Care Home: Heightlea

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What the care home does well Heightlea provides a good facility for the care of people with autistic spectrum disorders. People living in the home seem to be supported to a good standard and support is tailored to individual needs. There is a good range of activities available for individuals, and transport is provided so people can go out. Staff work in a manner to enable people living in the home to receive appropriate care, and make choices about their lives where this is possible. What has improved since the last inspection? The manager has been registered with the Care Quality Commission. Contracts of care have been developed for the people living at the home, and these were available for inspection. What the care home could do better: This inspection has resulted in the following statutory requirements. In summary the following is required: (1) Staff training needs to improve in some areas. (2)Improvement is required regarding arrangements to ensure the prevention of legionnaire`s disease. Otherwise the service is managed to a good standard. Key inspection report Care homes for adults (18-65 years) Name: Address: Heightlea Old Falmouth Road Truro Cornwall TR1 2HN     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Ian. Wright     Date: 1 3 1 0 2 0 0 9 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 25 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 Adults (18-65 years) 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. 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 Care Homes for Adults (18-65 years) Page 3 of 25 Information about the care home Name of care home: Address: Heightlea Old Falmouth Road Truro Cornwall TR1 2HN 01872263344 01326371099 mail@dcact.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Spectrum care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Date of last inspection Brief description of the care home Heightlea is a care home providing accommodation and personal care for up to three adults with a learning disability. The registered provider is Spectrum, an organisation that provides specialist services for adults with autistic spectrum disorders. The home is a detached building, situated on the outskirts of the city of Truro. The home has four single bedrooms. There are two lounges on the ground floor and additional lounge on the first floor. There is a conservatory, and a kitchen/diner on the ground floor. There is a shared bathroom on each floor. The home also offers a respite care and day care service. One person currently has regular respite stays when one of the other people using the service spends time with their family. Fees at the time of the key inspection in October 2009 ranged from £738 to £1112.00 per week. Additional charges are for service users personal shopping items. Care Homes for Adults (18-65 years) Page 4 of 25 Over 65 0 3 Brief description of the care home Copies of the homes statement of purpose and previous inspection reports are available on request from the registered persons, or free of charge from CQC via our website or call centre. Care Homes for Adults (18-65 years) Page 5 of 25 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection took place in five and three quarter hours in one day. All the key standards were inspected. The methodology used for this inspection was: (1) To case track two people using the service. This included inspecting their records, and where possible discussing their experiences of the service with them. (2) Discussing care practices with staff and management. (3) Inspecting records and the care environment. (4) Carrying out a survey of the views of people using the service, staff and professionals who work with the service. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. Care Homes for Adults (18-65 years) Page 6 of 25 What the care home does well: What has improved since the last inspection? What they could do better: 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. Care Homes for Adults (18-65 years) Page 7 of 25 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 8 of 25 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information provided to people who use the service (e.g. regarding services offered) is good. For example all people who use the service (and /or their representatives ) receive a statement of terms and conditions of residency or contract when they move in. This ensures people are aware of their rights and responsibilities. Pre admission assessment procedures are satisfactory and should ensure the registered persons check they can meet the persons needs before admission is arranged. Evidence: We inspected a copy of the homes statement of purpose and service user guide. These contain satisfactory information about the service. The registered provider has a satisfactory assessment procedure. For example prospective clients and their families visit the home before admission is arranged. Senior staff visit the person to meet them as part of the assessment process. The person concerned also visits the home. There has been no admissions to the service since the last inspection. We were able to inspect contracts / statements of terms and conditions of residency for people using the service. Information inspected was satisfactory. Care Homes for Adults (18-65 years) Page 9 of 25 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Satisfactory care planning procedures are in place. There is satisfactory opportunity for people to participate in making choices and be involved in decision making. Staff enable people using the service to take an appropriate level of risk so they can pursue as independent a lifestyle as possible. These measures ensure the needs of people who use the service are met and they are given the opportunity to make choices how they lead their lives. Evidence: A care plan was contained in the file for each person we case tracked. Care plans are accessible to staff. There is a review process in operation, and people who use the service (and / or their representatives) are invited to review meetings when these occur. From discussion and observation, people who use the service are as much as possible involved in making decisions about their lives, and how the home is run. Where restrictions are in place, these are recorded. Restrictions in place appear appropriate Care Homes for Adults (18-65 years) Page 10 of 25 Evidence: considering peoples needs. Suitable risk taking seems to take place to enable people using the service to live as independently as possible. The home has its own transport, which enable people to participate in community activities. Suitable risk assessments are kept on file, and reviewed as necessary. Care Homes for Adults (18-65 years) Page 11 of 25 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this 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 registered persons ensure people living in the home can live a lifestyle which meets their needs and wishes. Evidence: People using the service have the opportunity to pursue a range of activities such as going attending work placements. going to the gym, helping with the food shopping etc. Social and shopping trips are organised according to the wishes and needs of individuals. There is evidence from daily records that people participate in a suitable range of activities. People have opportunity to visit friends and relatives and these people also visit the home. Routines in the home seem appropriate. There was a relaxed and friendly atmosphere in the home during the inspection. The home has a menu with a suitable range of meals available. Records also show people appear to have a varied and nutritious diet. Care Homes for Adults (18-65 years) Page 12 of 25 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal and healthcare needs of people living in the home are satisfactorily promoted and met. The management of medication is satisfactory so people using the service and their representatives can be assured medication is managed appropriately. Evidence: We observed people using the service receiving suitable care and support from staff. Support was carried out in a professional, but relaxed and friendly manner. Documentation regarding how care tasks are completed is satisfactorily documented in care plans. People living in the home appear to have their personal hygiene needs met. All people using the service looked well cared for on the day of the inspection. Staff working in the home, who responded to our survey said the staff team worked well together to ensure the needs of people using the service are met. They said care is individualised and individual choices are encouraged. The manager said people living in the service have suitable access to health care professionals such as GPs, dentists, district nurses, chiropodists, opticians etc. Records of this support is well documented. Care Homes for Adults (18-65 years) Page 13 of 25 Evidence: We inspected the medication system. The medication policy seems satisfactory. Medication is stored appropriately in a medication cupboard. Medication is administered via a monitored dosage system supplied by a local pharmacist. Staff have received appropriate training regarding handling medication. Administration and recording of medication is satisfactory. Care Homes for Adults (18-65 years) Page 14 of 25 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this 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 registered persons have satisfactory complaints and adult safeguarding procedures. This should help to ensure any concerns, complaints and safeguarding allegations are investigated appropriately. Evidence: Copies of the complaints and adult safeguarding procedures were inspected and are satisfactory. We would advise the registered provider to include information regarding access to the social services complaints procedure within their procedure and /or within individual service user guides. People who are funded by local authorities have a right to use this procedure if they are funded by social services, and subsequently they should be made aware of this. The registered providers adult safeguarding procedure is satisfactory. Care staff said they would inform the manager if they suspected any abuse had occurred. Training regarding safeguarding is delivered to care staff as part of their induction. Staff who we spoke to, said they had no concerns regarding the attitudes of other staff or care practices in the home. Care Homes for Adults (18-65 years) Page 15 of 25 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Heightlea provides a suitable facility for the people living there. Evidence: The building was inspected. The home is registered for three people. However, there are a total of four people using the service. Two people only sleep at the home during part of the week ensuring there are only three people sleeping at the home at any one time. The rest of the time these two people live with their families. This is an unusual arrangement, which has been discussed with the commission. It would be advisable for the registered provider to register the home for four people so the two people could live at the home, in the future, on a full time basis should this become their wish or should it be necessary. Each person has their own bedroom. The home is a spacious house. There is a large lounge, and a kitchen / diner. There is also a second lounge with a conservatory attached to it. There is a spacious games room on the first floor which has a pool table which people using the service regularly use. Some of the carpets in the communal areas are beginning to become worn and stained and should be replaced in the next 12-18 months. There is a pleasant garden which people living in the home can use without staff accompanying them. There is suitable toilet and bathing facilities. The registered manager said thermostatic Care Homes for Adults (18-65 years) Page 16 of 25 Evidence: valves are fitted to all bath and shower facilities. The home was clean, warm and light enough on the day of the inspection. The kitchen was clean. Laundry facilities are satisfactory. The outside of the building and the gardens were maintained to a satisfactory standard. Care Homes for Adults (18-65 years) Page 17 of 25 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels appear satisfactory to meet the needs of people currently accommodated at the home. Recruitment checks are to a good standard. Improvement is required regarding staff training. First aid training needs to be prioritised for some staff. Suitable numbers of staff, who are recruited and trained to legal standards ensure people using the service receive appropriate support from professional staff. Evidence: On the day of the inspection there were satisfactory numbers of staff on duty. There were three people on duty during the day (i.e. within the core time of 09:00-15:00). One person was on duty in the evening (and then sleeping in) although the registered manager said there is usually two staff on duty in the evening. Some people, who responded to our survey, said at times there should be more staff to enable there to be more one to one activities. Some people said staff could at times be asked to work at other homes, within the group, due to staff shortages. When this occurred it sometimes made it difficult for people using the service to carry out their activities programmes, and this could be frustrating for all concerned. Where possible moving staff from the unit to assist other homes should be avoided if this is to the detriment of people living at Heightlea. For example agency or bank staff should be Care Homes for Adults (18-65 years) Page 18 of 25 Evidence: employed. However it is recognised that such action is necessary in emergencies. Personnel records were inspected for the staff on duty for the day of the inspection. These were satisfactory.Staff employed had two references, a Protection of Vulnerable Adults First check (POVA First) , a Criminal Records Bureau check (CRB) , a completed application form and evidence of identification. It would be helpful if a scanned copy of the POVA First check is stored with other personnel records on the Spectrum records system. This will help us validate this check has been completed before the member of staff has commenced employment. We inspected training records for the same sample group of staff. By law staff require the following training: * Regular fire training in accordance with the requirements of the fire authority. *There must always be at least one first aider on duty (at appointed person level) *All staff must have manual handling training and should have regular updates of this (e.g. annually) *All staff must have basic training in infection control. * Staff who handle food receive food hygiene training. * All staff must have an induction and there needs to be a record of this. * Awareness training regarding the needs of people accommodated. The delivery of training is generally satisfactory. The registered provider offers staff a comprehensive staff induction which covers the majority of the elements required by law. Staff subsequently attend follow up training which covers the areas more comprehensively. However, some of the staff files inspected show that some of the staff still need to attend training for example in first aid, food handling, and infection control. Although most people had a first aid certificate, these were dated 2005 or 2006 (April-December). Certificates are valid for three years so it is essential, where necessary, staff are priorised to obtain an appointed persons first aid certificate, particularly if they are working alone. Staff have received training regarding autism and how to deal with difficult behaviour. There is opportunities for staff to obtain a National Vocational Qualification in care. When staff have received an NVQ 2 there is the opportunity to obtain an NVQ 3 in care if this is deemed by management as appropriate. Care Homes for Adults (18-65 years) Page 19 of 25 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this 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 registered manager and the staff team are effective in ensuring the service is managed to a good standard. Quality assurance procedures are to a good standard. Health and safety procedures and checks are to a satisfactory standard, although improvement is required regarding the prevention of legionella. Evidence: The registered provider is Spectrum, a registered charity supporting people with autism / aspergers syndrome. A registered manager is also in post. The registered manager seems very organised, knowledgeable about people using the service and competent. The registered provider has a good approach to quality assurance. For example an annual development plan was inspected for the service. However, there is no policy regarding quality assurance on file. This needs to be obtained from the registered provider or written by the organisation if such a policy is not currently in existence. The registered provider has supplied the commission with their Annual Quality Care Homes for Adults (18-65 years) Page 20 of 25 Evidence: Assurance Assessment (AQAA) (an annual dataset, and self assessment required by CSCI). This was completed to a good standard. CQC / CSCI have received some notifications, required by the commission (e.g. regarding untoward incidents). However we noted two incidents in the homes records, regarding people who use the service, which we should have been notified of. One incident resulted in a hospital admission. However staff did appear to deal with the incidents competently. The registered persons do need to ensure we are notified of such incidents in future. People responding to our survey said they believed the service was well run,and staff do their best to meet the needs of people using the service. Policies and procedure files in the home are dated May 2003. It is important there is evidence these are being regularly reviewed and updated when required. Personal monies are managed by staff on behalf of people using the service. Money is held securely. Suitable records are kept recording any expenditure. However there appeared to be some minor discrepancies between what was recorded in records of peoples moneys and cash held in peoples cash tins. Management need to ensure systems are improved to avoid such discrepancies occurring-for example staff should regularly check cash held against totals in records, and ensure records are kept up to date. The registered provider has a health and safety policy. There is a fire risk assessment. Testing of fire extinguishers and the fire system appear to have been completed appropriately by external contractors. Internal checks on the fire system appear to have been completed appropriately by staff (e.g.emergency call points and emergency lighting). Health and safety risk assessments have been completed. However, we did not view any risk assessment or routine testing records regarding the prevention of legionella. We have been told a system is due to be set up regarding this matter. Records subsequently need to be kept and made available for inspection. Suitable records regarding accidents and incidents are kept. Portable electrical appliances have been tested and appear satisfactory. The electrical hardwire circuit was tested when building work at the home was completed. The test results were satisfactory.Gas appliances have been serviced. An up to date certificate of insurance is displayed. Care Homes for Adults (18-65 years) Page 21 of 25 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 22 of 25 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 35 18 Staff need to receive training as outlined in the body of the report. Staff training regarding first aid needs to be prioritised. This will ensure all staff have appropriate knowledge and skills, in accordance with the law and to meet the needs of the people accommodated in the home. 31/01/2010 2 42 12 Ensure a risk assessment is completed, and any subsequent control measures are introduced regarding the prevention of legionella. This should help to ensure staff and people who use the service are protected from this disease 31/01/2010 Care Homes for Adults (18-65 years) Page 23 of 25 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 22 Ensure there is reference to the Social Services Complaints procedure, in the homes complaints procedure, and /or service user guide, as people funded by local authorities have a right to use this if they have a concern or a complaint. Consider increasing the registration of the home to four people. The registered provider should avoid moving staff from the unit to assist other homes, to cover shifts, if this is to the detriment of people living at Heightlea. More bank or agency staff should be employed. 2 3 24 33 Care Homes for Adults (18-65 years) Page 24 of 25 Helpline: 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. 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. 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