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Inspection Summary


Overall summary & rating

Inadequate

Updated 5 June 2018

Our rating of services stayed the same. We rated it them as inadequate.

  • Patients could not access services when they needed them. Waiting times for treatment were not in line with good practice. The number of cancelled operations for non-clinical reasons was worse than the England average.
  • Not all systems in place were effective in recognising and responding to deteriorating patients’ needs. This included harm reviews of patients waiting for a procedure.
  • The trust was performing worse than the England average for patients waiting over 60 minutes before being handed over to emergency department staff. Not all patients were recorded as being seen by a specialist doctor despite being referred.
  • The trust did not ensure everyone completed mandatory training.
  • While staff understood the need to protect patients from abuse, not all staff had completed training at the required level to ensure they had the appropriate level of knowledge to do so.

  • There were inconsistencies in staff being able to recognise and report incidents.
  • Not all staff had received an appraisal.
  • The hospital had medical staff with the right qualifications, skills and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. However, there was insufficient medical cover to provide consultant presence in the department for 16 hours a day, as recommended by Royal College of Emergency Medicine.
  • The trust planned but did not provide services in a way that met the needs of local people.
  • Services did not always have a documented vision or strategy.
  • Information was not always collected, analysed, managed and used well to support activity.
  • Continuous improvement, and learning from when things go wrong was not evident across all areas.
  • There were inconsistencies with infection control and prevention techniques, particularly hand hygiene.

However:

  • Managers investigated reported incidents and shared lessons learned with the whole team. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Most areas had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The hospital had suitable premises in most areas and systems were in place to ensure most equipment was well looked after.
  • The hospital prescribed, gave, and recorded medicines well. Patients generally received the right medication of the right dose at the right time.
  • Generally, staff ensured that patients’ individual care records were well managed and stored appropriately.
  • Services took account of patients’ individual needs.
  • The hospital provided care and treatment based on national guidance and evidence of its effectiveness.
  • The hospital managed most patients’ pain effectively and provided or offered pain relief regularly. However, children’s and young peoples’ pain was not always managed effectively.
  • Staff generally gave patients enough food and drink to meet their needs and improve their health.
  • Multidisciplinary staff worked together as a team to benefit patients.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Most managers across the hospital promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
Inspection areas

Safe

Inadequate

Updated 5 June 2018

Effective

Requires improvement

Updated 5 June 2018

Caring

Good

Updated 5 June 2018

Responsive

Inadequate

Updated 5 June 2018

Well-led

Inadequate

Updated 5 June 2018

Checks on specific services

Critical care

Good

Updated 20 June 2017

We rated critical care as good because:

  • There was a positive safety culture. Staff recorded incidents, investigations were completed and staff received feedback. The service had a robust safety briefing in place, which was attended by all staff.
  • Staff maintained and monitored patient safety through local audits which included infection control, patient harms and risks. Action plans were developed to address any issues.
  • Patient records were contemporaneous, legible and stored safely. Evidence based assessment tools were used to monitor risk.
  • Mandatory training was generally in line with trust targets.
  • Medications were stored, prescribed and administered safely. There were systems in place to monitor safe storage and staff took appropriate actions in line with local protocol to address any concerns or anomalies.
  • The service used evidence-based guidelines, policies and protocols to monitor patient outcomes. Results were used to compile service dashboards, which were used to present audit results and monitor trends. Clinical leads reviewed these for compliance and trends and discussed results as part of the divisional and trust wide service meetings.
  • The service had a flexible approach to delivering patient care across both critical care units (Alexandra Hospital and Worcestershire Royal Hospital) to maintain patient safety.
  • Patient outcomes were used to benchmark the service against similar organisations to identify areas for improvement.
  • The service had access to additional specialists such as a pain specialist nurse, dietetics, microbiologists and pharmacy.
  • Staff competence was monitored and maintained through annual appraisal and competency reviews. External training was available for staff.
  • There was evidence that the multidisciplinary team was inclusive and well organised.
  • Patients were treated with dignity and respect, and in line with their individual beliefs and were involved with the care and treatment planning. Patients spoke positively about the care they received.
  • Relatives had access to facilities to enhance their stay on the unit, this included overnight accommodation, refreshments and information leaflets.
  • Patients were assessed appropriately for admission to critical care and received a full review by a consultant within 12 hours of admission to the unit.
  • There were no formal complaints regarding the service.
  • The service was well-led with strong local leadership, a service vision and robust governance systems in place.
  • All staff were positive about their roles, enjoyed working for the service and were dedicated to improving the standards of patient care.

However:

  • There were a small number of delayed discharges from critical care, which affected patient flow and experience.

Outpatients and diagnostic imaging

Inadequate

Updated 20 June 2017

We rated outpatients and diagnostic imaging as inadequate because:

  • There were long waiting lists for the majority of specialities and the trust had not met all cancer targets for referral to treatment times. The trust was failing to meet a range of benchmarked standards with regards to the time with which patients could expect to access care.
  • Mandatory and safeguarding training levels did not always meet the trust’s target and not all staff had received an annual personal development review.
  • Incidents were not always categorised appropriately in terms of the level of harm caused. Incidents were not always reviewed in a timely manner and we were not assured that learning from incidents was cascaded to all staff.
  • Complaints were not always responded to in a timely manner.
  • There was a lack of radiation protection infrastructure.
  • Old and unsafe equipment across the trust was inadequately risk rated and there was a lack of capital set aside to fund replacement items.
  • There had been two patient safety incidents in the trust involving unsafe x-ray equipment and which had resulted in patient injury.
  • We were not assured the service had a robust, realistic strategy for achieving its priorities and delivering good quality care.
  • Governance arrangements and the management of risk was insufficiently robust and further improvements were needed.

However:

  • Patient records were stored securely and effective systems were in place to ensure clinicians had access to appropriate and up-to-date patient information.
  • Patients were treated with kindness, dignity and respect and spoke positively about the care they had received.
  • Care and treatment was delivered in line with national guidance.
  • Some departments had developed services, such as one-stop clinics, in order to better meet the needs of patients and improve service provision.
  • There was effective multidisciplinary working across the outpatient and diagnostic imaging service.
  • Local leadership was strong, supportive and approachable. However, staff did not feel directorate and divisional leads were visible.
  • Staff were proud to work at the hospital and were passionate about the care they provided.

Urgent and emergency services

Requires improvement

Updated 5 June 2018

Our rating of this service stayed the same. We rated it as requires improvement overall. During this inspection we only looked at the safe domain and rated it as requires improvement because:

  • Not all systems in place were effective in recognising and responding to deteriorating patients’ needs. The trust was performing worse than the England average for patients waiting over 60 minutes before being handed over to ED staff. Not all patients were recorded as being seen by a specialist doctor despite being referred.
  • The service did not ensure everyone completed mandatory training. The trust target for mandatory training compliance was not met for nursing or medical staff.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, the service had not met the national trajectory of 85% by March 2018 in PREVENT training as set out by the NHS England.
  • The service did not control infection risks well. There was poor compliance with the use of control measures to prevent the spread of infection.
  • The service had suitable premises but did not always look after equipment well.
  • During the previous inspections of November 2016, April 2017 and November 2017 we highlighted concerns regarding the completion of the 24 hour re-assessment regarding venous thromboembolism. During this inspection we saw that the concern remained which meant they were not compliant with the National Institute for Health and Care Excellence (QS3) guidance.
  • Mortality and morbidity remained an area of concern during the previous inspection of November 2017 and had not improved. During this inspection we found that reviews lacked detail and there was little evidence of actions or learning as a result.
  • The service had medical staff with the right qualifications, skills and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. However, there was insufficient medical cover to provide consultant presence in the department for 16 hours a day, as recommended by Royal College of Emergency Medicine.

However:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The service had enough nursing staff with the right qualifications, skills and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • Generally the service prescribed and stored medicines well.

Outpatients

Inadequate

Updated 5 June 2018

  • We rated safe, responsive and well-led as inadequate and rated caring as good. We do not currently rate effective for outpatients.
  • Mandatory training attendance was low and did not meet the trust targets for all modules.
  • Mental Capacity Act and Deprivation of Liberty Safeguards training was low and did not meet the trust target of 90%.
  • Clinical harm reviews were carried out, however we were not assured these were carried out in a timely manner, psychological harm was considered or that those identified as coming to harm were reported as a serious incident as appropriate.
  • Incidents were not managed well and we were not assured that harm was categorised appropriately.
  • Patients could not always access the service when they needed it. Waiting times from treatment and arrangements to admit, treat and discharge patients were not in line with good practice. There were long waiting lists with many patients waiting up to 52 weeks for outpatient services. There was no improvement in most areas since our inspection in November 2016.
  • Due to the limited improvement in performance, we were not assured the leadership team could deliver the significant change required to improve patient outcomes.

However:

  • Patients were treated with kindness, dignity and respect and staff were attentive to their needs. They were involved in decision making about their care and treatment and were supported in this.
  • Staff and teams worked well together to deliver effective care and treatment. We saw good examples of multidisciplinary working and most staff had opportunities to develop their skills and roles to improve patient experience.

Maternity and gynaecology

Updated 8 August 2017

We carried out a focused inspection to review concerns found during our previous comprehensive inspection on 22 to 25 November 2016. We inspected parts of four of the five key questions but did not rate them. We found significant improvements had not been made in these areas:

  • Despite assurances from the trust, we saw no evidence that obstetrics and gynaecology mortality and morbidity reviews were held. Furthermore, whilst perinatal mortality and morbidity meetings were minuted, we were not assured that action was taken to address any learning identified from case reviews.
  • The trust had monitoring systems in place to ensure medicines were stored within recommended temperature ranges. However, these were not consistently followed across the service.

We also found other areas of concern:

  • Surgical nursing staff, who cared for gynaecology patients on the designated wards, had not received any specific gynaecology training, such as management of surgical miscarriage and bereavement care. However, the gynaecology medical team were available for advice as needed.

However, we found improvements in some areas:

  • All clinical areas we visited were clean and there was good adherence to infection control policies and the use of personal protective equipment.
  • There had been an improvement in compliance with safeguarding children level three training. Staff demonstrated awareness of safeguarding guidance, including female genital mutilation. Staff understood their responsibilities and were confident to raise concerns. However, training compliance was still below the trust target.
  • Equipment was clean, maintained and serviced to ensure it was safe for patient use.
  • Compliance with Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training had improved. Staff demonstrated awareness of relevant consent and decision making requirements relating to MCA and DoLS, and understood their responsibilities to ensure patients were protected.

Medical care (including older people’s care)

Requires improvement

Updated 17 January 2018

Our rating of this service improved. We rated it as requires improvement because:

  • During this inspection we found that mandatory training compliance had improved, however, did not meet the trust target level of 90%.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, staff did not always have training on how to recognise and report abuse and how to apply the learning.
  • The service mostly controlled infection risk well, however not all staff we observed followed the trust infection control and prevention policy.
  • We found progress had been made in assessments and responses to patient risk within each of the medical wards we visited. Initial venous thromboembolism assessments were completed on a patient’s admission to hospital. The assessments were not always repeated within 24 hours of admission.
  • Data showed that wards were regularly working with reduced numbers of qualified nursing staff. There was a high number of qualified nurse vacancies within the medical division however, in mitigation the trust filled vacant shifts with bank and agency staff when possible.
  • Medical cover overnight consisted of one registrar who was responsible for all inpatient areas.
  • There was variable performance in a number of national audits relating to patient safety and treatment.
  • The endoscopy department had their Joint Advisory Group accreditation deferred following a recent inspection.
  • Appraisal rates did not meet the trust target of 90%.
  • Mental Capacity Act 2005 and Deprivation of Liberty training compliance was poor.
  • The service did not always treat complaints in line with trust policy.
  • From October 2016 to September 2017, the service reported a high number of patient bed moves out of hours (10pm to 7am).
  • Managers had the right skills and abilities to run a service providing high-quality sustainable care. A stable leadership team had been in place for a period of six months only however, at the time of our inspection and there had been significant instability during the previous two years.
  • The trust’s vision and strategy remained under development at the time of the inspection. There was no documented local strategy for the service, and some staff were uncertain about the trust’s vision and strategy regarding the Alexandra Hospital.
  • Not all data across the trust was managed effectively to ensure it was accurate and reliable.

However, we also found;

  • The service prescribed, gave, recorded and stored medicines well.
  • The service mostly managed patient safety incidents well.
  • Medical notes contained comprehensive and detailed patient reviews, referrals to other clinicians, and clear treatment plans.
  • The service had introduced a safer staffing application (app) which was completed locally on wards daily. The app recorded the number and type of staff on duty each day and compared this to the ward planned establishment.
  • Patients had their needs assessed and their care was planned and delivered in line with evidence-based guidance, standards and best practice.
  • Staff from different disciplines worked together as a team to benefit patients.
  • Patients’ pain was assessed on admission to hospital and repeated at intervals throughout their stay.
  • Staff cared for patients with compassion.
  • The trust planned and aimed to provide services in a way that met the needs of local people.
  • Within the medical division, the capacity review had resulted in changes in the allocation of patient beds to improve patient flow.
  • The medicine divisional dashboard clearly demonstrated performance measure against key indicators, such as NHS Safety Thermometer data, infection control rates, complaints performance, bed occupancy, length of stay and readmission rates. The dashboards were discussed at divisional meetings and at board level.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

Diagnostic imaging

Requires improvement

Updated 5 June 2018

We previously inspected diagnostic imaging jointly with outpatients and therefore, ratings cannot be directly compared to this core service only. We rated the service as requires improvement because:

  • The service failed to meet trust targets for most mandatory training topics, including safeguarding adults and children and Mental Capacity Act 2005.
  • The service did not always control infection risk well. Staff did not always use control measures to prevent the spread of infection. There were inconsistencies with infection control and prevention techniques, particularly hand hygiene.
  • Although the premises were suitable and well looked after, the environment did not always provide appropriate waiting areas for patients. This meant that the service did not always take into consideration the patients’ individual needs.
  • Some equipment was old and overdue for replacement and there was poor oversight by managers of the preventative maintenance schedule for annual servicing.
  • There were not always processes in place to store, administer and manage medicines safely.
  • Appraisal rates for all staff groups were below the trust target.
  • There was limited engagement with patients and service users.

However:

  • The service had enough staff, however they did not all have the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment
  • The service outsourced activity to ensure timely treatment was provided.
  • Patient safety incidents were reported, investigated and any learning shared across all areas.
  • Care and treatment was provided in line with national guidance. Policies and procedures were up to date.
  • There was effective team working across all staff groups.
  • Staff were compassionate and caring.
  • Patients were able to access services across all sites.
  • Complaints and concerns were investigated fully and actions taken to reduce reoccurrence.
  • The service had managers with the right skills and abilities to run a service providing high-quality sustainable care. Managers promoted a positive culture that supported and valued staff.
  • Staff were generally happy with their work and the team.
  • There was a strong culture for delivering high-quality care.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and a systematic approach to continually improving the quality of its services.
  • The service was committed to improving services by learning from when things go well and when they go wrong.

Surgery

Inadequate

Updated 5 June 2018

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. For some essential skills, including resuscitation training, compliance fell short of the trust target.
  • Most nursing staff had received safeguarding training on how to recognise and report abuse. However, not all medical staff had completed safeguarding training to the required level. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Some areas did not have enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service did not have robust processes in place to ensure staff were competent for their roles.
  • Not all staff had received an appraisal. Not all staff received supervision to provide support and monitor the effectiveness of the service.
  • Effective systems were not always used to recognise and respond to deteriorating patients’ needs.
  • Most staff had not received training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards. Staff generally understood their roles and responsibilities under the Mental Health Act 1983 and the MCA.

  • The trust planned but did not provide services in a way that met the needs of local people.
  • Patients could not always access the service when they needed it. Waiting times for treatment were not in line with good practice. The percentage of patients whose operation was cancelled and were not treated within 28 days was worse than the national average.
  • The service did not have a documented vision for what it wanted to achieve. However, plans for the future vision were in development with involvement from staff, patients, and key groups representing the local community.
  • Staff recognised incidents but did not always report them. Managers investigated reported incidents and there were systems in place to share lessons learned when incidents had been reported.
  • Not all systems in place were effective in recognising and responding to deteriorating patients’ needs. This included screening patients for sepsis, harm reviews of patients waiting for a procedure, and reassessment within 24 hours for venous thromboembolism.
  • Information was not always collected, analysed, managed and used well to support activity.
  • Continuous improvement, and learning from when things go wrong was not evident across all areas.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service generally controlled infection risk well. Most staff kept themselves, equipment and the premises clean. Some control measures were in place to prevent the spread of infection.
  • The service had suitable premises in most areas and systems were in place to ensure equipment was well looked after.
  • Most areas had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The service managed patients’ pain effectively and provided or offered pain relief regularly.
  • Staff generally gave patients enough food and drink to meet their needs and improve their health.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • The service took account of patients’ individual needs.
  • Multidisciplinary staff worked together as a team to benefit patients.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

Services for children & young people

Requires improvement

Updated 5 June 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service provided mandatory training in key skills to all staff but data provided by the trust showed they did not ensure staff completed it. The trust identified issues with data quality which may have resulted in under reporting of the actual position.
  • Staff understood the need to protect patients from abuse but had not always completed training at the appropriate level to ensure they had the appropriate level of knowledge to do so.
  • Standards of infection prevention and control were not always maintained.
  • The premises and equipment were not well maintained.
  • There was no protocol or standard operating procedure for staff to follow if a child or young person became unwell in the department and nursing staff did not use an early warning score to identify when a patient deteriorated.
  • Staff kept appropriate records of patient’s care and treatment, but some hand written records were not clear and there was an increased risk of unauthorised access to the patient records via unlocked computers.
  • The facilities and premises were not always suitable for the service being delivered. More than two thirds of children were seen in adult outpatient areas. Play specialists were not available to support children in outpatient clinics.
  • The service had an annual audit plan. However, there were few audits which considered the effectiveness of children’s outpatient services.
  • Children’s and young peoples’ pain was not always managed effectively. Staff in fracture clinic did not assess patient’s pain and offer pain relief when needed.
  • The service had systems to monitor the effectiveness of care and treatment for inpatients and used the findings to improve, but there was little monitoring of outcomes of outpatient care.
  • Staff were aware of their responsibilities for obtaining consent for treatment and their roles and responsibilities under the Mental Capacity Act 2005 (MCA). However, staff completion of training in MCA was low and no audits of consent were completed.
  • The service did not monitor waiting times within the clinics for patients. Fracture clinics were busy and patients and staff reported that waiting times could be lengthy and the percentage of patients not attending for a follow up appointment was high.
  • Leadership of children’s services was provided from the Worcestershire Royal Hospital site and the amount of time dedicated to children’s services at the Alexandra Hospital was very limited. There was no oversight of services for children provided in the adult outpatient departments by the children’s directorate team.
  • The service had a vision how children’s services would be configured in the future and what it wanted to achieve, but did not have a documented strategy or action plan to enable the vision to be realised.
  • Governance processes were becoming more established and had improved since the inspection in 2016. However, there was little engagement and involvement of nursing staff at clinic level in governance processes.
  • The service did not have effective systems for identifying risks, and coping with the unexpected. They measured key performance indicators on a monthly basis but there was little evidence of improvement in some indicators over the period of a year.
  • Information on some aspects of performance was available, however, the utilisation of information to bring about improvements was not maximised. Trust information was not always available due to problems with the trust’s IT systems.

However:

  • Staff cared for children and young people with kindness and understanding.
  • Staff provided emotional support to patients to minimise their distress.
  • There were enough medical staff with the right qualifications and experience to provide care in children’s services at the hospital.
  • Suitable arrangements were in place for the ordering, dispensing, prescribing, recording and handling of medicines.
  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and provided feedback to staff. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Multidisciplinary staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • The service took account of patients’ individual needs.
  • The trust promoted a positive culture which valued staff and based on shared values but staff whilst saying they embraced this, did not feel it was embedded within the trust.

End of life care

Good

Updated 20 June 2017

We rated the end of life care service as good because:

  • Staff understood their responsibilities to raise concerns and to record safety incidents. Incidents relating to end of life care were reviewed by the lead nurse for specialist palliative care. DNACPR (do not attempt cardiopulmonary resuscitation) records were generally completed well and the trust were making use of audits and learning from incidents to drive improvements.
  • There was good identification of patients at risk of deterioration and those in the last days of life. There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. There was consistent promotion of the delivery of high quality person centred care. Several audits had been undertaken to evaluate the service with associated action plans to address improvements identified.
  • A comprehensive programme of end of life care training was available for the full range of staff within the trust. However, we were not able to establish compliance with mandatory training (including safeguarding adults training) for specialist palliative care staff, including their annual appraisals rates. Evidence for this was requested but not provided by the trust.
  • There was good evidence of multidisciplinary working and involvement of the specialist palliative care team throughout the hospital including allied healthcare professionals as well as medical and nursing members. The specialist palliative care team provided a seven day face to face assessment service across the trust.
  • The trust had taken action to improve the service since the previous inspection. This included the replacement of fridges, flooring and improving the hot water facilities within the mortuary. Issues relating to obtaining syringe drivers had been addressed and appropriate anticipatory prescribing was used at the end of life.
  • There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. The trust had begun to record and audit preferred place of care and there were clear systems in place to make improvements in this area.
  • The specialist palliative care team responded quickly to referrals and would see patients within a few hours if the need was urgent. The majority (92%) of patients were seen within 24 hours and there was a good balance between cancer patient and non-cancer patient referrals.
  • Patients and relatives told us that the staff were caring, kind and respected their wishes. We observed staff communicating with patients and relatives in a manner than demonstrated compassion, dignity and respect.
  • There was a clear vision for the service and a draft strategy was in place, highlighting the key areas the trust were focusing on in relation to end of life care.