Care Home: Catchpole Court Residential And Nursing Home

What the care home does well What has improved since the last inspection? Two requirements were made at the previous inspection for risk assessments to be countersigned by a relative or external professional, to ensure that decisions regarding restraint are made on the basis of proper consultation. Evidence was provided reflecting that the home has consulted with Craegmoor clinical governance team and relatives, where items such as bed rails are being used. The second requirement was for formal supervision to take place in line with the home`s policy, and sufficiently regularly to support and monitor staff. Staff files and discussion with staff confirmed regular supervision is in place. What the care home could do better: Key inspection report CARE HOMES FOR OLDER PEOPLE Catchpole Court Residential And Nursing Home Walnut Tree Lane Sudbury Suffolk CO10 6BD Lead Inspector Deborah Kerr Key Unannounced Inspection 9th September 2009 09:00 DS0000024351.V377537.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Catchpole Court Residential And Nursing Home Address Walnut Tree Lane Sudbury Suffolk CO10 6BD 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) 01787 882023 01787 378836 catchpole.court@craegmoor.co.uk www.craegmoor.co.uk Speciality Care (REIT Homes) Ltd Miss Victoria Ann Hemsworth Care Home 66 Category(ies) of Dementia (66), Old age, not falling within any registration, with number other category (66) of places Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is 66 13th August 2008 2. Date of last inspection Brief Description of the Service: Catchpole Court was built and first registered in 1991. Its current owners, Craegmoor Healthcare trading as Speciality Care (REIT homes) Limited, acquired the home in 1998. The home is located opposite to the Walnut Tree Hospital within a short distance of Sudbury town centre. The home is a large modern red brick building that is divided into two separate houses and can accommodate up to 66 residents. Gainsborough House accommodates up to 37 older persons with a diagnosis of dementia, Constable House accommodates up to 29 older persons, some of whom are physically frail and some have dementia who are best cared for on this unit. The home is built upon two floors with a shaft lift provided for access. Communal lounges, dining areas and conservatories are available for the use of the residents. Good car parking facilities are available for visitors. Fees range between £650 and £750 per week depending on the assessed needs of the individual. Social Care Services are able to access a number of places for frail elderly residents at weekly fees of £387 and for residents with dementia at £630, a Health Authority payment of £106.30 is paid in addition to this. Where people have had their needs assessed as requiring continuing health care funding, care fees range from £720 to £820. The fees do not include hairdressing, chiropody, daily newspapers, toiletries or clothing. This was the information provided at the time of the inspection; people considering moving to this home may wish to obtain more up to date information from the care home. Catchpole Court Residential And Nursing Home DS0000024351.V377537.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 service is 2 stars. This means the people who use this service experience good quality outcomes. This was a key inspection, which focused on the core standards relating to older people. The inspection was unannounced on a weekday, which lasted eleven hours and included a one and half hour Short Observational Framework for Inspection (SOFI). SOFI is a tool developed in conjunction with the University of Bradford, used to gain feedback from people, who due to their mental frailty may be unable to complete a Care Quality Commission (CQC) survey. This enabled the inspector to observe four people during the lunchtime meal. During this time the inspector was able to look, and record how the residents spent their time, how it affected their mood and well being, and how well staff engaged (interacted) with the residents. Observations made, are included in the daily life section of this report. The report has been written using accumulated evidence gathered prior to and during the inspection, including information obtained in the Annual Quality Assurance Assessment (AQAA) issued by the Care Quality Commission (CQC). This document gives the provider the opportunity to inform CQC about their service and how well they are performing. We also assessed the outcomes for the people living in the home against the Key Lines of Regulatory Assessment (KLORA). A tour of the premises was made and a number of records were inspected, relating to people using the service, staff, training, the duty roster, medication and health and safety. Time was spent talking with the four people living in the home, three relatives and five staff. The manager was present throughout the day and fully contributed to the inspection process. What the service does well: During our visit we spoke with four people who shared their experiences of what it is like for them, living in the home. They told us, “people here are very kind to me” and “the food is very good, staff are always attentive and kind” and “the home is very good, I am perfectly happy here”. Another person told us, “I am a vegetarian and the catering staff bend over backwards to provide me with vegetation options”. People told us they are able to choose how and where they spend their time and that they are treated with dignity and respect. Relatives told us, “we can not speak highly enough of the service, we acknowledge that our relative has severe dementia, and possesses extremely Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.2 Page 6 difficult behaviours and is not easy to cope with, however the staff still provide care and support to them, despite their aggression” and “the staff are absolutely brilliant, they always make time, I don’t know how they cope, they really try their best and try to explain things to our relative”. Other comments included, “the staff look after my relative very well, I am confident that their health and welfare is being monitored” and “the staff are very pleasant and I am kept well informed”. One relative commented, “I have had previous experience of dementia care in other residential homes, in comparison, the care here is very good. Another relative commented, “the manager is very supportive, they explained a lot about the symptoms of our relative’s dementia, so that we had a better understanding of them. This makes our visits easier, and to understand that their behaviour is not directed at us personally, but is part of their dementia”. Positive feedback was seen in the relative’s quality assurance surveys, with comments reflecting how well the service is meeting people’s needs. Comments included, “all staff are very friendly and helpful and every one at Catchpole Court is committed to providing the best service within their capabilities, well done” and “I am very happy with the way my relative is cared for”. Other comments included, “the home has a very relaxing environment, for visitors and residents, with lots to look at and lovely to see home grown lettuces, wonderful lunch” and “we have been very pleased with the improvement in our relative since they have been in Catchpole Court, it seems to have given them back their life”. An area where the home has excelled is the improvements made to the décor in Gainsborough unit. Themed areas have been created and reminiscence items and objects have been placed around the home, providing people with a dementia, with items from their passed and something interesting to engage with. The décor provides suitable and meaningful visual aids and memorabilia, as well as helping people to find there way around their home. What has improved since the last inspection? What they could do better: Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.2 Page 7 Improvements could be made to care plans, redeveloping the format to make them more user friendly, and focusing on the implementation of life histories to provide more person centred care, especially for people with a dementia, who may have impaired cognitive ability and variable levels of confusion. Whilst the home has made significant improvement to the décor in Gainsborough unit, equal input into the décor in Constable Unit would enhance the environment for the people living in this part of the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6, People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may use this service are provided with a range of information they need to help them choose if this service will meet their needs. EVIDENCE: A copy of the statement of purpose was provided at the inspection. This document has recently been updated and provides all the information as required under the National Minimum Standards (NMS) and provides prospective users of the service with information they need to know about the home. Information provided in the AQAA and verified at the inspection confirmed the statement of purpose and service user’s guide is available for each resident. The Service User Guide is in a language easily understood and has been produced in larger type for easier reading. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 10 Additionally, a number of booklets with easy read information, using pictures and symbols were seen about the home. The booklets included general information about the home, pictorial menus, what to do in hot weather and a range of emotions, of particular use to help people with a dementia to show how they are feeling. The manager advised us they are in the process of developing a welcome pamphlet, using the same format incorporating the service user’s guide, which will be issued to each person on arrival, providing information about the services and what they can expect. The records and care pathways of three people living in the home were tracked, to ascertain how well the service is meeting their individual needs. All three people tracked had a pre admission assessment completed, with input from a multi-disciplinary team of people involved in the care, support and placement of the individual. These have included the Primary Healthcare Trust (PCT) and the Suffolk Mental Health team. The assessment covered all areas of their health, personal and social care needs, including, relationships, keeping active and keeping safe. Additionally, where people had been referred through social services a copy of the social workers assessment had been obtained, held on file and used to complete the individuals care support plan. To ensure people’s assessed needs are met, people’s care plans reflected there has been input from health care professionals, where required, including consultants, the Community Practitioner Nurse (CPN), dietician, falls prevention, tissue viability, diabetic nurse specialist, Parkinson’s nurse, Physiotherapist, Occupational Therapists and the Macmillan Nurses. Additionally, staff are provided with training to ensure they have the knowledge and skills to provide care and support appropriate to the needs of the individual(s). Training has included, palliative care, health for life, personalise exercise and nutrition, nutrition and health, dementia, Parkinson’s and tissue viability. The AQAA reflects prospective service users and their representatives are always invited to visit the home prior to admission. The manager was observed showing two people around the home, they were made welcome and provided with time to ask questions. Additionally, the pre admission assessments identified people had been provided with the opportunity to visit the home, and shown the room available. Each person had been issued with contract between Craegmoor Healthcare setting out their fees, terms and conditions of residence at Catchpole Court, including the roles and responsibilities of the provider and the rights and obligations of the individual whilst living in the home. The home does not provide intermediate care. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11, People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service receive health and personal care, based on their individual needs and wishes. EVIDENCE: The records and care pathways of three people living in the home were tracked, to ascertain how well the home is meeting their individual needs. These had photographs in place of individual residents to identify and personalise the care plan document. Care plans are divided in to sections, which include personal life and medical history, support plans, assessments, medical and professional interventions, reviews, support plans and risk assessments. These collectively set out the actions required by care staff to ensure that peoples’ health, personal and social care needs are met and describe the expected outcomes for the individual. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 12 Examination of care plans and discussion with Craegmoor’s own dementia specialist, visiting the service confirmed these are difficult to use. Although they contain all the information, they are lengthy and staff need to flick backwards and forwards to find a trail of information about the care needs and well being of the individual. Improvements have been made to the care plans, to make them more person centred. They have been written in the first person, such as ‘people who are important to me’ and ‘things that are important to me’ and ‘things you need to know about my mental health’ however it was discussed how effective these are, in establishing truly person centred care. Where people with a dementia have variable levels of confusion, how were they able to impart this information. Where as a pen picture completed at the back of the care plan provided a very good overview of the individuals past and present life and how these contributed into making the individual, who they are and the way they are likely to react to situations. Staff spoken with were able to give a verbal account of the needs and preferences of individual residents. Conversation with people living in the home confirmed that staff treat them with dignity and respect. They told us, “staff are always attentive and kind” and “I am perfectly happy here, the staff treat me very well”. Interactions between residents and staff, during the day were observed to be friendly and appropriate. People living in the home are able to access health care services and social care professionals. The home has a positive relationship with the local General Practitioners (GP) and district nurses, who make regular visits to the home. Two GP’s from a local surgery were observed visiting their patients during the day. Additionally, a nurse was observed providing feedback to the manager of contact they had made with a resident’s GP and the Marie Curie nurses to arrange a visit to assess the individual’s decline in health. Dates and details and outcomes of appointments had been clearly recorded, in peoples care plans. Supporting assessments are in place, identifying the risks for activities of daily living, such as mobility, falls and personal hygiene and the action required by staff to minimise these, whilst enabling the individual to retain some independence and choice. For example, moving and handling assessments, clearly reflect the aids and equipment they require. Other plans and assessments cover keeping safe in bed, nutrition, pressure ulcer care and prevention. Where bed rails are being used these have been fully assessed and discussed with Graegmoor’s clinical governance team, the individual and their relatives. Peoples nutritional needs are closely monitored with regular weight checks being undertaken. Plans state where people have special dietary requirements, such as a soft diet. Pureed foods and thickened fluids are provided in consultation with the Speech and Language Therapist’s (SALT) recommendations. The plans contain a good description of support required to assist individuals that require assistance to eat their meal. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 13 Gainsborough unit has contracted beds with the PCT and Mental Health Team providing placements for people who have a dementia and assessed as having difficult behaviours. Where people have been referred to the home, their care plans contined detailed mental health plans, which provide staff with a good description of the action required, to support the individual at such times and to maintain their well being. Anti Social Behaviour Charts (ABC) are being completed to monitor people’s behaviours. These reflect what happened prior to an incident occurring, what was observed during the incident and the response and/or action taken immediately after an incident has occurred. Records reflect the staff are supported by regular in put from the CPN to help reassess and monitor the individuals behaviour. Information provided in the AQAA and verified at the inspection confirmed the home has robust medication polices and procedures in place. Time was spent going through the process with nurse on duty, on Gainsborough unit. Medication was not reviewed on Constable unit on this occasion. The home uses the Monitored Dosage System (MDS). Photographs of residents had been attached to the Medication Administration Records (MAR) charts folder to avoid mistakes with the persons identity. The MAR charts inspected were found to be completed correctly. The practice of administering medication is being generally well managed. Only nursing staff are responsible for administering medication. We were advised there are normally two nurses, on shift, one for each floor, however there was only one nurse on duty. The manager acknowledged they are currently experiencing problems recruiting registered nurses, but were making sure that additional carers are rosterd to make up the shortfall. The nurse spoken with confirmed they were being well supported by managers and support staff to ensure they are able to have time to administer both lots of medication. The medication room is situated on the top floor, which services both units. A check of the medication room reflects the controlled drugs cabinet meets with the required specifications as specified in the Misuse of Drugs (Safe Custody) Regulations 1973. There are currently six people prescribed controlled drugs, living in the home. A check of three people’s medication against the controlled drugs register was made and found to be accurate. Information provided in the AQQA and verified in discussion with staff, confirmed medication training is provided by Boots pharmacy and additional training has been sought by other pharmaceutical companies. Additionally, yearly medication competencies are undertaken by all qualified staff through Craegmoor Healthcare. The manager was clear that they are opposed to the use of chemical restraint to control people’s behaviour and that it is important to look at causes of behaviour. They told us, with the residents and relatives agreement new clients admitted to the home have their medication reassessed by the GP, and mental health team with a view of ‘ stripping back’ of previously prescribed medication and to start a fresh, to find out who the person really is, and to give them freedom to be who they are. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 14 Constable unit provides care and support to people who are experiencing beginning and end stages of dementia and end of life care. The AQAA states people’s individual wishes with regard to sickness, treatment, death and dying are identified within their care plans. Information provided in care plans confirmed that the home uses the Abby pain scale to help assess if people, particularly those who are unable to tell staff if they are unwell or in pain, due to their dementia. Pain assessments had been completed, providing staff with a good description of signs to look for to know if the individual is experiencing pain. These are being regularly reviewed. The Liverpool care pathway is implemented, with the involvement of other healthcare professionals, such as McMillan Nurses. Additionally, some care and nursing staff have undertaken intermediate national diplomas in palliative care to help support people using the service through death and dying. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service are provided with activities that meet their expectations and which meets their social and recreational interests. EVIDENCE: The AQAA reflects from January 2009 activities hours have been increased. However the manager confirmed the activities post for Gainsbourgh unit has until now been vacant. A new member of staff, who is experienced in working with people with a dementia, is due to commence employment next week, to take up fulltime hours, which will be flexible to meet resident’s needs. Additionally, Gainsborough unit has an art therapist, who visits every Friday. Constable unit has a part time activities post from 10am to 4pm, five days a week. The co-ordinator has recently retired and there are plans for the activity hours to be used to roster additional carers to undertake activities as part of their role. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 16 During our visit we spoke with four people who shared their experiences of what it is like for them, living in the home. They told us, “I had a lovely bath, and hair wash, this morning, the staff were lovely and my hair feels so soft and silky” and “people here are very kind to me” and “the food is very good, staff are always attentive and kind”. Another person told us, “the home is very good, I like my room, I have a good view over the garden with a lovely tree in view. I am perfectly happy here, the staff treat me very well, some are better than others, but I have no complaints. I am a vegetarian, the food is OK, the catering staff bend over backwards to provide me with vegetation options. Due to my physical disability and health I choose to stay in bed and I spend my time watching TV programmes of choice and reading”. Discussion with relatives told us, “we can not speak highly enough of the service, we acknowledge that our relative has severe dementia, and possesses extremely difficult behaviours and is not easy to cope with, however the staff still provide care and support to them, despite their aggression” and “the staff are absolutely brilliant, they always make time, I don’t know how they cope, they really try their best and try to explain things to our relative”. Relatives also told us, “the manager is very supportive, they explained a lot about the symptoms of our relative’s dementia, so that we had a better understanding of them. This makes our visits easier, and to understand that their behaviour is not directed at us personally, but is part of their dementia”. All three relatives spoken with confirmed they were kept well informed about their relative and that there has been a significant improvement in the service within the last six months. They told us, they had especially noticed improvements in the environment and that the staffing group has remained stable, with no dramatic changes, and commented, “there used to be a lot of overseas staff, which caused some language issues, however there seems to be a better balance now”. Other comments included, “the staff look after my relative very well, I am confident that their health and welfare is being monitored” and “the staff are very pleasant and I am kept well informed”. One relative commented, “I have had previous experience of dementia care in other residential homes, in comparison, the care here is very good. Information provided in the AQAA and verified at the inspection confirmed individual menu plans have been created, providing daily choices and specialist dietary requirements are catered for. Discussion with the chef manager who confirmed all new people who move into the home are provided with the opportunity to discuss their culinary likes and dislikes. This is then reviewed through the working party menu group, consisting of a cross section of residents and staff, who have been formed to assess the daily menu feedback and formulate new menus and introduce new food tastes. Time was spent discussing the menus, food preparation and presentation, particularly for people with specialised diets. The chef had a very good understanding of the needs of the people that they cater for. The home has a four week rolling menu, which is changed seasonally. Menus are displayed on a board and are Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 17 also provided in a picture format for people, who have dementia so that they can identify foods and make choices at meal times, of what they wish to eat. Separate menus have been produced for people who are vegetarians. The food is mostly home cooked and people told us, they were very happy with the food. The chef confirmed they have the appropriate qualifications for their role. They have completed a National Vocational Qualification (NVQ) 2 in catering and is hoping to go onto complete level 3. Additionally, staff have completed training to assist in their understanding of specialist dietary requirements, assistance with meals, nutrition and health. Where required, external healthcare professionals, such as dieticians and the speech and language therapists are involved where problems are identified with an individuals diet and health. The home has introduced an open all hours ‘Tuck’ and ‘Sweet Shop’, in two areas of the home, for people to access and which provides high calorific snacks. Additionally, there are plans to open up the dining area and to create an all day food service. As part of the inspection a Short Observational Framework for Inspection (SOFI) was undertaken in dining room on Gainsborough unit. The SOFI started 12 noon and finished at 01.30pm and enabled us to observe the lunch time meal and in particular four people. We looked at and recorded how the residents spent their time, how it affected their mood and well being, and how well staff engaged (interacted) with them. Staff started to escort people into the dining room at 12 noon, the interactions between staff and residents was good, staff were attentive and patient and communicated well with residents, providing explanation about what was happening, where they were going, and asked them where did they want to sit. Through out the mealtime staff provided a lot of physical contact, touching and stroking people’s arms, showing genuine affection. Staff were observed acting promptly to residents requests or signs of ill being and agitation. The mealtime itself was reasonably paced, people were offered seconds and allowed time between courses, staff offered and provided assistance where required. People were provided with choices and offered the opportunity to provide feedback about their meal. Residents were actively engaged in the mealtime, there were some attempts of residents to engage with each other, but mainly engagement was with objects, such as cutlery, aprons etc or with staff. Staff were respectful of peoples individuality enabling them to take part in the mealtime, which provided a sense of inclusion, belonging and in some cases fun and laughter. We noticed staff at the end of the meal were observed talking to each other across the dining room discussing the wellbeing of a person who, due to declining health was moving across to Constable unit, that afternoon and this was feedback to the manager. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 18 People using the service are being supported to maintain and develop relationships. The home operates an open door policy at all times, for relatives friends and professional visitors, the number of entries in the visitors book confirmed this. Care plans contained assessments and support plans developed to support two people living in the home that have developed an intimate relationship. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service have access to a robust and effective complaints procedure and are protected from abuse. EVIDENCE: The policies and procedures for dealing with complaints, whistle blowing and safeguarding the people living in the home were examined. These reflect the procedures in place to protect people using the service and identifies the actions staff should take if they receive a complaint, or if an incident of abuse is discovered or reported to them. The safeguarding procedure includes the process of reporting allegations to internal personnel and the contact details for the local area safeguarding adult protection team. People using the service and staff confirmed they were aware of the complaints procedures and were clear they would talk to the manager if they had any concerns and were confident that there concerns would be dealt with. Residents, relatives and staff told us the manager, is very approachable and they feel able to discuss any concerns openly with them. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 20 The complaints procedure is on display in the entrance hall and on notice boards around the home. This is also available in an easy read version. Additionally, the views of people using the service and their relatives are sought through Craegmoor healthcare’s Your Voice questionnaire, an initiative, called Ask. Listen. Do. Questionnaires are available in the home, and ask for people’s feedback about the home, support and care, staff and any additional compliments or complaints, which are used to improve the service. The complaints log reflects from 4th May 2008 to date, nine complaints have been made. These have been fully investigated and a response provided to the complainant, addressing the issues raised. All complaints are entered on a complaints form, which is sent to Craegmoor customer services manager and entered onto a database, generating an identification number, investigation and to monitor the outcomes. Information provided in the AQAA and verified at the inspection confirmed that by continuing to operate an open door policy and providing structured management cover across seven days per week there has been a reduction, in the number of complaints made. More effective reporting has contributed towards an open and honest approach and assisted in improving the service. Staff files seen confirmed all staff are subject to Criminal Records Bureau (CRB) checks prior to commencing employment and have completed Safeguarding of Vulnerable Adults (SOVA) and Primary Prevention training to protect people living in the home from people who should not be working with vulnerable adults. Staff spoken with were clear about their role and their duty of care to raise any concerns they may have about other members of staff conduct and in reporting of incidents of poor practice and suspected situations of abuse, including reporting to incident to the local authority safeguarding team via Social Services, Customer First service. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26, People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Catchpole Court provides a safe, well maintained, comfortable and homely environment, which encourages independence and wellbeing. EVIDENCE: Catchpole Court is a large modern red brick building that is divided into two separate houses, Gainsbourgh and Constable. Gainsborough House provides accommodation for people with a diagnosis of dementia, where as Constable provides accommodation for older persons, some of whom are physically frail and some who have later stage dementia and who are best cared for on this unit. The home is built over two floors with a shaft lift provided at each end of the building for access to the first floor. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 22 Both units have a range of communal areas, including a lounge, dining area and conservatories. Each unit has a satellite kitchen, which are available for residents and relatives to make tea and coffee. The manager accompanied us to look around the home and talked us through the information provided in the AQAA of the plans for an extensive refurbishment programme of both units. This will include the purchase of new fixtures, fittings and furniture. The refurbishment includes plans to merge the dining room and lounge on Gainsborough unit into one. The dining area already contains a ‘tuck shop’ providing sweets and biscuits, however only a few residents know where it is. Opening up the dining area will provide a large open space, to create an all day café, which in addition to a main meal, will offer smaller snack type meals that can be provided quickly, in a stimulating and visual area, with smells that will encourage people to maintain healthy appetites. The corridors and some bedrooms have recently been redecorated, on Gainsborough unit and has commenced in Constable. Carpets are to be replaced in the corridors on both units. Residents bedrooms, were viewed on both units, these are of various sizes and nicely decorated with some more personalised than others, depending on the occupant. People’s rooms had their name, picture and signs on their bedroom doors, so that they can identify their room. The manager confirmed they are in the process of decorating and replacing furniture in bedrooms and replacing old style beds, with adjustable height beds, providing safety for residents and staff whilst attending to people’s personal care needs. The home has sufficient bathrooms and toilets available to meet the needs of the people living there. These include toilets at frequent intervals in corridors, assisted baths and a wet room, which doubles up as a hairdressing salon. There are plans to create further wet rooms and install additional assisted baths as part of refurbishment of the home. Two rooms on Gainsborough unit have en-suite facilities, the remaining bedrooms have vanity units installed. The home is generally equipped with aids and equipment to promote mobility and maximise peoples independence, there are a range of hoists, grab rails and other aids, which are available in corridors, bathrooms, and toilets, and where required, and in residents own rooms. Two staff were observed using a hoist to transfer a resident into an arm chair, they provided good communication and eye contact with the person providing reassurance throughout the process. Records kept in the home confirmed all equipment is being regularly serviced as per the manufacturer’s recommendations. A call system is provided throughout the home, including individual’s rooms and all communal areas, so that residents’ have access to staff when they need them. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 23 Information provided in the AQAA and verified at the inspection confirmed the home has become more personalised by furnishing the internal walls and reception area with displays of art work, created by the people who use the service. An area where the home has excelled is the improvements made to the décor in Gainsborough unit. Corridors around the unit have been decorated with themes, such as nautical items, a corridor has been named ‘Our Street’ with a range of enlarged old pictures of Sudbury on the walls. Additionally, reminiscence items and objects have been placed around the home, such as a peg tin containing pegs, providing people with a dementia, with items from their passed and something interesting to engage with. The décor provides suitable and meaningful visual aids and memorabilia, as well as helping people to find there way around their home. Whilst the home has made significant improvement in this unit, equal input into the décor in Constable Unit would enhance the environment for the people living in this part of the home. At the bottom of the stairs from Gainsbourgh unit 1st floor, an old fashioned “sweet shop” has been built, with an attractive display of sweets reminiscent of the 1950s and 60s, where residents are able to visit and get sweets of their choice. A small quiet lounge leads off from the sweet shop, providing a nicely decorated area for residents with later stage dementia. The room has been decorated with garden murals and butterflies, which provide a calming affect. A small group of residents were observed sitting in the lounge, with two staff who were observed interacting with residents. One of the residents was observed stroking a carer’s hair. The carer confirmed the individual finds this comforting and was happy for the resident to continue doing this. Another resident was provided with a toy cat, which they were observed stroking and laughing in a relaxed and happy mood. Walls in the corridor leading to dining room in Gainsborough unit have been decorated with large bright colourful pictures of food and ornaments of plastic fruits and vegetables. The manager told us, they have concentrated on making mealtimes more interesting to residents, as there was a lot of weight loss, when they first took over service, about three years ago. There is a range of finger foods, sweets and biscuits available on dresser in the dining room, for people to access throughout the day, as and when they require providing high calorific extras to their main meals. The AQAA reflects the home has raised funds to develop the gardens. Access has been made from the dining area on Gainsborough unit to an enclosed and secure sensory garden, which has a gazebo, range of seating and interesting objects for people to look at and touch, such as large ornamental butterflies, lady birds and plants. The manager confirmed there are further plans to develop the garden area to the rear of the building to include a herb garden and a raised vegetable patch, and to introduce hens and ducks. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 24 The laundry facilities contain the appropriate equipment to launder soiled linen, clothing and bedding. Red dissolvable bags are provided for dealing with soiled linen, soiled garments and bedding are placed directly into the bag and into the washing machine on a sluice cycle minimising staff contact and the risk of spreading infection. Appropriate protective equipment, such as aprons and gloves and hand washing facilities of liquid soap and paper towels are provided in the laundry, all en suite and toilet facilities, where staff may be required to provide assistance with personal care. Additionally the AQAA states staff undergo infection control training. This was confirmed in discussion with staff and training records and has recently been tested due to the recent events, of Tuberculosis identified in the home. The AQAA identifies that the Health Protection agency and specialist from the centre of communicable disease, recognised that the homes infection control policies and procedures were detailed and it was evident to them, that staff were aware and followed these. Feedback from people spoken with during the inspection and in quality assurance surveys returned to the home, highlighted that there are times when the home is odorous. This was discussed with the manager who is in process of trying to eliminate odours, by replacing carpets and trying out the use of fresh natural fragrances and herbs. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service are supported by a staff team that are available in sufficient numbers and who are trained, skilled and competent to do their jobs. EVIDENCE: Information provided in the AQAA and verified at the inspection confirmed the staffing levels and skill mix were increased within the 2009 budget, which has allowed the management to flex staffing levels to meet the individual care needs of people living in the home. The manager confirmed there is a strong core of staff, but identified they currently have a shortage of registered nurses and are trying to recruit to these posts. Each unit has its own staff team, however staff confirmed they do occasionally work on each of the units, to cover staff sickness and holidays. They felt this has helped to stop divides developing between the units and that staff are working as a whole team. Working on both units provides staff with the opportunity to get to know the residents and work pressures on either unit. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 26 Examination of the duty roster confirmed, staffing levels for Constable unit is two nurses and six care staff in the mornings, with an additional carer to support breakfast between 8 to 11.00 am. This person provides additional support for people who require one to one assistance to eat their breakfast. Afternoons are staffed by one nurse and five care staff, with one nurse and two care staff at night. In addition to this, there are six hours for activities, five days a week. Gainsborough Unit has two nurses and eight care staff, in the mornings, plus an additional carer to support breakfast between 8 to 12.00 am. Afternoons are staffed by two nurses and six care staff, with one nurse and three carers at night, with an additional twighlight staff between 6pm and 11pm. There is a full time activities co-ordinator post providing eight hours a day, which are flexible hours to meet people’s needs. Staff acknowledged there are a number of nurse vacancies, but confirmed that staffing levels are generally good, and that additional care staff are being used to cover the vacant nursing hours. The AQAA states the home has a robust recruitment processes in place. The initial recruitment process is commenced at the home, following company policy and procedures and supported by Graegmoor human resources department. The recruitment and selection of employees from overseas, is done within Craegmoor overseas recruitment department, from Worcester Support Centre. The AQAA reflects that an area where the home could improve is to involve residents more effectively in the recruitment process, and when identifying training needs. Examination of three staff files confirmed all relevant documents and recruitment checks, required by regulations, to determine the fitness of the worker had been obtained prior to them commencing employment. Records and discussions with staff confirmed they had been recruited fairly and that they received good training and support to ensure they have the skills and knowledge to do their jobs and to meet the different needs of the people living in the home. This was reflected in the AQAA which shows that 50 of care and nursing staff have undertaken specific training in dementia care, with plans for all care staff to have completed, the Yesterday, Today and Tomorrow dementia training by the end of 2009. Most recent training has included palliative care, dying, death and bereavement, health for life, personalise exercise and nutrition, nutrition and health, dementia, Parkinson’s, boots advanced medication, tissue viability, Safeguarding Vulnerable Adults (SOVA), infection control care and nursing, equality and diversity, mental capacity act and depravation of liberty. Staff also confirmed they had received training for supporting people to manage difficult and challenging behaviour, the manager also confirmed they are looking into staff attending Non Abusive Psychological and Physical Intervention (NAPPI) training for the prevention and management of violence and aggression. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 27 Staff confirmed they had completed the Skills for Care, Common Induction Standards and had had an informal induction into the service, which included reading the policies and procedures, an orientation tour, information about Craegmoor and working shadow shifts along side a senior member of staff. Information provided in the AQAA and verified at the inspection confirmed NVQ training is currently at 34 , which is a percentage increase of 12 since 2008. Five staff are currently undertaking NVQ’s and this will bring the service up to compliance level of 50 of care staff to hold a recognised qualification, towards the end of 2009. Nine staff are qualified overseas nurses working as senior carers, these staff are in the process of undergoing there accreditation to obtain a level 3 NVQ. Additionally, the NVQ programme has been extended to ancillary staff including administration, management, housekeeping and catering to develop their knowledge and skills. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 28 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38, People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect and is run in the best interests of the people living there by a competent and qualified manager. EVIDENCE: Victoria Hemsworth is the registered manager of this service. She is a first level Registered Nurse (RN) who has seventeen years experience of running multi complex care homes. She has also completed the Registered Manager’s Award (RMA) and completed a leadership and development programme. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 29 The AQAA states that the home has an open and honest environment, and has a management presence seven days a week, which has helped to develop and build trust, with residents, relatives and staff. Feedback provided at the inspection by residents, relatives and staff confirmed this stating that the manager is very approachable, understanding and helpful. Comments included, “the manager is here a lot at weekends, they are the best manager we have ever had, they have been here nearly three years, and the service is definitely 100 better” and “the manager is easily approachable, we were kept well informed about the tuberculosis situation, we felt well supported by them and the situation was well managed”. The manager provided us with an update on the outcome of the recent outbreak of tuberculosis. A small number of staff are undergoing treatment, medication and regular screening and are being supported by the company to take time off when required, to avoid fatigue. Some residents have been diagnosed with latent TB, however tests are unable to distinguish between those who have contracted TB, or those that may well have already had latent TB. The home continues to monitor the situation, which has been a learning curve for all involved including the health protection agency. Information provided in the AQAA and verified at the inspection confirmed that the manager seeks to include the opinions of all those involved with the service, which enables them to develop services further and tailor them to meet individual, assessed or requested care needs. Feedback is actively sought and evidenced within the homes quality assurance systems. The home sends out annual relative questionnaires internally from the home and an annual ‘Your Voice’ questionnaire, which is sent out centrally from Craegmoor. In addition to this opinions have been sought via questionnaires internally on activities, housekeeping and menu planning. Daily opinions are sought and recorded via Menu feedback plans. The most recent quality monitoring survey completed this year to obtain feedback from relatives of people using the service was mostly positive. To date thirty one surveys had been returned, comments included, “the environment is very good, gardens are above average, personal care standard has improved and everyone tries to make my relative as comfortable as possible” and “all staff are very friendly and helpful and every one at Catchpole Court is committed to providing the best service within their capabilities, well done” and “I am very happy with the way my relative is cared for”. Other comments included, “the home has a very relaxing environment, for visitors and residents, with lots to look at and lovely to see home grown lettuces, wonderful lunch” and “we have been very pleased with the improvement in our relative since they have been in Catchpole Court, it seems to have given them back their life”. Less positive comments were made by several relatives with regards to odours in the home, previously mentioned in the environment section of this report. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 30 The AQAA also reflects that to ensure people using the service and their representatives have their say, monthly ‘Your Voice’ meetings with relatives, friends, residents and staff, are held to allow an exchange of views for the development of service from which action plans are made to facilitate change. The ‘Your Voice’ initiative implemented by Craegmoor, enables people using the service, who are unable to make their own decisions to have a voice through key workers, named nurses and where required external advocates. Information provided in the AQAA and verified at the inspection confirmed that Craegmoor Healthcare company policies and procedures are adhered to with regard to financial matters. Audits are undertaken both internally and externally to ensure compliance. Each resident has an individual financial care plan and a personal funds account, which is held electronically, and as hard copy, on which interest is paid. Personal fund statements are sent out monthly. Each resident has an individual financial profile within their care plan which sets out their money management skills and how they are supported to manage this. To ensure the safety of people living in the home, all radiators are guarded with radiator covers, which minimises the risk of people falling against them and sustaining burns. All hot water outlets to baths, hand wash basin and showers have been fitted with thermostatic valves, which regulate the temperature of the water, to ensure these do not exceed the safe recommended temperatures. A recent unannounced inspection from the Suffolk Fire Service reflected the home complies with relevant legislation. Craegmoor also had an independent fire safety assessment of the home completed in April 2009 and on their advice are in the process of replacing all bedroom fire doors throughout home. The fire logbook showed that the fire alarm, emergency lighting and fire fighting equipment is regularly serviced. Emergency lighting and the fire alarm system are tested weekly. The home continues to take steps to safeguard the health, safety and welfare of people living and working in the home. The maintenance file shows weekly and monthly checks are completed by the maintenance person to ensure facilities and equipment in the home are maintained and kept in good working order and compliant with safe working practices. The most recent Gas, Electrical Safety certificates, including Portable Appliance Testing (PAT) were seen. Certificates confirmed the passenger and moving and handling equipment is regular checked and serviced, including Lifting Operations and Lifting Equipment Regulations (LOLER) tests. All temps of fridges, freezers, food deliveries and temperatures at which food is served are being recorded and monitored in line with food safety standards. The home has recently been inspected by Babergh District Council, environmental health team, who have assessed the home as having a good standard of compliance, for food safety and management. They have a scoring system referred to as ‘scores on the doors’, which reflected that Catchpole Court had received a positive 4 star rating, out of a possible 5. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 31 Information held on staff files confirmed that improvements have been to the supervision process and that regular supervision is now taking place. The documentation reflects that these sessions include discussion about performance, attendance, working with the team, staffing issues and areas of development and training needs. Staff confirmed they have regular supervision with a named nurse, felt supported in their role and have access to regular staff meetings, which kept them informed about changes within the organisation and the service. Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 32 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 33 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations Improvements could be made to care plans, redeveloping the format to make them more user friendly, and focusing on the implementation of life histories to provide more person centred care, especially for people with a dementia, who may have impaired cognitive ability and variable levels of confusion. Whilst the home has made significant improvement to the décor in Gainsborough unit, equal input into the décor in Constable Unit would enhance the environment for the people living in this part of the home. 2 OP19 Catchpole Court Residential And Nursing Home DS0000024351.V377537.R01.S.doc Version 5.3 Page 34 Care Quality Commission Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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