Care Home: Meridian Walk

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What the care home does well The home has an excellant approach to involving people living in the home in decisions that affect their lives. This includes developing ways of communication that suit the residents. The quality of care is very good and this is well evidenced in the records. The Registered Manager and his team take a proactive and positive approach to working with people with complex needs. The home environment is constantly adapted to meet people`s changing needs. What has improved since the last inspection? All requirements from the last inspection have been met. Healthcare appointments are made and recorded. Medication received into the home is properly accounted for. Complaints records include information about how complaints are dealt with and resolved. Staff training records are up to date and staff receive regular supervision. The home has a quality assurance system in place. Staff have completed health and safety training. What the care home could do better: No requirements have been made at this inspection. Key inspection report Care homes for adults (18-65 years) Name: Address: Meridian Walk 80 Meridian Walk Tottenham London N17 8EH     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: Margaret Flaws     Date: 0 3 1 2 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 26 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 26 Information about the care home Name of care home: Address: Meridian Walk 80 Meridian Walk Tottenham London N17 8EH 02083650023 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: meridian.walk@heritagecare.co.uk www.heritagecare.co.uk Heritage Care Ltd care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: The maximum number of service users who can be accommodated is: 6 The registered person may provide the following category of service only: Care Home Code PC to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Learning Disability - LD Date of last inspection Brief description of the care home Meridian Walk is a purpose built care home in Tottenham, North London owned by Metropolitan Housing. The home is managed by Heritage Care based in, Loughton Essex and has homes in Newham, Norfolk, Westminster and Hertfordshire. Meridian Walk is registered to provide specialist support to six adults, male and female, with profound learning disabilities, some of whom also have physical disabilities. The home is very spacious and well equipped. It has two floors with a lift for wheelchair users. The residents bedrooms are spacious and all have en-suite facilities that are adapted to individual needs. The lounge, kitchen, dining room and sensory Care Homes for Adults (18-65 years) Page 4 of 26 Over 65 0 0 6 6 2 7 0 3 2 0 0 9 Brief description of the care home area are in one large room, divided into separate areas that are easily identified by residents who have sensory difficulties. The garden area is paved with raised flowerbeds. All areas of the home are accessible by wheelchair users. The home is situated near an industrial site, some of which is being redeveloped for residential use. It is quite a distance away from Edmonton Angel, Tottenham and Wood Green shopping areas. The home has its own transport with a tail lift for residents with mobility problems. The aim of the home is to provide a friendly, warm, relaxing and homely environment striving to preserve and maintain the dignity, individuality and privacy of the residents and remain sensitive to each service users changing needs. The residents have access to a range of specialist services geared towards meeting their individual needs. The fees for the service are 1145 per week and there are no additional charges. Care Homes for Adults (18-65 years) Page 5 of 26 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 over one day. During the inspection, the Registered Manager assisted throughout. We spoke to three staff, two residents and two day centre staff. We toured the premises and observed interactions in the communal areas. We also looked at care, staff and general home records. The home sent us an good quality Annual Quality Assurance Assessment that informed this inspection. Care Homes for Adults (18-65 years) Page 6 of 26 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 26 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 26 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. Prospective residents can be assured that they will have their needs thoroughly assessed and have opportunities to visit the home to decide, with support, if the service is right for them. Pictorial information is available to help people with different communication abilities. Evidence: Since the last key inspection in March 2009, one new person has moved into the home. We saw this persons file and the files of three other people living in the home. Thorough needs assessments are completed prior to each new person moving in and they had had the opportunity to make trial visits and get to know the home beforehand. Alongside the homes own assessment, there were detailed assesssments on file from other care and health professionals. We discussed the needs of the people with living in the home with the Registered Manager and care staff. Residents have complex physical, social, emotional and Care Homes for Adults (18-65 years) Page 9 of 26 Evidence: mental health needs. Staff we spoke to had an in depth understanding of each person and were able to describe how they assessed and met their needs. We observed staff interacting sensitively and knowledgeably with the residents. The home has a statement of purpose and service user guide which provide good information about the service. The service user guide is pictorial to make it more useful and friendly to people with learning disabilities. Care Homes for Adults (18-65 years) Page 10 of 26 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. Residents are supported to make their own choices and live the lives they wish to. Their care is planned with them using visual media, which helps them communicate in a way that is comfortable for them. Their needs and potential risks are assessed and regularly reviewed. Evidence: We saw the files of four residents and discussed their content with the Registered Manager and two staff members. Residents had comprehensive care plans and risk assessments in place. The care plans (individual person centred support plans) were clearly arranged to cover the main areas of each persons needs. They contained full assessments, reviews, information on appointments and correspondence. Regular reviews had been completed by social workers, care managers and specialist consultants. They were updated to a very good standard. Care plans are in a process of review and recreation, with support from Care Homes for Adults (18-65 years) Page 11 of 26 Evidence: another member of the organisation with responsibility in this area.The Registered Manager showed us the evidence of how this review process is progressing. The Registered Manager showed us one persons support plan completed in a visual multimedia format. He explained how it was being used as a communication tool with both the residents and staff. He described how the visual images could communicate peoples needs and wishes more powerfully and simply than written words. This was confirmed by a new staff member and another long term staff member. The home works with each resident on a computer to develop the plans visually. Most of the residents in the home are non verbal and respond mainly to visual and physical cues. Peoples communication styles were explained clearly so staff could understand. The files and care plans also contained information on peoples cultural backgrounds and needs, how personal care was to be given and nightcare plans. Care plans were written or created from the point of view of the person. Each person had detailed risk assessments, which had been regularly reviewed and updated to reflect any new risks to their wellbeing. These assessments demonstrated how the risks could be managed without making life constrained for each resident. The risk assessments gave good guidance to staff, with details of behavioural early warning signs and ways to support the residents. There was excellant detailed guidance for the staff on the wide range of equipment used to meet peoples physical needs, manual handling risk assessments, assessments by occupational therapists and eating and drinking guidance by speech and language therapists. Because residents go on regular holidays, possible risks on their holidays were also assessed. Throughout the inspection, we observed positive, kind and warm interactions between the staff and the residents. The residents appeared very comfortable and confident with the staff and able to express their wishes and needs, to the degree to which they were able. Staff were observed to be sensitive and responsive. The daily life of the home appeared relaxed and residents were clearly spending time as they wished. Care Homes for Adults (18-65 years) Page 12 of 26 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. Residents are supported to live the lives they wish to. They are able to maintain good family and social contact. The home supports residents wellbeing through providing good quality food and nutritional choices. Evidence: Throughout the inspection, we saw good evidence that the residents are encouraged to develop as individuals and improve their independence and wellbeing, as much as they are able to. Activities are clearly recorded in the residents records. Their activities were also documented with photographs.During the first part of the inspection, most residents were at day centre. When they returned home, we were able to speak to the day Care Homes for Adults (18-65 years) Page 13 of 26 Evidence: centre staff who bought them home.They told us the residents from Meridian Walk were the best we see. They told us that their wellbeing was excellant, that the staff kept in constant communication with them and that they were very caring to the residents. The day care staff also said that they had seen continuous improvement in the residents wellbeing. The home has a sensory programme for the residents, including visits from an aromatherapist. The home places a strong emphasis on supporting residents to have holidays. Holidays were organised in consultaion with residents and families. Residents had recently been to Blackpool, the South Coast and to Disneyland Paris. The home had excellent photographic evidence of residents enjoying themselves on holiday. The home has a vehicle and staff members are able to drive. They take the residents on day trips around London. Activities included visits to the theatre, physical activities, using the computer to create stories, doing photography, listening to music and attending the local day centres. The Registered Manager told us that the residents maintain the level of family contact they wish to. Their choices are clearly documented in the care plans. Other choices are supported by the home, for example, their preferences around food, music, religeous observance and day to day activities. Food choices appeared to be flexible, to meet the residents wishes. There was plenty of good quality food in the kitchen and the staff were making a wholesome dinner of chicken curry. Menus were flexible and offered good choices. Peoples healthcare needs related diet and nutrition were properly assessed and worked with. Care Homes for Adults (18-65 years) Page 14 of 26 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. People using the service are supported in a way that protects their privacy and dignity. Peoples healthcare needs are regularly assessed, planned for and met. Medication is safely managed in the home in a way that supports and protects people. Evidence: We observed during inspection that people were supported with personal care in a dignified and respectful manner. People living in the home have en suite bathrooms which helps with personal care. They have complex physical needs and require considerable input from staff. There was good guidance on the care files about how to meet peoples personal care needs. We saw the heathcare records of four residents. These records were comprehensive and covered a wide range of healthcare needs. Residents have all had regular healthcare appointments and checkups (for example, opticians, dentists, GPs appointments). There were also records of how the home has worked with key Care Homes for Adults (18-65 years) Page 15 of 26 Evidence: professionals in supporting a resident with epilepsy. These meet requirements from the last inspection. There were good assessments, care plans and risks assessments to meet peoples continence, eating and drinking, mobility and gender specific needs. We saw the medication arrangements in the home. The home uses a blister pack system from the local pharmacy. At the last inspection, medication received into the home was not recorded on the Medication Administration Record (MAR Sheet). When we checked the records, there was a good record of all medication received. A staff member with medication audit responsibilities showed us the storage and administration arrangements. These were in order. As required (PRN) medication now has written guidance in place of when this should be administered. This also meets a previous requirement. We also saw all the training records and saw that staff have received medication training. They were able to confirm this when we spoke to the staff on duty. This meets a requirement made at the last inspection. Care Homes for Adults (18-65 years) Page 16 of 26 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. People living in the home have access to an appropriate complaints policy and procedure. They are protected by the homes safeguarding arrangements. Evidence: We saw the complaints records for the home. The complaints recording has improved with the addition of a section on the outcome of each complaint. The Registered Manager showed us how he had worked to achieve a good outcome for a complaint received earlier this year. The positive outcome and actions taken were recorded. There have been no complaints since the last inspection. We observed that residents were able to express their views in their own way and staff on duty were able to understand and respond to them. The home has a safeguarding policy and procedure and staff understood what to do if they receive or have a safeguarding concern. Staff have been trained in safeguarding adults, meeting a requirement from the last inspection. Care Homes for Adults (18-65 years) Page 17 of 26 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. People living in the home live in a homely and well kept environment to meet their needs. They have specialised facilities to enable them to lead a good life. Evidence: During the inspection we toured the building with the Registered Manager. Later we spent time observing residents in the communal areas at evening meal time. The home was clean, tidy and maintained in good condition. It has been designed to meet the residents needs. A housing association is responsible for the building maintenance. The residents bedrooms were highly personalised and adapted for their needs. For example, adaptations have been made to the bedroom of a resident with severe epilepsy. There were ceiling hoists in three bedrooms for residents who needs to be taken to the bathroom using this system. The bedrooms were very nicely kept. The open plan living space was clearly appreciated by the residents and staff. For example, one resident was able to watch food preparation in the kitchen, which she clearly enjoyed. Staff said that the space also enabled them to be closely in touch with Care Homes for Adults (18-65 years) Page 18 of 26 Evidence: the residents while doing other tasks. One resident spent time in his own chair in the conservatory . Staff said he liked to do this regularly but the open plan space also enabled staff to keep a watch on him. The conservatory also includes a computer which the AQAA stated was used by residents and staff to work on care plans together. The AQAA also stated that the home has a sensory room which we saw. This space is used for massage, aromatherapy and other sensory activities. Carpets and floor coverings were clean and in good order. Care Homes for Adults (18-65 years) Page 19 of 26 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are supported by a committed and stable staff team. Staff are safely recruited, properly trained and supported. Evidence: We saw the staff rota which demonstrated that there were sufficient staff on duty in the home to meet peoples needs. Since the last inspection, the Registered Manager is now working permanently back in the home, which has improved stability within the home. We saw the files for two staff. All staff had had appropriate preemployment checks and there were copies for Criminal Records Bureau (CRB) checks, written references and evidence of right to work on file. We spoke to one new staff member who was still in the process of induction. He described a comprehensive induction process and orientation period. He said that he felt confident and supported to work with the residents. He was also able to describe how his induction had covered the homes philosophy and how to support residents to develop through taking assessed risks. Peoples induction processes were thoroughly recorded and signed off. Care Homes for Adults (18-65 years) Page 20 of 26 Evidence: We saw the training records and the Registered Manager showed us how he kept records of training received by staff. Training received is recorded and certificates kept in order for each staff member. This meets a requirement from the last inspection. Staff have received a wide range of training relevant to the residents needs. This included manual handling, epileps, infection control, safeguarding adults, health and safety, fire safety, medication, first aid, equalities, specialist learning disability training, and NVQ qualifications. Some training is provided face to face and other training is done using computer e-learning. Staff are now supervised more regularly and they told us that supervision helped them work professionally with the residents. Supervision records were detailed and took place for all staff roughly every four to six weeks. This meets a requirement from the last inspection. We also saw the records of day and night staff meetings, which are held regularly. Staff were positive about the homes ethos and teamworking approach. Care Homes for Adults (18-65 years) Page 21 of 26 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. People living in the home are protected by sound management, quality assurance and health and safety systems. Evidence: The management of the home has now stabilised since the last inspection earlier this year. At that time, the Registered Manager was moved to cover another home and was unable to resource Meridian Walk with full time management support. Staff also said that the management was now more stable. The Registered Manager has now completed his NVQ4 in Care and is developing improved management and care systems for the home. We saw the homes quality assurance system. There is a new survey for relatives and professionals, which has been sent out for this year. We saw copies of positive feedback from relatives to the home. The Registered Manager said most relatives maintain close contact with the home and they are able to address any issues as they arise. There is also a thorough quality assurance process and audit completed by Care Homes for Adults (18-65 years) Page 22 of 26 Evidence: Heritage Care twice a year. This meets a requirement from the last inspection. The home has a health and safety management system in place. Staff have been trained in health and safety, fire and infection control. All health and safety certificates were in place and in order. The home has regular fire drills, fire equipment checks and there is an up to date fire safety assessment in place. Care Homes for Adults (18-65 years) Page 23 of 26 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 24 of 26 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 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 Care Homes for Adults (18-65 years) Page 25 of 26 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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