Care Home: Sanford House Nursing Home

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What the care home does well The service user`s guide summarised all information for potential service users, providing an opportunity to choose the service if new referrals liked it. Residents` documents, such as care plans, risk assessments and daily records, were accurate, reviewed regularly and showed the involvement of residents in care planning. The observed process of care and daily life of residents showed that the relationship between staff and residents was built on trust, respect, and created a safe and comfortable environment for residents in the home. A resident spoken to commented: "I have no complaints. Staff are very good to us. They help us and they listen when we talk to them." The staff team was, in particular, well organised: everyone knew what they were doing and residents benefited from a well-structured daily routine. Although the home was operationally divided into two units (that matched residents` conditions), the staff worked accross the home and knew all residents well. The management of the home gave clear directions to staff and organised life in the home so that residents felt comfortable and safe, enjoying the benefits of a friendly and respectable atmosphere. However, the responses from the head office to requirements made by the manager and supported by the operational-regional manager slowed the progress the home would otherwise have made and delayed improvement in conditions and care to residents. What has improved since the last inspection? Access to the garden by all residents was now accommodated, as a new secure fence was erected and improved safety for residents. The quality assurance review had just been completed and the operational manager and the manager were going to review results and create an action plan. What the care home could do better: The home had two hoists, one newer type and one older. Some residents had to wait to be helped and increased high needs of residents clearly indicated the need for at least another hoist. Kitchen budget currently was used to pay a delivery charge to a contracted food supplier and thus reduced the amount spent on food for residents. There was a need to either review the budget, or review the supplier`s contract and spend money on primary allocation-food. Despite repeated orders, some kitchen equipment was not repaired or replaced. The cook used to bring in her own cake mixer to rectify the situation. Table mats were worn and needed replacement. The management explained the the whole dining room was due for re-decoration, but the table mats and the beakers with handles could be addressed before and separately. Lack of appropriate storage space for fresh vegetables affected the orders - less fresh vegetables were ordered. The main cook was wearing a uniform, a t-shirt with holes. The uniforms too needed replacement. Key inspection report Care homes for older people Name: Address: Sanford House Nursing Home Danesfort Drive Swanton Road East Dereham Norfolk NR19 2SD     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: Dragan Cvejic     Date: 0 4 0 6 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 Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. 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 Older People Page 3 of 28 Information about the care home Name of care home: Address: Sanford House Nursing Home Danesfort Drive Swanton Road East Dereham Norfolk NR19 2SD 01362690790 01362690890 sanford@caringhomes.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Sanford House Limited care home 43 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Maximum number not to exceed forty-three (43). The home may accommodate two (2) people with a physical disability. The home may accommodate up to forty-two (42) elderly people over the age of 65 years, of either sex, who may or may not have dementia. Date of last inspection Brief description of the care home This home provides care with nursing to a maximum of 43 older people. The home is located on a private driveway close to the centre of the market town of East Dereham. The home was purpose built in 1998 and all accommodation is located on the ground floor. Wheelchair access and car parking are located at the front of the home. The building is divided into 2 units. The Carrick Unit cares for older people plus one Care Homes for Older People Page 4 of 28 0 0 2 Over 65 42 42 0 Brief description of the care home person with a physical disability; the Shannon Unit cares for older people with dementia. There is a secure courtyard garden in the centre of the home, with access from some bedrooms. There are shrubs, flower borders and lawn areas to the front of the home. Garden seats and tables are located in the courtyard garden. Any additional charges are listed in the Service user Guide. Prospective residents and their representatives are advised of the fee rates at the time of enquiry and also when assessments and other contacts take place. Care Homes for Older People Page 5 of 28 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 Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. After revieving the service through an Annual Service Review last year, the home continued to provide very good service to the people that were cared for and supported in Sanford House. We monitored the service through reporting activities. We asked users of the service and staff to fill in questionnaires about the quality of service and received a good response, one staff member and 4 users returned their comments. We asked the home to provide self assessment using the AQAA (Annual Quality Assurance Assessment) form that they returned as requested. This inspection included a site visit on 08/06/09 and lasted for 5 hours during which two service users were case tracked and two more files were checked. A further 5 service users spoke to the inspector, as well as three staff members, the operational Care Homes for Older People Page 6 of 28 manager who visited the home at the same time, and the manager. We attended the staff handover, which demonstrated how the staff effectively shared information and addressed each individual resident. Some documents, user and staff files were also checked. A tour of the home provided direct information about the environment. We checked the kitchen and spoke to the cook in length. We checked medication and financial procedures and checked money held by the home for 3 residents. Care Homes for Older People Page 7 of 28 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 Care Homes for Older People Page 8 of 28 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 Older People Page 9 of 28 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 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 and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. 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 them 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 and their relatives could choose the home based on information provided prior to admission and on properly conducted initial assessments as an indicator that the assessed needs would be met. Evidence: The manager stated that the statement of purpose and users guide were reviewed and updated where necessary. In their self assessment, AQAA, the home reported that contracts were issued to either users of the service or their relatives. Questionnaires returned indicated that relatives and some residents were aware of the contracts and that all necessary information was included in contracts. Two of the returned questionnaires confirmed a detailed initial assessment was carried out prior to admission. Four randomly chosen residents files contained a comprehensive assessment of the assessed needs and contained a detailed risk assessment drawn up at the same time. The initial assessment indicated and Care Homes for Older People Page 11 of 28 Evidence: highlighted areas that needed to be addressed in care plans. Although residents needs were met, a slower response to their mobility needs were affected by only two hoists used in the home. Two residents spoken to and three staff commented that there was a need for at least another hoist. This issue is addressed in the environment and equipment section of this report. Care Homes for Older People Page 12 of 28 Health and personal care 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 health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they 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. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them 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. Residents benefited from an individual approach to their care, from good staff knowledge of their needs and from the respect shown to their abilities to remain as independent as possible. Evidence: Four residents files were checked. Care plans were drawn up from the initial assessment and addressed all assessed needs in detail. Clinical conditions were properly checked prior to admission and the monitoring continued. The personal care needs, including mobility, were also described in detail, allowing staff to use appropriate thechnique and respect residents wishes when helping them. One of the files addressed mobility: Moving from bed to chair over almost half a page, thus being very clear on how to move the resident. Social and spiritual needs were assessed and recorded, as well as past life history, which guided the activity co-ordinator to plan appropriate activities for each individual. Reviews of care plans and risk assessments wern dated and signed and showed that monthly reviews were held. Residents or their representatives were asked to sign a number on consent forms: to receive medication by staff, to be moved by the use of a Care Homes for Older People Page 13 of 28 Evidence: hoist, to have bed rails installed for their safety and some other forms. A resident spoken to stated that she received appropriate care, but thought that she would benefit form physiotherapy and stated that she would tell staff her wish. External professionals were involved in care when there was a need. The record of G.P. rounds was kept in the staff room. Healthcare records and comments from residents confirmed that this aspect of care was appropriately addressed. Medication records, storage, administration process and the amount of some medication for three residents were checked and found to be appropriate. Privacy and dignity were respected. Some users preferred to have their bedroom doors open and stated that :They(staff) do not need to knock, I keep my door open. Yes, they fully respect our privacy, commented another resident spoken to. The returneed questionnaires also indicated that privacy and dignity were respected. Observation of the care process for 45 minutes also demonstrated full respect for residents dignity. Care Homes for Older People Page 14 of 28 Daily life and social activities 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 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. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. 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. Although activities within the home were appropriate, the issues regarding kitchen and food reduced better outcomes for residents within this group of standards. Evidence: Residents spoken to stated that their daily life and routine were organised in the way they liked. Questionnaires returned indicated that residents were happy with daily life and routine. A resident spoken to stated: We can get up and go to bed when we want, there are no restrictions. The records of activities were kept in two folders, one listing the planned and organised activities and the second one listing individual residents participation. This method of recording helped the activity organiser and the manager monitor activities in order to make necessary addaptations. The homes AQAA reported: We provide a programme of group and individual in house activities. We have an activities co-ordinator who tries to involve residents in developing the social activities programme and also provides more personal 1-to-1 experience for clients who do not wish to be involved in group activities. We offer entertainment or activities from external entertainers on at least a monthly basis. We try to identify our service users interests from their biography details. Care Homes for Older People Page 15 of 28 Evidence: Currently the local clergy are in interregnum. However we are able to contact them should the client wish or the need arises. Autonomy and choice were promoted through the choice to join in activities, to choose the menu,and to control self care as much as possible. A resident stated: I do not need them, I am quite independent, but when I do call, they come. Another user confirmed that she had a few coins with her, as she wanted to. The comments on food did not demonstrate any dissatisfaction with the quality or quantity. The menu and the suggested menu proposed by the residents and shown to us by the cook also confirmed that a relatively balanced diet was offered to residents. However, the cook presented some of the problems: it was not possible to keep fresh vegetables in the fridge, as there was not enough room in. Keeping it in an open cupboard, as they were currently doing, would not ensure that fresh vegetables can be kept for 7 days when the deliveries were organised. This resulted in very little fresh vegetables being used. The week of the site visit, the only fresh vegetable was cabbage. When discussed with the manager and the regional operational manager another problem became apparent. The home followed the organisations procedure for ordering food. The organisation had a contract with a big supplier. A delivery charge was payable from the homes food budget. This significant figure reduced real food items for residents. Both management members wanted much higher independence to manage the food, to buy from a different supplier, on a more frequent basis and to pay much less for delivery. Care Homes for Older People Page 16 of 28 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. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. 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. Clearly displayed and appropriately followed complaints procedure reassured residents that they could complain with confidence and that they were protected by the appropriate protection measures being in place. Evidence: The home reported in their AQAA: We keep a full record of all complaints and details of investigations and actions. We attempt to use any comments or complaint to improve the care and service we give to our residents. We have a clear and comprehensive complaints procedure. We ensure that all complaints and comments are investigated in a clear, open, and comprehensive manner. We ensure that complaints are responded to in an appropriate and timely manner. The use of recliner chairs and bedrails is always discussed with residents and relatives, gaining their permission before use. The files checked also showed a number of conset forms signed by residents or their relatives, that ensured better protection of both residents and staff. There was an on-going POVA (Protection Of Vulnerable Adults) procedure at the time of the inspection. The manager explained the details surrounding it. There was no immediate danger to residents resulting from this case. The number of deaths in the last year in the home was relatively high and this issue was discussed with the manager and with two senior nurses separately. All indications Care Homes for Older People Page 17 of 28 Evidence: were similar: the home was accepting very frail people, in one case one accepted person died in the hospital the day after the assessment was carried out. However, the manager was fully aware of the facts and was closely monitoring the situation in co-operation with social services. Care Homes for Older People Page 18 of 28 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, 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. 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. A nice and pleasant environment appropriately divided into units helped residents feel relaxed and at home. However, the kitchen and dining room as well as some equipment were not satisfactory and reduced the effects of good care offered to residents. Evidence: The location of the home in a quiet residential area of Dereham, but with good access to the city centre was appropriate for its purpose. Another advantage was the structure of the home, all on the ground level. A regular maintenance programme was in place. The Access to garden for dementia care residents was now sorted, by the new fence that made it safe. The garden was also improved with new plants. The majority of comments from residents were positive and confirmed that the home was kept clean. The manager reviewed and updated infection control measures and policies. Division into units helped maintain a home free from infections. The manager reported in their self assessment, AQAA: We provide a home which is all on one level. Many rooms have direct access to a garden. There are communal lounge areas, and quiet areas should the person wish to be on their own We ensure the home is clean, safe, and well maintained. However, the cook reported insufficient numbers of beakers with handles. They were ordered on the day of the site visit. The cook reported a faulty cake mixer. Table mats were worn and needed replacement. The cooks uniform was torn and did not provide a Care Homes for Older People Page 19 of 28 Evidence: nice picture, it needed replacing. The home had two hoists that were insufficient for the increasing level of dependant residents. The staff and residents stated that they would benefit from another hoist. Infection control measures were in place. Care Homes for Older People Page 20 of 28 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 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 to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. 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. Residents benefited from being cared for by a dedicated, experienced and stable staff team, who were appropriately checked during the recruitment process and well trained to their job. Evidence: Appropriate staff cover on each shift contributed to good outcomes for residents. Dedication of staff was good and their attitude towards residents demonstrated not only respect for them, but ensured meeting their needs. Staff seen working in the units worked unhastily and found the time to talk to residents. This indicated that warm words shared with residents made the atmosphere pleasant, homely and friendly. A staff member was observed speaking to a resident who suffered from dementia who spilt something on the floor. The staff cleaned it and talked calmly and skilfully distracted the resident from negative thoughts. The AQAA reported: We ensure that staff are properly recruited and vetted to ensure their suitability for working with a frail, vulnerable client group. We ensure that staff receive comprehensive induction training in line with current standards. We provide a comprehensive training programme for all grades of staff exceeding the statutory requirements of current legislation including specialist needs such as dementia. Care Homes for Older People Page 21 of 28 Evidence: We ensure good lines of communication with all level of staff through regular meetings. We provide a programme of supervision for all staff. We have not used any agency staff since February 2007. We have raised the level of mandatory training taken by staff to over 90 . We have sourced distance learning courses for staff including dementia, palliative care, catering, and health and safety. We have introduced practical supervision of carers by registered nurses. Three staff files were checked and all relevant documents were present to confirm the reported facts in the homes AQAA. Care Homes for Older People Page 22 of 28 Management and administration 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 led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate 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. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. 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 quality of care provided in the home was strongly influenced by the strong management team that organised and managed work well and ensured that residents were not only well cared for but respected and treated as individuals. Evidence: The home presented their evidence in their self assessment, which stated: The Home manager is qualified as a Registered Nurse and holds the Registered Manager Award. the Administrator has worked in this field for the last 10 years. The home was once again awarded ISO 9001 in June 2008. We ensure the home meets all aspects of health and safety regulations and maintains the welfare of its service users. The quality assurance review had just been completed and the Regional operational manager and the manager were going to review the results and create an action plan. The administrator helped residents who needed help with finances. The records for two residents were checked and were accurate. Staff supervision was cascaded and ensured that all staff received appropriate Care Homes for Older People Page 23 of 28 Evidence: support. Seniors were using small cards to record observation of daily tasks of the staff they supervised and used their notes to better address topics discussed at supervision sessions. Staff spoken to confirmed that they felt supported and were supervised regularly. Safe working practices were in place and were closely monitored by the management team. Records of accidents and incidents were kept up to date and were used to minimise reoccurrence. Care Homes for Older People Page 24 of 28 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 Older People Page 25 of 28 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 15 16 The home must arrange for regular use of fresh vegetables in the planned nutrition for residents. This could be organised at the organisation level, if more flexibility of the budget and ordering process are reviewed. This would ensure better nutrition of residents. 30/07/2009 2 22 13 The home must have a 28/08/2009 sufficient number of hoists to meet the residents needs appropriately and reduce waiting times when they needed to be moved by this equipment. This would ensure better care for residents. Care Homes for Older People Page 26 of 28 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 2 22 22 Table mats should be replaced. This would improve the residents otherwise good experience when eating. Faulty kitchen equipment should be replaced. This would allow the cook to more easily prepare certain food items and concentrate better on quality and quantity of food, thus satisfying residents. The cooks uniform should be relpaced so that residents can see a tidy and comendable appearance in their cook. 3 22 Care Homes for Older People Page 27 of 28 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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