Latest Inspection
This is the latest available inspection report for this service, carried out on 17th September 2008. CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
For extracts, read the latest CQC inspection for The Broughtons Care Home.
What the care home does well The service ensures that they are able to meet people`s needs prior to them moving into the home. A system for recording care plans was available. Residents told us that staff treated them with respect. The home provides residents with a clean and comfortable environment to live in. The staff team have a good awareness of the needs and wishes of the residents. They have a programme of refurbishment. What has improved since the last inspection? This is the first inspection of the service since being purchased by the current owners. What the care home could do better: Improvements need to be made to the detail of information recorded in resident`s care plans about how their needs are to be met. Residents must have the opportunity to eat their meals and relax in a smoke free environment. The medication procedure needs to include information about how controlled drugs are stored and administered to residents. Procedures for the management of accidents should be reviewed to ensure residents receive appropriate support at all times. CARE HOMES FOR OLDER PEOPLE
The Broughtons Care Home 2 Moss Street Great Clowes Street Salford Manchester M7 1NF Lead Inspector
Adele Berriman Unannounced Inspection 11:50 17 September 2008
th 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 The Broughtons Care Home DS0000062302.V371493.R02.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. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Broughtons Care Home Address 2 Moss Street Great Clowes Street Salford Manchester M7 1NF 0161 708 9033 0161 792 8144 pru@broughtonhouse.org.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) Broughton Care Limited Mrs Doris Nordskog Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home provides accommodation for a maximum of 37 service users, who require personal care only by reason of old age (OP) 16th October 2007 Date of last inspection Brief Description of the Service: The Broughton’s provides residential accommodation with personal care for up to thirty-seven service users within the category of old age (OP). Accommodation is offered in 36 rooms, 35 single and one double, 31 of which have en-suite facilities. Lounge facilities are located on the ground and first floors. The home is situated in a residential area of Salford close to local amenities and transport systems. Parking facilities are available at the front and side of the property. Fees for the home range between £325.87 and £373.52. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means that people who use the service experience good outcomes.
A unannounced visit to the service was made at 11.50am on the 17th September 2008. The visit formed part of a key inspection of the service. During the visit several residents talked to us about their experiences of living at the home. Two residents and eleven staff completed surveys forms to tell us their views on the home. A selection of policies, procedures and records including care plans and staff files were seen during the visit. Prior to the visit taking place the manager of the service completed an Annual Quality Assurance Assessment (AQAA). The AQAA gave the opportunity for them to tell us what they do well, how they have improved and their plans for improvement over the next twelve months. The information in the AQAA only told us some of the information we needed. What the service does well:
The service ensures that they are able to meet people’s needs prior to them moving into the home. A system for recording care plans was available. Residents told us that staff treated them with respect. The home provides residents with a clean and comfortable environment to live in. The staff team have a good awareness of the needs and wishes of the residents. They have a programme of refurbishment. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 7 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 The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 8 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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service ensures that they are able to meet people’s needs prior to them moving into the home. EVIDENCE: They told us that once a referral was received the manager/assistant manager would visit the person to carry out an assessment of their needs. The purpose of the assessment was to gather information about the individuals’ day to day life and ensure that the home had the facilities to meet these needs. They had recently introduced a new format for recording information gained during the assessment which gave the opportunity to record people’s day to day needs.
The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 9 Information gained during the assessment was used in creating the person’s care plan. The Broughtons does not provide intermediate care facilities. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 10 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. People’s needs were being met by the staff team. Medication procedures protected people. EVIDENCE: Procedures were in place to record resident’s needs and wishes. We saw the care plans of four residents during the visit. The format for the care plans gave the opportunity to record people’s day to day needs and wishes, their previous history and information about healthcare needs. Some of the information on the care plans was not clear on what support people needed. For example, one care plan stated that the resident “needs encouragement daily” but did not state when and how the encouragement was needed. Care plans must contain detailed information about people’s needs to ensure that they receive the care they require. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 11 The care plans gave the opportunity to record individuals’ spiritual and religious needs. However, we saw no information about how the home planned to meet these needs. Individual risk assessments formed part of people’s care plans. We saw risk assessments for smoking, the environment, communication and moving and handling. Not all of the assessments seen considered all of the information on the person’s care plan. For example, one care plan stated that the resident was slightly unsteady on their feet and was being encouraged to use the bath hoist due to their unsteadiness. This information was not considered in the resident’s moving and handling risk assessment. Risk assessments must consider all known information to ensure that all risks are considered. The majority of staff told us that they were always given up to date information about the needs of the people they support. Two staff said they usually were. One staff member told us that they sometimes were given enough information about the needs of the people they support. They told us that resident’s care plans were stored in the manager’s office and only accessible when the office was open. Care plans must be available at all times to inform staff of individuals’ needs and wishes. Care plans demonstrated that residents had access to local healthcare professionals including their GP, chiropodist and district nurse service when required. A policy and procedure was available for the administration of medication. The documents informed staff of the home’s procedure when supporting residents with their medication. The procedure did not contain information about the storage of controlled drugs or how staff need to record this type of medication. This information should be available to ensure that controlled drugs are managed appropriately. A ‘self medication assessment’ was available to use if a resident wished to fully or partially self administer their medication. We saw that the appropriate storage facilities were available for medication. Staff recorded what medication they had administered on a Medication Administration Record (MAR) supplied by the dispensing pharmacist. We saw several MAR’s which were completed appropriately. Throughout the visit staff were observed supporting residents in a dignified manner that respected their privacy. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 12 The Broughtons Care Home DS0000062302.V371493.R02.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from having more choice of where they eat their meals and choice of menu. EVIDENCE: Activities available within the home were displayed in the foyer. These included manicures, bingo, film shows, crafts, hairdressing and dominoes. During the afternoon of the visit several residents watched a film on a large screen in the lounge. The residents who completed a survey form told us that there were sometimes activities arranged in the home that they could take part in. The service should continually review the activities they make available on a regular basis to ensure that they meet the recreational needs and interests of the residents. They told us that visitors were welcome at any time. We saw several people visiting their friends and relatives during our visit. One relative told us “the staff are very good. They keep in touch with me.”
The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 14 They told us that they were working with all their residents to meet their preferences and requests and that they had opened a small shop which is stocked with items residents had requested. They told us the shop was non-profit making. We saw residents eating their lunch in two separate dining areas. The dining tables were bare and contained no condiments. The service should consider setting the tables to promote mealtimes as a pleasant experience for residents. We saw three residents eating their lunch in the designated smoke lounge where another resident was smoking. Two residents told us that they did not smoke and that they had not been given an opportunity to eat their meals where people are not smoking. This issue was raised with the manager of the service who said that she would address the situation. All residents must be given an opportunity to eat and relax in a smoke free environment. Three residents told us that they did not have a choice of what they wanted to eat. One resident said the food was “alright” and another said “much of a muchness.” Another resident told us “you eat what you’re given.” Staff told us that residents were able to request an alternative meal in the morning if they did not like what was on the menu. They said that salads and omelettes were always available. All residents should have the opportunity to choose what they wish to eat for their meals. Several other residents said that they enjoyed the meals and one resident told us “the food is good.” Another resident told us that he was a vegetarian and that he always received food to suit his choice of diet. The Broughtons Care Home DS0000062302.V371493.R02.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. People knew who to complain to and were confident that any concerns raised would be acted upon. EVIDENCE: The service had a complaints procedure. Copies of the procedure were available throughout the home. All residents spoken to during the visit and both residents who completed a survey form told us that they knew who to speak to if they were not happy or had a complaint about the service. The majority of staff who completed a survey form told us that they knew what to do if a resident or their relative had concerns about the home. The service had received one complaint that had been dealt with by the manager of the service. No complaints had been made to the Commission regarding the home. A copy of the Salford Social Services joint agency safeguarding procedures was available. The manager told us that the Salford Social Services safeguarding co-ordinator had visited the home and offered advice about safeguarding procedures. They told us that they had found this visit beneficial. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 16 The service had an ‘abuse guidance policy’ that gave examples of the types of abuse, the definition of abuse and a checklist of what to do if abuse is suspected. The procedure did not inform staff to refer to the Local Authority Safeguarding procedures. This information should be included in the policy to ensure that any concerns are dealt with appropriately. They told us that the majority of staff had received training in Abuse issues. However, no staff had received awareness training of Salford Social Services safeguarding procedures. It is recommended that staff and managers of the home attend this training to ensure that they are fully aware of the correct procedures to follow in the event of a concern being raised. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Residents benefited from having a clean and comfortable environment. EVIDENCE: We visited several areas of the building, including resident’s bedrooms and communal areas. The communal areas were furnished to meet the needs of the residents and bedrooms were seen to be pleasantly furnished and personalised. New carpets had been fitted in the foyer and other communal area. They told us that there were plans to redecorate and fit new carpets to all bedrooms. We saw several internal doors that did not fully close. This was brought to the attention of the manager who stated that he would make arrangements for them to be fixed immediately.
The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 18 The home was clean and tidy. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 19 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. Residents are support by a staff team who are aware of and understand their needs. EVIDENCE: When we visited there were three carers, a senior carer, two general assistants and the handy person on duty along with the manager and the deputy manager, to meet the needs of the residents. Throughout the visit the staff team demonstrated a good awareness of resident’s needs, likes and dislikes. It was evident that positive relationships had formed between the service users and staff team. Residents spoke positively about the staff team. Comments included “they’re very nice the staff” and “they look after me very well.” Residents told us that staff were usually available when they needed them. Staff who completed survey forms told us that there were usually enough staff on duty to meet the needs of the residents. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 20 They told us that the majority of the staff team had achieved their NVQ (National Vocational Award) level 2 award and several staff had achieved their level 3 award. Senior staff responsible for administering medication were in the process of completing an NVQ award in medication. We looked at the files of four staff members. They contained evidence of completed application forms, written references and evidence that appropriate Criminal Record Bureau and Pova 1st checks had been completed. One file contained a reference addressed to ‘to whom it may concern’ and an application form on another file did not contain specific dates of previous employment. The service should only accept references addressed to the organisation applying for the reference and ensure that people disclosure actual dates of previous employment. There was evidence of some staff files that training in first aid and hoist training had taken place. They told us that staff had received training in abuse, infection control and medication in recent months. However, there was little documentary evidence to show that this training had taken place. They told us that they needed to arrange training for staff in moving and handling and health and safety. They said that they were going to record all training information electronically. Detailed records of all training planned and delivered to the staff team should be maintained to ensure that all staff received the training they require for their role. All staff who completed survey forms told us that they are always given training that was relevant to their role, that helps them understand and meet the needs of the residents and that keeps them up to date with new ways of working. The majority of staff said that usually felt they had the right support, experience and knowledge to meet the different needs of the people they support. The service had an induction programme for newly recruited staff at the start of their role. The programme was scheduled over a four day period but was flexible for whoever was going through the induction. The programme concentrated on people familiarising themselves with the layout and the operation of the home. The service should consider incorporating the national induction standards into their induction programme to give staff a basic knowledge of working in a social care environment. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents. EVIDENCE: The manager of the home had been in post for several years. The manager had achieved her NVQ level 4 award and the Registered Managers Award. They told us that they operate an ‘open door’ policy. Throughout the visit residents were seen entering the office and talking to the manager and the deputy manager. They told us that they do regular audits of the service for quality assurance. They said that they usually send out survey forms but had not done this for some time. The service should regularly ask the residents for their views on
The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 22 the service they receive and document their responses. The views of the people are very important when developing a service. Monies required by residents on a day to day basis were managed by the home. This involved maintaining records of all transactions, which were found to be accurate. We saw that accidents were being recorded in an appropriate book. Several records had not been signed or dated and the reports had not been stored in a manner that protected the personal details of the people involved. Two accidents recorded by staff stated “no visible injury.” There was no evidence that the staff who had assessed the residents for any injuries following the accidents were trained to carry out the assessments. Procedures for the management of accidents should be reviewed to ensure that the support people receive is appropriate. They told us that policies and procedures to protect the health, safety and wellbeing all were in the process of being updated. Records demonstrated that weekly checks were being carried out on the fire detection equipment around the building. They demonstrated that they temperature of the hot water available to residents was tested on a monthly basis. It is recommended that these checks take place on weekly so that any changes to the temperature of the water can be detected earlier to prevent scalding. We saw several designated fire doors around the building propped open with furniture. We raised this with the manager of the service who said that she would address the situation immediately. It is essential that fire doors are operational at all times for use in the event of a fire. Contact must be made with the local fire service for advice on fire door closure devices. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 23 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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. 1. Standard OP7 Regulation 15 Requirement Care plans must contain detailed information about how individual’s needs are to be met. Care plans must be available at all times to ensure that staff delivering care and support to residents have access to the information they need. 2. OP15 12 (1) (a) Residents must have the opportunity to eat their meals and relax in a smoke free environment. Contact must be made with the local fire service and advice sought about appropriate means of closers of fire doors. 07/11/08 Timescale for action 07/11/08 3. OP38 13 (4)(c) 07/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 25 No. 1. 2. Refer to Standard OP9 OP12 Good Practice Recommendations Medication procedures should include information about the appropriate storage and administration of controlled drugs A review of residents needs and wishes relating to recreational activities should take place on a regular basis. Tables should be set and contain condiments for residents to use as they please during their meal. The menu should be made available to residents at all times and they should be made aware of all alternative foods that are available at mealtimes. 3. OP15 4. OP18 Staff and managers should have the opportunity to attend awareness training on Salford Social Services safeguarding procedures. The service should ensure that application forms contain full details of people’s previous employment. The service should only accept references addressed to the organisation applying for the reference. 5. OP29 6. 7. 8. 8. OP33 OP38 OP38 OP38 Detailed of all training planned and undertaken by the management and staff should be maintained at all times. All completed accident records should be stored in a manner that protects individuals’ personal information. The temperature of the hot water available to residents should be monitored on a weekly basis to minimise the risk of scalding. The service should ensure that their review of their policies and procedures is completed to ensure that up to date procedures are in place. This should include a review of the accident procedures. The Broughtons Care Home DS0000062302.V371493.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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
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