Care Home: The Royal Elms

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What the care home does well Comments from people who use the service included "I wouldn`t move anywhere else", "they look after me too well sometimes" and "the girls are all very good". People living at the home enjoy the food provided. One person told us "I have never had to ask for something different, I like the meals".. Individuals spoken to told us that staff were "friendly and always polite". We saw that staff and residents had a good rapport. There is a stable staff team who work well together and clearly know the residents well. Residents are provided with a safe, clean, and comfortable place to live. What has improved since the last inspection? A new manager who has experience and knowledge of running a care home has been appointed. A number of communal areas and bedrooms had been re-furbished. The exterior of the home has been painted. The manager`s office has been moved from the outbuilding into the home. The time of the mid-day meal has been changed to balance the times between meals. What the care home could do better: The recruitment and selection process and the management of staff files could be more robust. The manager should have a job description. They should improve the infection control measures and not use terry towels in toilets. CARE HOMES FOR OLDER PEOPLE The Royal Elms The Royal Elms 23 Windsor Road Newton Heath Manchester M40 1QQ Lead Inspector Sue Jennings Unannounced Inspection 4th June 2008 08:47 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 Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Royal Elms Address The Royal Elms 23 Windsor Road Newton Heath Manchester M40 1QQ 0161 681 9173 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) Rajanikanth Selvanandan Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home will only provide a service to a maximum of 26 people whose primary need for care arises from old age. The matters detailed in the attached schedule of requirements must be completed within the stated timescales. 23rd October 2007 Date of last inspection Brief Description of the Service: The Royal Elms Care Home is a care home offering personal care for 26 older people. The home does not offer nursing care. The accommodation is provided on two floors in a Victorian style building, which is serviced by a passenger lift to all levels. The home has a modern extension that provides accommodation for five of the 26 residents accommodated at the home. The entrance to the home is at ground level and the garden area is accessible to all residents. There is a large garden to the rear of the property. It is set among similar sized well-established residential properties. There are three lounges; one of the lounges is the smoking area. There are two double rooms and twenty two single rooms; six of the single rooms provide en-suite facilities. There is an enclosed parking area to the front of the property offering off road parking for approximately eight vehicles. The home is situated in the Newton Heath area of Manchester close to good public transport links to Manchester City Centre and Oldham. Fees for the home are £373.54 per week with additional charges for hairdressing, chiropody and continence aids. The Royal Elms DS0000067697.V364668.R01.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 2 stars. This means the people who use this service experience good quality outcomes. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. The visit was unannounced and took place over the course of 5.5 hours on Wednesday 4th June 2008. During the course of the site visit time was spent talking to the manager, staff and the owner and 3 of the residents to find out their views of the home. A number of the Commission for Social Care Inspection’s survey forms were sent to people living at the home. Seven survey forms had been received at the time of the site visit. Time was spent examining records, documents, the residents’ and staff files. A tour of the building was also conducted. What the service does well: Comments from people who use the service included “I wouldn’t move anywhere else”, “they look after me too well sometimes” and “the girls are all very good”. People living at the home enjoy the food provided. One person told us “I have never had to ask for something different, I like the meals”.. Individuals spoken to told us that staff were friendly and always polite”. We saw that staff and residents had a good rapport. There is a stable staff team who work well together and clearly know the residents well. Residents are provided with a safe, clean, and comfortable place to live. The Royal Elms DS0000067697.V364668.R01.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 Royal Elms DS0000067697.V364668.R01.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 Royal Elms DS0000067697.V364668.R01.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): 1, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements were needed to the recording of pre-admission assessment information. EVIDENCE: There was a revised Statement of Purpose that included the new manager’s details. They told us that they are reviewing the Service User Guide and this should be ready within the next month. The manager said this would be made available in large print if requested. Of the sample of care plans seen only one had a completed pre-admission assessment. It is important that the service looks at how good quality person centred information is gathered within pre-admission assessments. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 9 We saw that where a pre-admission assessment had been completed some good information had been recorded. These assessments should help to capture the information needed to allow staff to provide personalised care and support. Some people placed by care managers and funded by the local authority had a care manager’s assessment of need on file. They told us that a new pre-admission assessment had been developed and would be used for future admissions to the home. Once residents are admitted a care plan is developed based on the home’s own assessment and the care managers assessments and amendments are made if required during the 6-week assessment period. One resident told us that her “family came to see the home” on her behalf. They do not provide intermediate care. The Royal Elms DS0000067697.V364668.R01.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and social care needs were met by staff. Medication practices protected residents care plans are in place for each resident these could be more detailed and person-centred. EVIDENCE: We looked at the care plans for three people. Each care plan sets out how people’s needs are to be met. This document is reviewed regularly. The plans could be improved to contain more individual information and to better address social needs. The manager told us that they have devised a new care plan format based on person-centred-planning. They told us that this would be in place within a month of the date of the inspection. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 11 Care plans seen for areas such as personal hygiene included phrases such ‘has weekly bath or shower’ and ‘maintain privacy and dignity’. Staff should review these and make sure that specific person centred information is recorded. For example, does the person like a bath or a shower, which bathroom do they use, what day or time do they prefer and who do they like to help them. A good practice recommendation is made that staff receive training in person-centred planning. To improve in this area daily notes kept by staff should also be looked at. We saw that some of these contain very repetitive and general statements such as ‘all care needs met’. Notes kept by staff need to be person-centred and contain good information, which can then be used to evaluate and review the care being provided. Risk assessments are completed around areas such as falls, pressure areas and nutrition. We saw that these were generally well-completed and kept under review. We saw that medication was stored correctly and that records were generally kept well. The manager told us that they were changing the medications system to the Boots ‘blister packs’. The pharmacy will provide training and this is planned for the 16th June 2008 prior to the new system starting on the 23rd June 2008. The manager told us that the deputy and senior staff have developed good relationships with district nurses and GP’s and this is beneficial to residents. Residents spoken to told us “they are all very good to us”, “they don’t make us do things we don’t want to do” and “if we need help with anything they are always there”. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 12 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are provided and residents are able to maintain contact with family and friends. Residents have a choice of varied, well-balanced meals. EVIDENCE: They told us as a result of listening to residents, meal times have been altered as the lunch was served anytime between 11-12. This was far too early for residents, some of whom may have only had breakfast at 10. The meal on the day of the visit was creamed potatoes, roast chicken and mixed vegetables. People spoken with said that they enjoyed the food offered with comments including “the food is good”, “very good”, “it’s cooked well” and “quite good”. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 13 Residents spoken to told us “I expect they would make something else if I didn’t like the meal but I like everything they cook so I can’t say I have ever needed to ask”. Care staff spoken to said that they routinely provided activities and saw this as part of their role. Residents told us they were able to participate as they choose in any activities and staff respect residents decision not to join in. One resident told us activities include “board games, singers and knitting, we knit squares and sew them together and send one to a charity to help them raise money”. The manager told us one member of staff takes a lead role in activities. She knits with residents and they send the blankets to charity or raffle them to make money for activities. Residents told us that they had a choice of how to spend their day e.g. what time go to bed, meals, activities and what time get up All staff spoken to stated that residents’ choices were encouraged and privacy and dignity was respected. Residents’ meetings were held with a good attendance and minutes were held in a file and available for inspection. It is recommended that an action plan be developed to show that the issues raised have been addressed. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 14 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place to safeguard residents from abuse and people are confident that their complaints will be acted upon. EVIDENCE: They had a complaint procedure that residents were aware of. “I would speak to one of the girls or the owner if I was not happy with anything”. Another told us “if I was not happy I would tell the manager and I am sure they would deal with it”. The manager said she operates an open door policy and relatives/visitors, staff and visiting professionals to the home are encouraged to raise any concerns or complaints. The manager had a book where all complaints are logged and details of the investigation and any action taken. The service has internal policies and procedures for the Protection of Vulnerable Adults (POVA). They had a copy of the Manchester Multi Agency policy and procedure on the protection of vulnerable adults. We saw that adult safeguarding training was arranged for the 23rd June 2008. Staff were aware of the procedures to be followed in the event of an allegation of abuse. One told us “I would tell the manager immediately”. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 15 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents lived in a safe and well-maintained environment with good standards of hygiene. EVIDENCE: People spoken to were generally happy with the environment. Comments from individuals included “I like my room”, “good” and “ok”. A sample of bedrooms were seen and residents spoken to said “I like my room”, “the place is very clean”, “it is always very clean and tidy they work very hard” and “I am really happy here”. There was evidence that residents had brought some personal belongings with them and those residents spoken to said that they were very happy with their The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 16 rooms. They told us that there is a domestic assistant for 6hrs a day and all rooms seen were found to be clean and tidy and nicely decorated. We saw that the dining room had an odour and it is recommended that the carpets in this area be deep cleaned. Two residents’ bedrooms were designated as smoking areas. As stated at the last inspection there was a smell of cigarette smoke along the first floor corridor. The recommendation made at the last inspection regarding the fitting of extractor fans is reiterated in this report. A full time handyman has been employed and staff told us “things are done very quickly, if a bulb goes out it is repaired straight away”. On the day of the visit the handy man was fitting handrails outside so that residents are able to get out into the garden. We saw that there was an ongoing programme of redecoration and refurbishment. On the day of the visit the outside of the house was being painted. One bedroom carpet has been replaced and six bedrooms were in the process of being decorated and having new carpets fitted. A major improvement is that the office is now located inside the building. This gives residents and staff access to the manager at any time. It is proposed that the out building, previously used as an office, will be utilised as an activity room and hairdressing salon. This will be seen as good practice as the hairdresser currently uses one of the resident’s bedrooms. The dining room was bright and airy with a relaxed comfortable atmosphere. This was located a distance from the kitchen and staff were carrying hot plates from the kitchen to the dining room. They should consider purchasing a trolley for staff to take the meals into the dining room. As stated in the previous report protective gloves should be provided in a variety of sizes to meet the individual needs of staff and minimise the risks of infection. The recommendation made in the last report is reiterated in this report. The broken toilet identified in the last report had been repaired but it was still not working properly. The owner told us that there is a problem with the way it had been fitted. Staff spoken to told us that there are enough toilets but it would be useful if this one was repaired. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are adequate numbers of staff on duty with the skills and knowledge to meet residents’ needs but the recruitment procedures should be more robust to fully protect residents. EVIDENCE: There were a number of night staff vacancies and where possible permanent staff were covering the shifts. New staff had been interviewed and they were waiting for references and POVA/CRB checks. They told us that if they use agency staff they try to make sure it is the same staff to give continuity. Staff are offered training in a number of topics such as manual handling, medication, fire safety, First Aid, and Protection of Vulnerable Adults. They told us that training in the Protection of Vulnerable Adults was planned for the 23rd June 2008. One member of staff told us “I am currently doing my NVQ 2 and I am really enjoying it I would like to do level 3 next”. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 18 Feedback about the way the staff carried out their duties was generally positive. Comments included “very helpful”, “the staff are kind” and “quite friendly” A sample of staff files was examined and these were not particularly well maintained. Some application forms had not been fully completed and where there were gaps in information there was no evidence that this had been discussed. The application form asks for work experience but does not allow space for previous employers to be listed. It is recommended that this form be amended to include this information. Staff files had copies of documents to verify the person’s identity. It was recommended that the manager sign the photocopy to indicate that they have seen the original documents. References were taken up for new staff but the manager was not able to clarify how they knew that the reference actually came from a current/previous employer. One person had references on file that were from a relative rather than a previous line manager. It is recommended that references from current or previous employers be backed up with a company stamp or letterhead and confirmed with a telephone call to ensure they are genuine. There was some confusion regarding who was responsible for the recruitment and selection of staff. Both the manager and the owner had recruited staff and some of the newer staff files were not complete. It is strongly recommended that the responsibility of recruiting staff be given to the manager. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 19 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is safe, well managed and run in their best interests. EVIDENCE: The manager has been recruited since the last inspection and has knowledge and experience of running a care service. As stated previously, areas for future improvement for the manager to look at include improving the recruitment and selection process and care planning. A requirement is made that the manager makes an application for registration with the CSCI. The manager showed a good understanding of the areas of weakness and there is a good capacity for the service to improve. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 20 The manager reported that she was in the process of making sure each member of staff had received supervision and all but two have had at least one supervision session. They told us that they plan to make sure that all full time staff receives this at least six times per year. The manager told us that during supervision she intends to look at policies and procedures with care staff to make sure they are up to date. In particular, they are reinforcing the home’s confidentiality policy. Health and Safety checks take place to make sure people are kept safe and good records are kept of these. Comments from staff about the management of the home included “seems OK” and “seems approachable”. A quality assurance system has been introduced. People living at the home and their relatives or representatives were sent questionnaires as part of the quality assurance process. The most recent survey was in November 2007 and the results of this are used to improve the service. A copy of this survey was forwarded to the CSCI. They told us that all the home’s policies and procedures were in the process of being up dated. The manager was aware of the Mental Capacity Act 2005 and its implications in relation to helping residents to make decisions that affect their lives. It is recommended that the home’s policies, procedures and working practices be reviewed to reflect the implications of the Mental Capacity Act 2005. It is recommended that the home develop a formal agreement between residents or their representatives, that staff can access people’s personal monies to purchase personal items. The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP29 Regulation 19(1)(a) Requirement Recruitment and selection processes must be more robust to ensure the safeguarding of residents. Application must be made to register the manager with CSCI. Timescale for action 15/07/08 2. OP31 9 15/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP12 Good Practice Recommendations It is recommended that daily records reflect the care provided based and links to the needs identified in the care plans. It is recommended that an action plan be produced following residents meetings to evidence that issues raised by residents are being acted upon. It is recommended that the carpet in the dining room be deep cleaned. DS0000067697.V364668.R01.S.doc Version 5.2 Page 23 7. OP19 The Royal Elms 8. OP19 It is strongly recommended that a more appropriate area be made available for hairdressing. It is strongly recommended that extractor fans be fitted to those rooms designated as smoking areas to reduce the smell of smoke in the adjoining rooms and communal areas. It is recommended that protective gloves be provided in various sizes. It is strongly recommended that: The application form be amended to include a section for an employment history. Recruitment and selection of staff should be carried out by the manager. Photocopied documents be signed and dated to indicate that the originals have been seen. References be backed up by a phone call or requests made that they are accompanied by a letterhead or verified with a company stamp to show they are genuine. It is recommended that the home develop a formal agreement between residents or their representatives, that staff can access people’s personal monies to purchase personal items. 9. OP19 10. 11. OP26 OP29 12. OP38 The Royal Elms DS0000067697.V364668.R01.S.doc Version 5.2 Page 24 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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