, whilst information was sparse or not clear for the third. For this latter care plan although the information was factual it did not provide information that would help staff to provide individualised tailored care. The manager is currently reviewing all the care plans to ensure these are comprehensive and provide detailed information over care, lifestyle and individual needs. Discussions with staff confirmed that they read the care plans, communicate using individual daily diaries and talk with the residents personally during the day. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 12 Seven residents were spoken with and all confirmed that they felt their needs were being met by the staff at the home. Residents stated that they could ask for anything and it would be provided. One resident said “if anyone has any complaints then they’re wrong”. Another resident said “I get very good care”. Residents were asked about privacy and dignity and all confirmed that they felt well respect and their privacy is maintained. Residents spoke about staff knocking on their doors prior to entering and this was observed during the inspection. During this inspection a Pharmacist Inspector made a detailed examination of the receipt, recording, administration and disposal of medication, including any controlled drugs and specialist prescriptions. A detailed report has been sent separately. Overall, the Pharmacist Inspector felt that there were some inaccuracies in recording and administration and advice and guidance has been provided to the registered manager of the home. Residents all confirmed that they felt their healthcare needs are being met. Comment from a District Nurse was seen in one care record which stated tha the staff were “doing a good job”. Records examined confirmed that the home is proactive in ensuring residents needs are met, with residents confirming that GP’s are requested if they are unwell or they ask for a GP visit to be arranged. It was confirmed that two hospital visits are to take place and the registered manager of the home is supporting the two residents concerned to attend. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Resident’s independence and choice is supported by the activities and routines at the home. Meals are balanced and nutritious and well managed giving the residents both choice and variety. EVIDENCE: Residents spoken with confirmed they are free to follow their own daily routines – “we do what we want”, “I please myself what I do”. Residents also confirmed that they make their own choices and follow their own interests, and community involvement it encouraged - one resident regularly going out to the local betting shop, another for walks. Two comment cards were received from residents, one stating that they felt the home provided suitable activities and the second commenting that they would like more things to do. Both staff and residents confirmed there are no restrictions on visitors to the home and family members are encouraged to maintain contact as much as possible. Discussions with the registered manager confirmed that all residents will have their own personal social profile built up over the next few weeks which will Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 14 provide information over their social and employment history, interests, likes and dislikes which will enable appropriate activities and interests to be sought. Residents stated that there were a range of activities going on in the home which they enjoyed taking part in. These include a range of DVD’s and CD’s that have recently been purchased; sessions of Tai Chi take place each week, there are a number of board games which have been purchased and the mobile library visits on a monthly basis. The home has a patio area which one resident enjoys planting out with summer plants. Digi-boxes have been purchased for two residents along with a personal DVD player for another resident who prefers to remain in their room. Two Cockatiels have been purchased at the request of the residents. The registered manager is keen to ensure the residents lifestyles are as they would wish. At present, the home does not provide any outings although this is an area for development in the future. The meals provided at the home were discussed with the residents and although most felt that they were happy with what was provided – “meals are very good” and “we get plenty to eat”, there was some comment that the meals were “bland at times” and the residents would welcome some different choices as the choices given at present are usually the same thing. The menu book was seen and evidenced that a range of nutritious and balanced meals are provided, although advice and guidance has also been provided over the recording of meals in the home. The manager confirmed that the residents could ask for anything to eat and, if possible, it would be provided. It was advised that he should review the current menus (as there seemed to be some repetition) after speaking with the residents to obtain their feedback and comments. The meals are currently being prepared by a designated member of care staff on duty. This means the meals are only as good as the cooking abilities of the member of care staff who makes them. This may potentially affect the quality the registered manager is keen to maintain. The meal eaten at lunchtime with the residents was hot, tasty and provided an adequate amount of food. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 The home has a satisfactory complaints system in place with evidence that residents feel their views are listened to and acted upon. The home has a robust system in place to protect vulnerable residents which means residents welfare and safety are protected EVIDENCE: The home has a formal complaints procedure which is on display in the hallway for visitors or relatives to the home. Residents spoken with confirmed they would speak with the manager if they had any worries or concerns and, if they have done, action has been taken to address the concern raised. At present, there are no formal residents meetings in place and, whilst the registered manager is available and speaks with residents during the day, this needs to be more formalised and manager-led. The manager confirmed that the home has not received any formal complaints and the Commission has also not received any complaints regarding this home. Staff confirmed that if there were any complaints or issues raised they would try and sort it out immediately and, if needed, would talk to the manager. The manager was advised that, as good practice, any minor concerns or issues, although dealt with at the time, should be recorded. From viewing care plans and talking with residents and staff, all are encouraged to take part in the electoral system – most preferring to vote by postal voting, although some residents are taken to the polling station to vote. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 16 Discussions with staff confirmed there is a good understanding of abuse and the action they should take should any concerns be raised and this has also been covered in their National Vocational Qualification training. All staff confirmed that they have read the policy and procedure for adult abuse and Whistle-Blowing. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No standards in this section were examined during this inspection EVIDENCE: Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The level and calibre of staff is good. Residents are cared for by a dedicated team of staff which means that residents needs are well met. Recruitment practices are generally good which means residents are protected. EVIDENCE: The staffing rota showed that there were above the minimum levels of staff on duty during the day. Residents and staff spoken with stated that there are always sufficient staff on duty Training records examined and, from discussion with the registered manager and staff on duty, 13 staff are employed with 8 having achieved National Vocational Qualification to Level II standard and 3 have achieved Levels II and III. There is also a planned training programme in place to address the fact that update training is now due. Staff spoken with all demonstrated a clear understanding of the care needs of the residents and how this must be provided in a sensitive and professional manner, with individual choices and rights being maintained at all times. Observations during this inspection confirmed that residents are treated with courtesy, respect and dignity at all times. Four staff files were examined and found to contain all the required information, although two recently appointed staff had not had a new CRB disclosure obtained. The registered manager was given advice regarding this. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 19 From discussions with staff it appears a while since a fire drill took place and the registered manager was advised that all staff receive update training in the fire procedure of the home. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 and 36 Experienced and qualified staff look after the needs of the residents which means that the residents live in a well managed home. Residents views are sought on an informal basis. Quality assurance systems have been introduced but not fully implemented. EVIDENCE: Staff are provided with leadership and the opportunity, through supervision, formal appraisals, training and staff meetings to review and improve on their care practices. The home is managed by a registered manager who is experienced and due to complete the Registered Managers Award in the next few months. As well as the manager there is also a designated senior care assistant and additional carer on duty. The manager is available most times during the day and speaks personally with the residents on a continual basis. It was advised that a more formal Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 21 system be put in place whereby more formal weekly meetings be held with individual residents which are recorded, along with any actions needed. This could also include other comments made by residents. For example, comments made about the meals in the home could be discussed with the residents on an individual basis and steps taken to address any issues raised. Formal feedback should also be obtained from relatives and outside professionals. However, it was noted in one residents record that the District Nurses had commented the staff at the home were “doing a good job”. The home has the “Investors in People Award”. Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 3 3 3 2 x x 3 x x Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1) Requirement The home must obtain full information prior to admission taking place, and ensures full information is obtained within 5 days for any emergency admission Care plans must provide full information over care needs and how the staff are to meet this and must be reviewed on a monthly basis Recommendations made by the Pharmacist Inspector to be addressed Records of food provided to residents must be in sufficient detail to ensure the nutrition is satisfactory Criminal Record Bureau checks must be obtained prior to any prospective member of staff starting work at the home Update training in the fire procedure for the home must be provided to all staff Update mandatory training must be provided to staff Quality monitoring systems that are in place must include other professionals, outside agencies, Timescale for action 19.5.05 2. OP7 and OP8 15(1) 30.6.05 3. 4. OP9 OP15 13(2) 17 Schedule 4(13) 19(1)(b) 19.5.05 19.5.05 5. OP29 19.5.05 6. OP18 7. 8. OP30 OP33 18(1)(a) and 23(4)(d) and (e) 18(1)(a) 24 31.5.05 31.10.05 31.8.05 Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 24 relatives/visitors to 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. 1. 2. 3. 4. 5. Refer to Standard 12 15 33 33 Good Practice Recommendations Outings should be organised for residents Residents should be asked for their comments and feedback over meals provided at the home Feedback over the service should be obtained from the residents and recorded Feedback should also be obtained from external professionals and relatives/visitors to the home Tregothnan Retirement Home F57-F09 S62631 Tregothnon V224774 050505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 2nd Floor, Unit 1 Tustin Court, Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 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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