Nightingale House 10 Strafford Road, Twickenham TW1 3AE

APRIL 10, 2015 Enter and View Report: Nightingale House 10 Strafford Road, Twickenham TW1 3AE Accommodation for persons who require nursing or personal care, Dementia, physical disabilities, sensory impairments, caring for adults over 65 yrs Healthwatch Richmond Enter and View representatives: Keisha Forteau, Linda Nelhams, Penny Alexander, Peter Hughes. HEALTHWATCH RICHMOND REGAL HOUSE, 70 LONDON ROAD, TWICKENHAM TW1 3QS info@healthwatchrichmond.co.uk 020 8099 5335

Contents Introduction... 2 Rationale... 2 The visit... 3 Methodology... 3 Limitations... 4 Findings... 5 General... 5 Accessibility... 5 Security... 6 Environment... 7 Fire Safety... 7 Staff... 7 Management structure... 9 Resident and staff interaction... 10 Procedures... 10 Complaints... 10 Safeguarding... 11 Home occupancy levels... 11 Care needs/assessments... 13 Involving residents in their own care... 13 Activities... 14 Recommendations... 15 Appendix 1-... 17 Page 1 of 34

Introduction Nightingale House is an adult residential home owned by Mrs Sushma Nayar and Vipin Parkash Nayar at 10 Stafford Road, Twickenham, Middlesex, TW1 3AE. At the time of the visit the home was registered with the CQC as Accommodation for persons who require nursing or personal care, dementia, physical disabilities, sensory impairments, caring for adults over 65 yrs. The CQC describe the service being provided as care home service without nursing. Mrs Sushma Nayar is the registered manager. Mr Kana Thirumalthasan manages the home on a day to day basis and appears to be responsible for the services provided. The home can be contacted on (020) 8892 1854. Rationale Healthwatch Richmond is a registered charity that acts as an independent voice for people in the London Borough of Richmond upon Thames. It helps to shape, challenge and improve local health and social care services. Healthwatch Richmond were set up by local government following the health and social care reforms of 2012 and superseded Richmond LINk. The Health and Social Care Act 2012 and its regulations granted Healthwatch powers to request information from health and social care providers and receive a response within 20 days, and to enter and view premises that provide adult health and social care services. With these powers, Healthwatch Richmond set out to undertake a series of enter and view visits across the borough after considering evidence collected from several sources including: CQC (Care Quality Commission) reports - the Regulator for health and social care Reports received from members about local residential care, and Discussions with London Borough of Richmond upon Thames Council. Nightingale House was selected as a priority for review because of its significant lack of engagement with London Borough of Richmond upon Thames Council and the Age UK peer review scheme. In preparation, a project team was appointed comprised of Page 2 of 34

volunteers and a community volunteer lead. All of the project team had completed the Healthwatch Richmond authorisation and training processes. Enter and view representatives were authorised via Richmond Healthwatch Appointment of Authorised Representatives for the purpose of Enter and View policy. This includes a written application; satisfactory references; an enhanced DBS check; training in safeguarding adults; and training in how to undertake Enter and View visits. An interview and observation guide was developed with the project team based on outstanding concerns to support Healthwatch Richmond s authorised representatives during the visit. The visit A visit was arranged with the care home manager Kana Thirumalthasan to commence on Monday 15 December 2014. The visit was conducted by a team of three volunteers and one member of Healthwatch Richmond staff between 11:30 and 15:30. A description of the visit is given within the methodology (pg. 4) and the residential care enter and view tool that was used by the team to collect data during the visit is provided as appendix (pg.17) Methodology The visit was planned in accordance with Richmond Healthwatch Richmond s Enter and View policy and with reference to the workbook designed for this purpose. The selection of Nightingale House as a priority was due to information received through intelligence gathering and the identification of certain discrepancies in the description on the CQC website, of the registered service being provided. Healthwatch Richmond made a request to Kana Thirumalthasan for the following information: Page 3 of 34

Current total numbers of residents and staff- including numbers of permanent staff, vacancies and numbers of bank and agency staff Numbers of staff on each shift (morning, evening, night, weekend shifts) Staff qualifications and training records Any guidelines that Nightingale House has for visitors Compliments and complaints record Confirmation that Nightingale House does not provide nursing services The manager was also notified that to confirm that records were being maintained, the team would require access to records during their visit. The visit was conducted over 4 hours. This consisted of Healthwatch Richmond representatives making observations on the home as well as interviewing staff, residents and Kana Thirumalthasan. This report was sent to the manager of Nightingale House for comments about accuracy and to provide an opportunity to respond to the report and its recommendations. Limitations The information provided before the visit was incomplete and limited in its scope. The home told us they have no records of any complaints. A list of staff and their current qualifications was provided but no staff training records. The manager did confirm that the home had no staff vacancies and did not use bank or agency staff. There are no written guidelines for visitors. The manager stated that visitors can come at any time without informing them. It was also confirmed that the home does not take residents that need nursing. There was insufficient time to complete all of the planned activities and observations during the visit. This was partly due to insufficient information being requested or Page 4 of 34

provided prior to the visit. Requesting and reviewing documents and information during the visit was not a practical or efficient use of the time available. Some residents we spoke to were unable to fully engage with the process due to varying degrees of comprehension. Due to lack of promotion of the Enter and View visit to the residents, we had limited interaction with friends and family members of residents. Kana allowed us to speak to a family member of one resident via telephone. We were able to speak to one visitor on the day. Findings General The home is situated in central Twickenham and is readily accessible by public transport. The exterior appears to be in a good state of repair and there is a small narrow garden which is well maintained. The building is a large private house which has been adapted for multi occupancy. The facilities and décor in the communal bathroom would benefit from new furnishing to improve residents' quality of life. Overall, the home appeared to be clean and airy. A slight odor (unidentified) was detected by a member of the team. Accessibility The accommodation is situated over three floors. There are some very narrow corridors and doorways which could be difficult for wheelchair users and those with mobility problems to navigate. The lift is also extremely narrow. Some rooms appear to be too small for helping residents in/out of bed, chairs and wheelchairs. Toilet and washbasin areas are too small for ease of use and access. When invited into residents' rooms it was clear that some of the rooms were not fit for purpose for wheelchair users. One resident in particular had complained about the room and its suitability Page 5 of 34

for a wheelchair user. Some notices and the menu are placed on the communal notice board at a height which is not easily accessible for wheelchair users: talking to residents confirmed this issue. The team suggested the home print off menus and provide them to residents with accessibility issues, at present the home has not acted upon this recommendation, we hope to see this in the near future. We are not convinced that the home is fully fit for purpose in terms of accessibility. Security The team was not asked to identify themselves or sign in when we arrived at the home. We took the initiative to sign ourselves in. It was observed that a visiting nurse did not show any ID. There is no visiting policy and staff members do not wear name badges: therefore, the security of the building is a cause for concern. Response from Sushma Nayar, Registered Manager The visiting nurse was not asked to show ID as this was not the first time that nurse had visited the Home. Some of the nurses have been visiting the Home for the last 15 years and since most of the staff have been here nearly the same time it has not been necessary to ask the nurses to show ID each time they visit. A new nurse visiting will be asked to show ID.We cover security of the Home in our statement of purpose. Our staff has been issued badges in the past which, some of the staff wore diligently and others as and when they remembered. I thank your team for pointing the lack of badges out and this has been reinforced to the staff. They are all now wearing badges. Further recommendations Sushma Nayar provided a copy of the sign in log for the day of the visit to reassure the team that sign in procedures are followed. The only signatures present were those of the Healthwatch Richmond team. The team witnessed a workman working on the home, a visitor for a resident and a nurse, none of whom were signed in on the document given (see Appendix 2). It is essential that the home keep accurate visitor logs in the case of an emergency situation (fire, gas, leak, flooding etc.) or if there Page 6 of 34

was an untoward incident (theft, assault, threatening behavior etc.) so that all persons on the premises can be accounted for, or brought to account. Environment The home was clean, with a homely feel. The main concerns about the environment were accessibility issues. Rooms only have a toilet facility. There are no en-suite bath or shower facilities. Bathrooms are used on a communal basis and are in present need of refurbishment. Baths are offered to residents on a weekly rota basis. Fire Safety It was noted during the visit that two fire exits are situated within residents' rooms. Only one of these exits was signed. Concerns were raised with Richmond Fire Service who clarified that in February 2014 that Nightingale House was broadly compliant within a fire safety check. It was confirmed by the Richmond fire service that as residents have lived in the home for an extended period of time and are aware of the exits, signage is not needed. It was also confirmed that a locked door between the external fire exit was not an issue as night staff were provided with keys and, at the time of the check, were fully trained in fire safety. Staff Staff training records were provided in the form of a tick box list and were dated 2013/2014. The list names 14 staff members who have attended training sessions for: Mental Capacity Act, Fire safety, Food hygiene and infection Equality and diversity and inclusion. No training was recorded for: End of life care, Skin care or pressure sore care, Manual handling, Page 7 of 34

Specific dementia training, CPR Caring with people with long term conditions. We were made aware via telephone from a mental health support worker that one resident had a moderate learning difficulty. It is not clear if staff are adequately trained to meet the needs of those residents with learning difficulties. We were told by two residents that the home does not have separate cleaning staff. The manager confirmed that the carers on the evening shift undertook the cleaning duties. This raises the issue of cross-contamination. In sharing the draft report with the manager, we asked for information about the precautions taken to avoid cross contamination and ensure continuity of care while staff are cleaning. Response by Sushma Nayar We have never used agency staff at Nightingale House, where as other homes are constantly cribbing about agency staff. We overcome short staffing issues by having a trained member of staff as an extra member of the team, who takes on cleaning duties and extra hours of care. This staff member can then be called in to cover sickness, holidays, extra cleaning, extra care etc. Recommendations Evidence provided did not demonstrate staff training for long term conditions or learning disabilities or training for staff to avoid cross contamination while cleaning. Training records were given for dementia and nutrition. It is suggested by Healthwatch by Healthwatch Richmond that staff are sufficiently trained to care for residents with learning disabilities and trained to manage the risks of cross contamination whilst cleaning. Page 8 of 34

Management structure The CQC (Care Quality Commission) scope of regulation 2013 states that A manager is a person who is in day-to-day charge of the delivery of a service provider's regulated activity, or a service provider's regulated activity in a particular location. Mrs Sushma Nayer (one of the owners of the home) is listed as the registered manager in the CQC report dated September 2013. All communication with the home from November 2014 to February 2015 to plan and arrange the visit was with Kana Thirumalthasam. Kana presents himself as the manager and runs the home on a day to day basis. In the draft report, we requested written confirmation that Kana Thirumalthasan is the registered manager of Nightingale House and, if that were not the case, clarification over the role of Kana. Response by Sushma Nayar I am the Registered Manager and provider at Nightingale House since 1998 and Kana has been the Operations Manager since Nov 2007. I could not be present at the time of your visit as I was away on holiday. Recommendation Due to lack of clarity around management within our involvement with Nightingale House, we suggest that roles in Nightingale House are made clear to the CQC and management is correctly registered. It is also suggested that roles are made clear to professionals and members of the public contacting the home. Page 9 of 34

Resident and staff interaction The interaction between staff and residents that was observed on the day of the visit was very positive. The staff appeared to relate well to the residents and were friendly both to residents and each other. They were observed to be chatting with the residents and responding to their questions and comments. Help and assistance was provided for residents to go to and from the dining room and with eating lunch. Some residents who were interviewed commented that the staff did not have as much time to chat with them as they would have liked, as they were too busy. Procedures Complaints At the time of the visit, it was unclear if an effective complaints procedure was in place. At the time of the visit, the only information regarding complaints was an information sheet on the table in the entrance hall. A copy of the complaints policy was requested prior to the visit and on the day of the visit, but was not provided. The manager confirmed that there has never been any complaints at all and certainly none are recorded. The residents spoken to did not appear to be aware of any complaints procedure. As no complaints policy was seen, it is not clear how any complaints would be recorded or investigated. Residents said they had made complaints to the manager, some verbally, others written on a piece of paper but they had not been formally recorded. When asked who they would go to if they had a complaint about the manager, residents said they did not know. Response by Sushma Nayar I am not sure why we didn t provide you with the complaints policy when asked. I believe one of your team saw the copy of the complaints policy on the reception desk and asked Kana for a copy but he got too busy with other things. Please find a copy attached. Also see attached, Complaints flow chart, which is on the notice board in the Lounge and the dining room. Apart from this there is a big S.O.V.A poster from Richmond council with the relevant telephone numbers in the dining room.kana Page 10 of 34

misunderstood the team s question regarding complaints to mean complaints to CQC or the Local Authority. We have not had any complaints made to the regulating bodies for some time now. The residents complaints were initially written in their daily notes as was the outcome. We have over the past few months worked towards recording them separately. I have attached copies of some. In general all complaints are dealt with immediately. How to complain was also addressed at the residents meeting in November. Residents meetings are held monthly. Since your report, I have also put complaints and compliments forms at the reception desk, and on the notice board in the lounge. Recommendation The home appears to be inconsistent in how it recognises complaints. This should be addressed through staff training, with a focus on ensuring that management recognise, record and deal with complaints. Safeguarding No records of safeguarding incidents were seen. The manager stated that the home had only one safeguarding incident recorded which was not evidenced. No records detailing staff training in safeguarding were provided. An information sheet regarding safeguarding was available on the entrance hall table, a copy of which was requested but not provided. No incident logs or safeguarding policy were seen. Staff that were spoken to were aware of safeguarding procedures. Home occupancy levels The home is registered for 21 residents. At the time of the visit there were 15 residents and what appeared to be 6 vacancies. This appeared to be an unusually low level of occupancy considering the moderate fees charged by the home. The home were asked for clarification over the vacancies. More than one resident commented that some spare rooms were used by other men. They did not work at the home and were not residents. Representatives were concerned about the suitability of the Page 11 of 34

occupants of the spare rooms. Within the draft stage of the report given to Nightingale House, we requested clarification around the occupants of the spare rooms and assurance about the suitability of these occupants of these rooms supported by records demonstrating who stayed in the home. Response by Sushma Nayar The Home does not have capacity for 21 residents as reported by the team. The Home is registered for 21 residents, however we converted some of our double rooms into large single rooms and as per our statement of purpose, we only have 18 residents. We never changed the registration because we had planning permission to add another 4 rooms. At the time of the visit there were 15 residents. We lost one of our resident on the 8 th December 2014, a week before your visit. Your team has reported being told that the spare rooms were used by other men that did not work at the home and were not resident. We have only had residents occupying the rooms in the Home. There is an on call room that is used by staff on call duty at night. There are no male staff members using the on call room. We do however, have residents staying for respite, the recent one being gentleman who, stayed with us for 4 weeks of respite in June and July 2014. The Home has never had any relatives stay over either. Recommendations Although the home provided clarification around the vacancies, we were not provided with any documents requested, to clarify occupancy of the spare rooms. The documents provided to us did not identify that the home has a system to record all visitors to the home and therefore it could not provide documented evidence about the occupants of the spare rooms. In relation to comments made by residents, the home would benefit from keeping accurate records of visitors and occupants on record to evidence occupancy when concerns are raised by residents. Page 12 of 34

Care needs/assessments The home has some residents who are self-funding. Others are funded by the Local Authority or a health authority. In the case of one self funder, the team were not satisfied that this person s care needs had been properly assessed at the time of admission. We asked the home about how they care for a resident with nursing care needs. Response by Sushma Nayar Your team has referred to a resident receiving nursing care. Other than her own home, Nightingale House is the only other home she has known. She came to us in October 2010 and when she became poorly in Feb 2011, her family requested that she be cared for at Nightingale House and not in the hospital and did not want to consider her move to a Nursing Home. We care for this resident with the input from the district nurse, the Acorn surgery and a very supportive family. Involving residents in their own care Some of the residents that were spoken to were not aware that they could request an extra bath: at present, residents were offered a bath once a week on a rota system. Some residents spoken to, particularly those with mobility issues, were unaware of the menu for the week. At the time of the visit, residents did not seem aware that they could be involved in menu choices. Response by Sushma Nayar We write the weekly menu on the board, however the residents are asked daily for their preference and a record of their choice made in the cooks dairy. One of the resident makes daily request either verbally or in writing which is passed on to the cook. I have attached copies of some of the written requests. Page 13 of 34

Activities There are scheduled activities for the residents, one of which -cheese tasting - was carried out while our representatives were present and they witnessed staff involving residents. In our interviews, a few of the residents mentioned that they enjoyed activities such as visits to the pub and the residents' Christmas and birthday parties and would like more activities. Response by Sushma Nayar Your team reported, residents to be overall, happy with the activities. Activities are organized with consideration to each resident s needs. We will continue to support the recreational needs of our residents. I hope I have covered all the concerns raised in your report. Please feel free to call me if you need any further information. We have always viewed inspections as a positive input to the Home, a chance for us to get a different view point and make improvements. Page 14 of 34

Recommendations 1. General Recommendation: Facilities and décor in the communal bathroom would benefit from new furnishing to improve residents' quality of life. 2. Security Recommendation: Visitors should sign in. This is vital to improve building security, ensuring residents are in a safe protected environment. Response: As a result of our staff, all staff are now wearing identification badges. 3. Accessibility Recommendation: The team encourage Nightingale House management to ensure all information displayed in the home is fully accessible. A positive example of this would be ensuring that residents had the option to receive a print out of the weekly menu. 4. Staff Recommendation: It is suggested that staff are sufficiently trained to care for residents with learning disabilities and trained to manage the risks of cross contamination whilst cleaning. Staff training in safeguarding is also suggested. 5. Management structure Recommendation: Roles of staff should be made clear to professionals and members of the public contacting the home. Nightingale House should reconsider their management registration with the CQC. 6. Procedures Recognising and dealing with complaints: Staff training on recognising, documenting and responding to complaints may be beneficial to staff, in particular, management staff. 7. Home occupancy levels The home should consider documenting the occupancy of spare or vacant rooms when filled with short term residents. This should assure both residents and professionals that occupants of the room are suitable for the home. Page 15 of 34

8. Involving residents in their own care Recommendation: The home should ensure that they communicate effectively to residents how they can request changes to their care, especially in regards to baths. We would also encourage the home to offer more of the activities mentioned in this report that residents appear to enjoy. Page 16 of 34

Appendix 1- Residential Care Enter and View Tool Page 17 of 34

Residents Questions For the Manager (1) Question / Comments How many residents are there now and what is the residents capacity? How do you monitor resident satisfaction? Is there a complaints procedure that s easily accessible to residents and staff? Is there a safeguarding procedure that s easily accessible to residents and staff. How do you involve residents/ carers: In their own care? In the running of the home? Can evidence be supplied? Staff: What do you look for when recruiting staff? How many staff are there? Full time, Part time, Bank/agency What is the staff to patient ratio? How do staffing levels vary at different times of the day? What level of training do staff have? Page 18 of 34

How do you ensure that all staff maintain appropriate skills and qualifications? What is the rate of staff turnover? Manager status and qualifications Is there a member of staff competent to assess and report changes in a resident s medical condition? Can evidence be supplied? (see checklist) Medication: How is medication managed? Who is authorized to dispense medication? What do you do if residents refuse their medication? Is there a member of staff at each shift to dispense and oversee medicines safely? If a resident is self-medicating, are they competent to do this safely? Can we see the policies? (see checklist) Page 19 of 34

Policies, Procedures, Records Can evidence be provided of the following: / Notes/ comments Staff records Staff Qualifications e.g. RGN, NVQ Absence rate, rate of turnover DBS checks for all staff Confirmation that staff have relevant levels of communication Staffing levels, (Regular, Agency, Bank) Staffing levels on each shift Are there Supervision records Training Records Who carries out and authorises and how often: Moving and handling Safeguarding Vulnerable. Adults Dementia Infection Control First Aid/ CPR Falls Pressure care Caring for people with Long-term Conditions e.g. Diabetes Incident Book Is it used and up to date? Does it reflect a range of incidents including low level and severe incidents Care Plans Are there Care Plans for all residents Is there evidence of appropriate consideration of care provision such as? Use of story books for people with dementia Plans for managing challenging behaviour Page 20 of 34

Care Records Are important observations noted about residents; their care and health on a daily basis? Is it clear that the procedures allow for these to be passed on between staffing shifts? Is there evidence that care records are reviewed and relate to care plans? Are there records for residents accessing health care? Complaints procedure Is it accessible? Does it require investigation by an uninvolved member of staff and provide protection of the relevant resident s residents anonymity Page 21 of 34

Observe Care provision (1) Observation / Comments Care: What can you tell of the culture of the organisation from watching care being provided? Are staff courteous and friendly to residents and to each other? Do staff respond to residents requests in a timely fashion? Are residents treated with dignity? How are residents abilities respected? Are residents asked for their consent before care is given? Are they given choice, supported to be independent? How are residents needs met in relation to their activities of daily living? (dressing, eating, drinking, mobility, hygiene, grooming, bathing, toileting,) How do staff assist people around their special needs? Dementia support Communication problems Comfort and bed or chair positioning Do residents seem content with the care they are receiving? How happy would you be receiving the care you have observed? Page 22 of 34

Interaction/ activity: What is interaction like between staff and residents? From what you see on your visit, do staff chat/talk with service users as they carry out care and support tasks? Is the room set up appropriately for residents to interact with each-other? Are they appropriately supported to do so? Is there evidence of social, leisure, exercise and other activities being available on and off site? (Leaflets, notices etc.) Does the residence engender a sense of community by allowing residents to participate in daily life? Page 23 of 34

Questions for Staff Questions / Comments Medication: What are the procedures around medicine - how is it dispensed? What do you do when errors occur? What do you do if residents don t want their medication? Safety: Do you have everything you need to move people safely? Equipment Training Time/ staff numbers Is there anything you think could be done to make the home safer? How would you spot abuse? What would you do if a resident might be at risk of abuse? What would you do if someone had a concern or complaint about care being received in the home? Page 24 of 34

Interaction: How much time do staff and residents get to interact? How do they get to know individual needs? What activities are staff involved in? What activities do residents like most; least, or would like to see in the future? Staff: What is it like to work here? Are there enough staff at all times of the day? How often do you have training? How often do you have supervision? Would you recommend this home to a relative who needed care? Can you give examples of when you ve made a difference to someone s life? How, why? What services work well? What could they do better? Page 25 of 34

Observe care provision (2) Observation / Comments Medication: Where is medication kept? Is it secure, safe and locked? How and by whom is medication given out or administered. Is it dignified and caring Page 26 of 34

Food & hydration Do people have supported access to hydration? What is the food like? Is the range of food available appropriate and reasonable? Is it appealing? How is it served? Do people eat/ drink what is given to them? Is appropriate support available? Do residents wash/wipe hands before a meal? When is food and drink served? Are times flexible? What is the environment like where people eat? How can residents exercise choice around meals? Safety: Are people moved and handled safely with appropriate equipment and techniques? Are consent, choice and dignity observed? Is there appropriate equipment? Is it used? Can you see any hazards? Are there any signs of abuse? Page 27 of 34

Information Is information provided in an accessible format? Are menus, activity boards etc. clearly written in a format that people who live at the home can understand (e.g. pictorial) Page 28 of 34

Questions for Residents and Relatives (1) Questions / Comments General: How long have you lived here? What are the staff like? Do you think they have the right skills and knowledge? What are the best and worst things about living here? What do you think about cleanliness and the environment? Is the home meeting all your needs? Are you happy here? Does this feel like home? Is your laundry done well? Would you recommend this home to someone you knew? Are your relatives welcomed? Page 29 of 34

Care: Are your medical needs are being met? Do you know the medication you are taking/are you happy with it? Do staff respect your privacy? Do they knock before they enter? What would you do if you had a complaint or didn t like how a member of staff was treating you? If you need help is it given in a way you are happy with? (I.e. is modesty/privacy maintained, do you get a choice etc.) Do staff spend time talking with you when they re working? Page 30 of 34

Questions for Residents and Relatives (2) Questions / Comments Activities and Events: Is there enough to do? Do you like the planned activities? Are your cultural needs met? Do you go to any of the social events or activities at the care home? What are your favourites? Have you been taken on any outings recently? Were they good? Page 31 of 34

Food: Do you like the meals? Is there enough choice etc. Do you have enough time to eat at mealtimes? Can you have a meal privately in your room/ if you want? How much choice do you have about what food you get? e.g. are you involved in menu preparation or asked about the food provided by staff or the cook? Can you always get access to a drink if you want one? Do you have the support you need to eat and drink? Page 32 of 34

Choice: Are you involved in planning your own care? Do you understand your care plan? Can you choose when you have care? (When to get up, eat, bath etc.) Are you involved in planning how the service is run (recruiting staff, planning menus, and choosing activities)? Do you have enough choice about meals, events, activities, decoration of the home etc.? Are you always asked for your consent before you have care and treatment or medication? Can you get help to do things (gardening, house work) on your own? Page 33 of 34

Appendix 2- Visitors log for 15.12.2015 provided by Sushma Nayar Page 34 of 34