Linden Manor

Linden Manor is a Victorian property converted into a residential home, with accommodation over three floors which can be accessed via a lift. There is a communal lounge and dining area.

People’s experience of using this service and what we found

Improvements were required around assessing and monitoring risks to people, safe medicines and infection control. The registered manager made some improvements during the inspection to reduce risks to people.

The provider’s systems and processes to monitor the quality and safety of the service required some improvement to ensure they were effective in identifying and actioning concerns. However, the provider and management team were open and transparent throughout the inspection and made immediate improvements to safety during and after the inspection.

People were protected from the risk of abuse and told us they felt safe. Staff knew how to raise concerns and were confident to speak up.

The home was clean and free from odour. Personal Protective Equipment [PPE] and infection control guidance was available throughout the home for staff, people and visitors.

There were enough regular staff members available to meet people’s needs. Staff knew people well and worked as a team to cover holidays and sickness to ensure continuity of care for people. Care staff received regular training and supervision to ensure they had the skills they needed.

Accidents and incidents were monitored and lessons learned when things went wrong.

People’s needs were assessed prior to them moving into the home to ensure their needs could be met. People had access to healthcare monitoring and healthcare services as and when required.

People had enough to eat and drink and specialist dietary requirements and preferred choices were met.

The home had been adapted to support people with varying care and mobility needs. There was a lack of dementia friendly signage but this had not impacted on people currently in the service.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were treated with respect and told us that staff were kind and caring, Staff spoke fondly of people in their care and we observed positive relationships. People’s religion and culture were included in care planning and people were supported to take part in religious activities and celebrations for their choosing. People’s individual communication needs were assessed and planned into care.

People were supported to be independent and make their own choices. Care plans were written in a person centred manor and included people’s likes, dislikes, personal and work history and hobbies. People enjoyed group and 1:1 activity of their choice and were supported to maintain relationships with their relatives’, friends and the local community who were all welcomed into the home.

There was a positive culture in the home with staff and management working together and with other healthcare professionals to get the best outcomes for people. Feedback was sought via regular meetings and questionnaires with people, their relatives, staff and healthcare professionals we saw that this was positive.

People’s end of life wishes were assessed and planned into care; staff could access information quickly to guide them in an emergency.

The provider had a complaints process and relatives told us when they raised concerns these were resolved. People, relatives and staff spoke well of the management team and felt well supported to voice concerns and share ideas.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 1 April 2023). The service remains requires improvement. The service has been rated requires improvement for the last 3 consecutive inspections.

The provider was issued with a warning notice at the last inspection. At this inspection we found the provider remained in breach of regulation.

Why we inspected

The inspection was prompted in part due to concerns received about care and support in an emergency. A decision was made for us to inspect and examine those risks. We also followed up on action we told the provider to take at the last inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Linden Manor on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to the managerial oversight of the safety and quality of the service.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Linden Manor is a care home providing accommodation and personal care to up to 28 older people and people with dementia. At the time of inspection there were 24 people living at the service.

People's experience of using this service and what we found

There were insufficient systems in place to assess, monitor and improve the service. The governance and oversight in place had not identified the concerns found at this inspection.

Risks to people were not always identified or managed safely. At the time of our inspection, Linden Manor staff were administering insulin to people with type 2 diabetes as a delegated healthcare intervention. One person did not receive the care they required when their blood glucose levels were outside the safe range for a prolonged period. [Social care employees may be asked to carry out healthcare interventions, sometimes called delegated healthcare activity, that are delegated by a regulated healthcare professional. These are specific clinical interventions to support people’s care, independence and experience of care.]

Medicines were not managed safely; people did not always receive their medicines as prescribed and medicines records were not fully completed.

People's care plans and risk assessments did not always reflect people's current needs. People's care records did not reflect they had been provided with all the care they required. For example, where people required regular support to reposition to prevent skin damage.

People told us staff were not always deployed in sufficient numbers, but staff worked hard to meet their needs.

Some environmental safety needed to be addressed to ensure that the environment people lived in was safe. People were not always protected from the risks associated with infection because the service did not consistently implement processes to reduce the risk of infection and cross contamination.

Staff knew people well and understood how to protect them from abuse. There were policies covering adult safeguarding, which were accessible to all staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff felt supported within their roles and felt confident to discuss any concerns they may have with the management team.

There was a positive and inclusive culture at management level, feedback was sought from people, relatives and staff to identify where improvements were needed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (Published 29 June 2021). The service remains requires improvement. The service has been rated requires improvement for the last 2 consecutive inspections.

Why we inspected

We received concerns in relation to staffing levels, safeguarding and environmental safety. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has not changed following this focussed inspection and remains requires improvement.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Linford Manor on our website at www.cqc.org.uk

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and governance and leadership at this inspection and the provider has been issued with a warning notice.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Linden Manor is a Victorian property converted into a residential home, with accommodation over three floors.

People’s experience of using this service and what we found

During a tour of the building we came across bedroom doors that were propped open with items of small furniture. The rooms had been recently cleaned and the reason for the doors being open was to provide some ventilation and fresh air. The registered manager confirmed they would ensure staff close all bedroom doors unless they were fitted with devices (that close the door in response to the fire alarm being activated).

We also found three-bedroom doors which did not fully close, the registered manager immediately arranged for these door closures to be recalibrated. (The closures are designed to self-close the door to reduce the risk of fire spreading throughout the building). The registered manager said they would ensure all bedroom doors were checked during the daily walk around, health and safety checks.

People’s changing health needs were monitored and reviewed. However, we found on return from hospital one person's care plan and risk assessments had not been updated to reflect changes in their health condition. Staff were aware of the person's current needs and during the inspection, the person's care records were updated to reflect the changes.

People were referred to the relevant healthcare specialists and staff followed the advice of the specialists.

People told us, and we observed the mealtimes were a pleasant experience for people using the service. People commented “The food is very good food here.” And, “There is a choice of meals, and there are plenty of drinks through the day, and there is always jugs of orange juice.”

Most people told us they felt safe living at the home. Systems were in place to safeguard people from abuse and they followed the local authority safeguarding protocols. Staff received training to recognise abuse and protect people from the risk of abuse. They understood how to report any concerns following the safeguarding and / or whistleblowing procedures.

There was enough staff available to meet their needs. One person said, “The staff do come quickly when I use the call bell.” Another person said, “The staff are kind and respectful, and they do pop in for a chat sometimes.” The service had a vacancy for an activity person. Some people told us they were bored and would welcome having more activities, especially as during the pandemic visits from external entertainers had ceased. Another commented about the visiting restrictions that had been in place. They said they understood why their family had been unable to visit, as they did not live in the county. They said they had a tablet to make video calls and staff help them to use the tablet to contact their family. At this inspection we found that visiting indoors had resumed and people were supported to visit family members on outings.

Safe staff recruitment and selection procedures were followed to ensure people received care from staff that were suitable to work at the service. People received their medicines from staff that were trained in medicines administration.

People were protected from the spread of infection including COVID -19. Personal protective equipment such as gloves and aprons were readily available. The environment was clean, and a repairs and refurbishment plan was in place to ensure redecoration and improvements to the environment were continually addressed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. The registered manager had submitted Deprivation of Liberty Safeguarding applications (DoLS) to the local authority and was awaiting the authorisation decisions.

People and staff told us the registered manager was approachable. Staff said that staff morale was good, and they all commented on how they took a pride in working at the service.

People and their relatives were involved in planning their care. CQC were informed of notifiable events that had happened at the service. A notification is information about important events which the service is required to send us by law in a timely way.

The provider had implemented their action plan following the last inspection and sufficient improvements had taken place in the quality and monitoring systems at the service. The service mostly worked in partnership with other professionals to provide holistic, timely support. This was especially important with people's complex health needs, including people living with dementia.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update:

The last rating for this service was requires improvement (report published 25 February 2020) and there were breaches of regulation 12 (Safe Care and Treatment), 18 (Staffing) and 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

A targeted inspection took place, in response to concerns received by CQC about infection prevention controls (IPC) at the service. We looked at the IPC measures the provider had in place and no areas of concern were found. (Report published 23 November 2020). Targeted inspections do not change the ratings of services and the rating remained Requires Improvement.

Why we inspected

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions Safe and Well-led which contain those requirements.

The inspection was also prompted in part due to safeguarding concerns we had received about the service. A decision was made for us to inspect and examine those risks.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service remains Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Linden Manor on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice.

¿ When people were admitted to the service, which was usually from hospital, they isolated in their rooms for the length of time recommended by government guidance.

¿ There was a regular programme of COVID-19 testing in place for staff and people using the service. This meant swift action could be taken if anyone received a positive test result.

¿ The provider had ensured there was a plentiful supply of personal protective equipment (PPE) and we saw staff use this appropriately. There were a number of PPE stations in the corridors near people’s bedrooms. This meant staff had easy access to plentiful supplies of masks, gloves, aprons and hand sanitiser to use when they were in close contact with people.

¿ Cleaning schedules had been updated to meet the new infection control advice. There were posters and information about COVID-19 on display throughout the service.

¿ Areas were cleaned and disinfected with approved products to reduce the potential of transfer of infection. Staff were aware of the process to disinfect floors and hard surfaces.

¿ Risk assessments had been completed to protect people and any staff who may be at higher risk and measures were in place to support them.

¿ Visitors had been discouraged by the organisation to enter the service, following national and local guidelines. Garden visits had taken place in the summer months and relatives were able to book window visits with their loved ones. The provider had recently built a new structure in preparedness for the winter season, to ensure, if restrictions on visitors had to continue, options would still be available to reduce social isolation.

¿ Safe arrangements were in place for visits by health professionals and visits were planned in advance. This included a temperature check upon arrival and the provision of PPE including masks and hand sanitiser.

¿ Infection prevention and control audits were carried out monthly by management.

Further information is in the detailed findings below.

Linden Manor provides accommodation and personal care for up to 28 older people, some of whom live with a dementia. The three-storey home was pleasantly furnished and had an accessible garden area.

People’s experience of using this service and what we found

There was a lack of oversight in falls monitoring and medicines management and this had the potential to place people at risk of harm.

Staffing levels required reviewing to ensure there was enough staff adequately deployed to consistently meet people’s needs in a timely manner and according to their wishes. Staff received irregular supervision, were not supported with their well-being and were restricted in their professional development.

Safe recruitment practices were not always followed. This placed people at risk of being cared for by staff unsuitable for the role.

Mental capacity Assessments and best interest meetings required reviewing to ensure they were decision specific and in line with law and guidance.

The systems and processes in place to monitor the safety and quality of the service required strengthening. Concerns identified at this inspection had not been identified by the provider, however, they took immediate action to respond to the concerns raised.

Staff understood their roles and responsibilities to safeguard people from the risk of harm. People were supported to access relevant health and social care professionals. People were protected from the spread of infection. Personal protective equipment such as gloves and aprons were readily available.

The environment was clean, and repairs and maintenance were completed in a timely manner. The service had a refurbishment plan in place to ensure redecoration and improvements to the environment were continually addressed.

People received care from staff they knew. Staff had a good understanding of people's needs, choices and preferences. People were encouraged to make decisions about how their care was provided and their privacy and dignity were protected and promoted. Staff gained people's consent before providing personal care.

People and their relatives were involved in the planning of their care which was person centred and updated regularly. People were supported to express themselves, their views were acknowledged and acted upon. There was a complaints system in place and people were confident any complaints would be responded to appropriately.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection – The last rating for this service was Good (published 21 July 2017).

Enforcement

We have identified breaches in relation to safe care and treatment, staffing and lack of governance and oversight of the service.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At our last inspection on 8 June 2016, while improvements had been made, we did not revise the ratings for the key questions; safe, effective, responsive and well-led. As to improve the ratings to 'Good' required a longer term track record of consistent good practice. At this inspection we found the provider had consistently maintained good practice.

Since the last inspection there had been a change of management, a new manager had been appointed and they were going through the process to register with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations.

Improvements had been made to ensure individual risks were managed in a safe way. People's risk assessments reflected their current needs.

Improvements had been made to ensure robust recruitment checks were carried out and the staffing numbers were sufficient to meet the needs of people currently using the service.

Improvements had been made to ensure people were protected by the prevention and control of infection.

The service worked to the Mental Capacity Act 2005 key principles. People's consent was sought in line with legislation and guidance. Improvements had been made to ensure assessments of capacity were carried out where needed.

People were supported to receive sufficient nutrition and hydration and maintain good health. Systems were in place to ensure that health conditions were consistently monitored and people had access to the support of healthcare professionals in a timely manner.

People received personalised care that was responsive to their needs. Improvements had been made regarding internal quality monitoring systems, to support the service to deliver good quality care.

People felt safe living at the service. Staff had been trained to recognise signs of potential abuse and keep people safe.

Systems were in place to ensure people's daily medicines were managed in a safe way and that they got their medication when they needed it.

Staff had the right skills and training to meet people's needs, they were motivated to provide care and support in a caring and compassionate way. People's privacy and dignity was respected and promoted.

Systems were in place to enable people to raise concerns or make a complaint. The quality monitoring systems had been strengthened to ensure that routine management checks were carried out to cover all aspects of the service delivery.

Linden Manor provides a service for up to 28 people who have a range of care needs including dementia, sensory impairment and physical disabilities. There were 11 people living in the home on the day of this inspection, although one person was in hospital.

At our last comprehensive inspection on 7 October 2015, we found that the service was in breach of legal requirements in a number of areas. The overall rating for the service at that time was ‘Inadequate’ and the service was put in ‘Special measures’. Services in special measures are kept under close review. We also imposed a condition of registration to suspend new admissions to the service until improvements had been made and the service was no longer in breach of legal requirements.

After the inspection we had a meeting with the provider to discuss our concerns, and they sent us regular updates outlining the actions they were taking to improve the service. This inspection was carried out to check the provider had made the required improvements. We found that they had done so.

A registered manager was not in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations. However, a new manager had been appointed who confirmed she had begun the process to register with CQC.

Improvements had been made to ensure individual risks were managed in a safe way. However, further work was required to ensure people’s risk assessments reflect their current needs, and ensure staff have adequate guidance in terms of the control measures to follow where risks are identified.

There were sufficient numbers of suitable staff. Improvements had been made to ensure robust checks were being carried out for all staff, to make sure they were suitable to work at the service.

Improvements had been made to ensure people were protected by the prevention and control of infection.

Improvements had been made in terms of the leadership and management of the home. A new manager and area manager had been appointed, who were providing effective leadership at the service.

We found that the service worked to the Mental Capacity Act 2005 key principles, which meant that people’s consent was sought in line with legislation and guidance. However, improvements were required to ensure assessments of capacity were available and clear.

People were supported to have sufficient to eat and drink. However, some people required different eating aids, to enhance their independence and overall meal time experience.

People were supported to maintain good health and have access to relevant healthcare services. Some improvements were required however, to ensure people’s health conditions were consistently monitored and appropriate action taken in a timely manner.

People received personalised care that was responsive to their needs. Although, some care records needed reviewing; to ensure the care recorded met each person’s current needs and also reflected their involvement.

Improvements had also been made regarding internal quality monitoring systems, to support the service to deliver good quality care. However, there was still room to improve these further, particularly in terms of auditing people's care records.

People felt safe living at the service. Staff had been trained to recognise signs of potential abuse and keep people safe.

Systems were in place to ensure people’s daily medicines were managed in a safe way and that they got their medication when they needed it.

Staff had the right skills and training to meet people’s needs.

Staff were motivated and provided care and support in a caring and meaningful way.

Staff listened to people and supported them to make their own decisions as far as possible.

People’s privacy and dignity was respected and promoted.

People were given opportunities to participate in meaningful activities.

Systems were in place to enable people to raise concerns or make a complaint, if they needed to.

We found that the service promoted a positive culture that was person centred, inclusive and empowering.

Given the level of progress, and the provider’s commitment to continue with this, we have assessed that the service should no longer be in special measures. We have also removed the condition to restrict new admissions. We will continue to monitor the service to check that the progress made is being sustained and continually improved upon.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive to people's needs?

' Is the service well led?

This is a summary of what we found:

Is the service safe?

We found that the home did not have robust arrangements in place to ensure that people who used the service were safe and that their health and welfare needs were met. This was because there were not enough skilled and experienced staff to meet their needs at all times. We asked the provider to tell us what they were going to do in relation to ensuring there were sufficient staff on duty to meet people's assessed needs.

Some areas of the home had been redecorated, however we noted that some areas were not appropriately cleaned and a frayed carpet at a threshold was a potential hazard to the people using the service. We asked the provider to tell us what they were going to do in relation to ensuring people lived in a safe clean environment.

Is the service effective?

Staff we spoke with had a good understanding of people's needs and knew how they preferred to be supported. However staffing shortages meant that care could not always be provided in a way that supported these preferences and people's interests.

People told us they liked the food. One person said, 'The food is always good.' We saw that people's nutritional needs were met and the staff knew how to seek advice and support if necessary.

Is the service caring?

During our visit we observed positive interactions between the staff and the people who used the service. People were supported and spoken to in a kindly manner by all of the staff. One person said, 'Everyone is nice, they look after us.' A visitor told us that they felt welcome in the home at any time and the staff kept them informed of any changes in their loved ones condition.

The staff we spoke with had good knowledge about people's medical conditions and needs. However the documentation was not written with specific instructions to ensure all staff would be able to provide the required level of care.

Is the service well led?

The registered manager was on leave during our inspection. Staff told us the manager was approachable and supportive and had made a number of positive changes to the environment in the time they had been managing the service. However the ratio of staff on duty to the number of people using the service meant some areas of people's care, particularly activities, were not being met. We also noted that areas of the home, particularly toilets were not as clean as they should be.

This is a summary of what we found-

Is the service safe?

One person was able to tell us they felt safe living at Linden Manor. Individual plans of care contained risk assessments to promote people's safety such as risk assessments for malnutrition, the risk of falls, the effects of pressure on the body and movement and handling.

We saw bedrooms were fitted with appropriate safety equipment such as window restrictors, radiator guards, call bells and fire doors were fitted with automatic closure devices. We found both the bedrooms and the communal living areas were either fitted with non-slip flooring or carpets. No slip or trip hazards were identified. We looked at the accident records and found that there had been no accidents where the cause had been attributed to the safety of the environment. We saw when accidents had occurred they had been followed up to ensure that people had not sustained an injury. Where people had sustained injury appropriate medical advice had been sought.

We found that staffing levels were regularly reviewed to ensure that people's individual and collective needs could be met and that a training plan was in place to ensure staff had the right skills to care for people safely.

Is the service effective?

All of the people living at Linden Manor had an individual plan of care; these had been regularly reviewed to ensure that they contained appropriate information.

We saw people were comfortable and relaxed within their environment, people looked well cared for and they were dressed according to their age, gender, culture and the weather conditions. We saw that people had access to a range of aids and adaptations to support their independence and mobility.

However the provider may wish to note that during the morning the radio in the conservatory was set to play 1980's pop music which may not have engaged people with dementia and who were in their 80's.

Is the service caring?

One person was able to tell us that the staff were nice to them. We saw that staff treated people with respect and consideration and they were also mindful of people's privacy.

We also observed that staff supported people to eat their meals with patience and consideration. We also observed that people who used the service were referred by their preferred name.

People looked well cared for and they were dressed according to their age, gender and the weather conditions. We saw that people had access to a range of aids and adaptations to support their mobility and independence.

Is the service responsive to people's needs?

Staffing levels had been maintained at an appropriate level in relation to the assessed individual and collective needs of the people who used the service; this meant that the quality of care and support that staff were able to provide was maintained.

There were regular and varied activities that people could engage in if they chose to do so.

Records showed that people had access to appropriate care, including access to pressure relieving equipment. Records also showed that people had access to health professionals and NHS services.

Is the service well lead?

The registered manager and the provider had had conducted the appropriate checks to ensure that people who used the service were safe. Systems were in pace to ensure that staff had the right skills to care for people safely. Individual plans of care reflected people's health care needs and personal preferences and these were regularly reviewed. Risk assessments were in place to reduce and manage the impact of identified risk factors. Identified risks were followed up with appropriate specialist such as the falls prevention service.

A range of audits were conducted on a regular basis to assure the quality the service provided. These included audits of the fire safety systems, hot water temperature safety checks, medication systems, infection control systems, health and safety systems and the safety of environment. Individual plans of care and risk assessments were also reviewed on a regular basis.

However the provider may wish to note that although people at risk of dehydration had fluid charts in place they were not always accurately completed; nor was their 24 hour intake calculated. Without this being done and reviewed on a daily basis the management could not be assured that people were in receipt of an adequate amount of fluids.

We spoke with three members of staff who had a good knowledge of people's care needs.

We observed staff responding to one person who repeatedly voiced dissatisfaction. We saw that some staff did not offer the person explanations or engage with the person in a respectful or appropriate manner. We observed staff responding to other people living in the home and saw that they were respectful and did offer explanations and reassurance where needed.

We saw that people using the service and their relatives had been able to give feedback about the service through quarterly satisfaction surveys. We looked at a selection of these and saw the feedback from people using the service and their relatives was positive.