Care Home: Keate House

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What the care home does well What has improved since the last inspection? To ensure that residents are cared for by well supervised staff the manager now ensures that formal supervision sessions take place six times a year with records kept that comply with the Data Protection Act 1998 in regard to storage of information and confidentiality. Progress has been made in staff obtaining NVQ level II in Care, and there are now over 50% of care staff with this award. To enhance the care and support given to residents, care plan records now include information gained by key workers during individual time spent with residents; areas of change are now noted on the care plan review sheets; and development of residents` life history information and recording of activities that the residents like is being currently undertaken. To ensure compliance with the Data Protection Act 1998 the details kept in the accident book have been addressed. To ensure that residents medication is administered appropriately issues raised in the last report have been addressed by the home adopting a new monitored dosage "blister pack" system. To ensure that residents are protected by the homes recruitment procedures identity checks are now made on all staff employed at the home. What the care home could do better: The home provides an excellent service to its residents. The residents themselves confirmed this through discussions with the inspector and from information from questionnaires received and also through discussions with the staff team. Surveys were also sent to family members and other professionals.The home has a good reputation in the local community and it is important for them to maintain the high standards that they are currently achieving. The inspector considered the home looked after people very well. CARE HOMES FOR OLDER PEOPLE Keate House Brookfield Road Lymm Warrington Cheshire WA13 0QL Lead Inspector Maureen Brown Unannounced Inspection 12 October 2007 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Keate House Address Brookfield Road Lymm Warrington Cheshire WA13 0QL 01925 752091 01925 754022 keatehouse@tiscali.co.uk 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) Mrs Avis Clarkson Mr Malcolm Clarkson Mrs Avis Clarkson Mr Malcolm Clarkson Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 48 service users to include: * Up to 48 service users in the category of OP (old age, not falling within any other category). 2. Bedroom numbers 1 & 94 only may be used to accommodate two service users. 24 October 2006 Date of last inspection Brief Description of the Service: Care and support are provided at Keate House for up to 48 older people. The home is located in Lymm, close to the village centre shops, pubs, restaurants and banks. The home was opened in 1989 and consists of a four-storey building with resident accommodation on the ground and first floors. In December 2004 a three-storey extension was completed providing additional single bedroom ensuite accommodation. The home has forty-four single and two double bedrooms, all of which are en-suite. There are two passenger lifts. Car parking is provided at the front of the building and there is a garden to the side. The home has thirty-one staff that comprises of the Registered Managers, care and administration managers, senior care assistants and care assistants. The cook, general assistant, domestic and laundry staff and maintenance people support them in their roles. The fees at Keate House are £445.00 per week. Items not covered by the fees include hairdressing, chiropody, newspapers, magazines, toiletries, sundries and bingo. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place on 12 October 2007 and lasted seven hours. This visit was just one part of the inspection. Before the visit the home was also asked to complete an annual quality assurance assessment to provide up to date information about services at the home. Questionnaires were also made available for residents, relatives and other professionals to find out their views. Other information since the last key inspection was also reviewed. During the visit various records and the premises were looked at. A number of residents and staff were also spoken with and they gave their views about the service. Twenty-four out of thirty-eight standards were assessed and all were met. All the key standards were assessed. Feedback was given to the manager at the end of the visit. What the service does well: The home had an established staff team who were keen for high standards to be maintained. Residents’ plans of care and individual case notes were well documented and reflected each resident’s needs. Meals were varied and reflected each person’s preference. They offered choice and variety. With the help of care staff and the senior care staff the activity co-ordinator manages daily activities and entertainments well and provides a range of activities. A good standard of hygiene was seen throughout the home and the standard of décor was high. Residents said that “she and her husband were very happy, it was like a five star hotel and you couldn’t be better looked after”, “the staff were good to them and helped them when needed” and “the food was good and most said they enjoyed the activities provided”. Other comments included “I am very happy here and the staff are excellent”. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 6 Visiting professionals stated, “they have a good relationship with the staff and service users. They work well together and it is a good home.” Staff said, “the training is good”, “the staff support each other well”, “the support from the management team is good”, and “it’s a very friendly home”. Observations made during the site visit included discussions between the manager and the staff team and interactions between residents and staff. Staff were respectful towards residents and had an easy and friendly manner. Staff were also seen providing support to residents in a caring and sensitive manner. What has improved since the last inspection? What they could do better: The home provides an excellent service to its residents. The residents themselves confirmed this through discussions with the inspector and from information from questionnaires received and also through discussions with the staff team. Surveys were also sent to family members and other professionals. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 7 The home has a good reputation in the local community and it is important for them to maintain the high standards that they are currently achieving. The inspector considered the home looked after people very well. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Keate House DS0000027005.V347679.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 Keate House DS0000027005.V347679.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient information is provided for residents to make a decision about moving into the home. EVIDENCE: The statement of purpose and service users guide are produced in a bound file and include information about the facilities, services provided, fees and terms and conditions of residence. A copy of the most recent inspection report was available. Residents and relatives confirmed that they were aware of the service users guide and the inspection reports. The statement of purpose and service users guide were reviewed in September 2007. The manager stated that copies were given to residents and others on request. It was produced in plain English and standard print format. At present the manager is developing a simplified guide to the home entitled “Welcome to Keate House”. This will cover some of the information in the service users guide but also have other relevant information about the home. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 10 This has been designed to help people have access to other relevant information regarding the day-to-day running of the home and was developed from frequently asked questions. A draft copy was seen and it had a photo of the home on the cover. It gave good and clear general information about the home. This will be an excellent addition to the information already provided and be a valuable resource to prospective and current residents. In each residents file a needs assessment had been completed. This covered the basic areas of care and support that a person may require. Relatives confirmed they had been involved in the assessment process. The manager stated that intermediate care was not provided at Keate House. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: Four residents’ care records were seen during this visit. These were comprehensive and well presented in individual binders. Each contained basic information, all areas of personal care information, social activities, a record of visiting professionals and a copy of the daily report sheets. The residents signed care plans to show that they agreed with the contents. Areas of improvement since the previous visit included recording information gained by key workers within residents plan of care; developing the life history information in the care plans; and including areas of change on the care plan review sheets. These previous recommendations have been met. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 12 Many of the residents within the home were not able to confirm that they had been involved in the care planning or review process. However they were able to confirm that staff helped them when they needed it, such as with personal care tasks and that staff were “always available when you need them”. Observations made during the site visit included seeing staff interaction with residents throughout the day. The staff were attentive to residents needs and helped them when required. Daily record sheets seen showed day-to-day activities of each resident. They were written clearly, easy to follow and were signed by carers. The medication was stored in a locked trolley and the home had changed its medication system to a new Monitored Dosage “blister pack” System. Some residents had controlled drugs and these were stored and administered appropriately. Medication administration record sheets were seen and were appropriate. Staff spoken to said “they had received medication awareness training”. Recommendations made regarding medication issues have been met following the change in the system. Professional visits were recorded and it was seen that the GP’s, district nurses, optician, audiologist and the chiropodist visited on a regular basis. Also Social Worker visits to complete annual reviews were recorded. The general atmosphere within the home was warm and friendly. Staff were also friendly towards visitors and were observed offering visitors refreshments. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ were able to take part in a range of activities of their choosing. Personal and family relationships were encouraged by the home and the staff team supported people with this. EVIDENCE: Residents’ privacy and dignity is discussed with staff during the induction process. It is also documented in the statement of purpose and reflected in the service users guide. During the inspection a sample of bedrooms were seen and these were decorated to residents’ personal tastes. They also had their own belongings, photographs and personal mementos in the bedroom. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 14 Visits from family and friends were recorded in the case notes. Residents shared with the inspector the contact they had with family members and said they could choose to see visitors within their own room or in the shared lounge/dining area. Relatives said that they were always made very welcome by the staff and were offered refreshments. They said that they could visit their family in the privacy of their own bedroom or in one of the lounges. The home now provides an activities co-ordinator who plans the weekly activities in conjunction with the residents. The range of activities provided included bingo, hairdressing, library service, day excursions, arts and crafts, dog patting service, sing-a-longs, clay modelling, dominoes, quizzes, garden activities and trips out in the homes mini bus. Also family outings, parties inhouse and “contact the elderly” monthly afternoon tea sessions and barge trips are also enjoyed. Regular religious services are held. During this visit residents were enjoying playing skittles with the staff and the “pat a dog” service was also in the home. The residents appreciated being able to stroke and chat to the dog and their owner. Records are kept of activities completed by each resident and individual time is also given to each resident. Most residents confirmed there was a range of activities they joined in with. A previous recommendation regarding adding more details of activities residents like in the care plans had been met. It was noted by the inspector that residents were able to exercise choice over many aspects of their daily life. Whether to join in activities or not; choosing when to get up and go to bed; choice of food from the daily menu, (and whether to eat in company or not); and having their own personal possessions within their bedrooms. Samples were seen of the four-week rota of menus. These showed that a varied diet was provided to the residents. There was a choice of meals at lunch and dinnertime. A wide variety of meats, fish, cheese and vegetables were on offer. Residents confirmed they enjoy the meals provided. Hot and cold drinks are provided throughout the day. Juice and water is available in jugs in each lounge. All appropriate records are kept in the kitchen including fridge temperatures and records of hot cooked foods. The kitchen was seen to be clean and tidy during this visit. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear policies are in place to ensure that residents were protected from abuse, neglect and self-harm. EVIDENCE: The policy on complaints was seen and relevant paperwork was available in the event of a complaint being received. The Commission had not received any complaints since the last visit. The home had received one complaint since the last visit and this is still ongoing. Residents spoken with confirmed they would contact the manager if they had any problems. Discussions with residents and relatives indicated that they were aware of the complaints procedure and if they had a problem then they would contact the manager. The home had policies on the prevention of adult abuse, whistle blowing, challenging behaviour and harassment. These policies were consistent with the “No Secrets” guidance from the Department of Health. The homes policy included information on the types of abuse such as physical, verbal, sexual and neglect, signs and symptoms and reporting abuse. A copy of Warrington Social Services policy on Adult Protection was available within the home and was accessible to staff. Staff confirmed that they were aware of the procedures and who to contact with any concerns. All staff had undertaken training on Adult Protection. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a good, clean and comfortable environment for the people to live in. EVIDENCE: The home was furnished in a domestic style with additional equipment such as grab rails, raised toilet seats and hoists provided as necessary to meet the residents’ needs. There was an excellent standard of décor throughout. Heating and lighting was sufficient throughout the home. Residents confirmed the home was always warm. The garden area is enclosed and residents are encouraged to sit outside during the better weather. The home was clean, tidy and free from any unpleasant smells. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 17 The home has a good redecoration programme in place. Since the last visit the conservatory had been renovated and had new furniture, tables, chairs and full redecoration. New windows had been fitted in three bedrooms. The continued renovation of bedrooms and external decoration to the building was progressing well. The laundry and training rooms had also been decorated and new garden furniture and gazebos had been purchased. This had significantly improved the facilities for resident. The majority of the bedrooms are a good size and the furnishing and fittings are of a high quality and are well maintained. Wooden flooring has been provided in most bedrooms. The manager said that residents were given a choice of wooden flooring or carpet in their bedroom on arrival. Rooms had been personalised by the residents with their own furniture, pictures and mementoes. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Records were maintained in a satisfactory manner and residents are protected by the homes recruitment policy and practices. EVIDENCE: The staff rotas showed the staff on duty over the week. This appeared to meet the needs of the residents. Residents confirmed that enough staff were around to help them and observations made during the site visit showed staff were attentive to residents needs. The staff team included the co-owners, managers, deputy manager, senior care assistants, care assistants, domestic staff, laundry staff, cook, kitchen assistants, maintenance staff and administration staff. Significant progress had been made towards achieving over 50 care staff trained to NVQ level II in care. Sixteen out of twenty-six staff had this award and three staff were working towards it. The previous recommendation regarding this is now met. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 19 All staff have completed a two-week induction programme. Mandatory courses undertaken included manual handling, food hygiene, fire awareness, abuse awareness and first aid. Other courses included diabetic care, optical awareness, malnutrition training, wound and pressure care and medication. A selection of certificates were seen on staff files. The formal training of staff given ensures they are able to use the knowledge and experience gained to provide a good standard of care to residents. The recruitment procedure ensures that the staff are suitable to work with vulnerable people. Six staff files were examined and these showed that all relevant pre-employment checks were carried out. This included application forms, two references, Criminal Record Bureau checks and terms and conditions of employment. Following a previous recommendation identity checks have been completed for all staff and this has been met. Other areas where staff are able to voice their opinions include staff meetings, which are held regularly, the last one in June 07 with sixteen staff attending. Issues discussed included residents, general issues, NVQ, staffing issues and any other business. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of the residents are protected by the robust procedures in place and the views of residents are obtained to influence the running of the home. EVIDENCE: The manager provides clear leadership to the staff team and is supported by seniors, maintenance staff and administration support. The manager has the Registered Managers award is an NVQ assessor and moving and handling trainer. She has worked at the home for fourteen years, of which eight as the manager. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 21 A quality assurance process was in place. This included service users surveys, residents meetings, a newsletter, day-to-day contact with residents and key worker time with residents. Resident meetings are held on a regular basis in an informal manner and notes are kept of the meetings. Resident’s surveys are carried out. The last one was in March 2007. Comments included “the care provided is sufficient for general residential care”, “I am very happy with the care and attention given”, “staff are extremely kind”, “I am happy here, plenty of activity and visitors are made welcome” and “I feel the food is excellent”. Visiting professional surveys from August 2007 stated “everything to a high standard”, “ I have always felt welcome and at ease with the staff”, “staff behave in a polite, professional manner”. The manager stated that money is available for residents at the home. Records of these transactions were seen and appropriate. Some residents have their own money or families are invoiced on a monthly basis. Safe working practices included fire safety in which all weekly checks are carried out and recorded, up to date certificates for electrical safety, gas safety, portable appliance testing and tests and servicing for all equipment for moving and handling. These checks ensure that the residents are being protected by the procedures in place. The accident book was seen and appropriate records were kept. The previous recommendation regarding storage of information has been met. The manager said that one to one staff supervision was given on a regular basis. Supervision notes were seen and up to date. Previous recommendations regarding the frequency of the sessions and the method of recording have been met. Observed day-to-day supervision of staff was good and the staff team confirmed they were supported by the manager and the senior staff in their role. Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 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 X 4 X 3 3 X 3 Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 23 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. Refer to Standard Good Practice Recommendations Keate House DS0000027005.V347679.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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