Children's Home run by Derby City Council in Derby

SC036019 Unique reference number 4 June 2009 Inspection date Chris Fuller / Rosemary Dancer Inspector Key Type of Inspection

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2 December 2008 Date of last inspection .

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This document may be reproduced in whole or in part for non-commercial educational purposes, provided that the information quoted is reproduced without adaptation and the source and date of publication are stated.

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You can obtain copies of The Children Act 2004, Every Child Matters and The National Minimum Standards for Children's Services from: The Stationery Office (TSO) PO Box 29, St Cripins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop

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About this inspection

The purpose of this inspection is to assure children and young people, parents, the public, local authorities and government of the quality and standard of the service provided. The inspection was carried out under the Care Standards Act 2000. This report details the main strengths and any areas for improvement identified during the inspection. The judgements included in the report are made in relation to the outcome for children set out in the Children Act 2004 and relevant National Minimum Standards for the establishment.

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The inspection judgements and what they mean

this aspect of the provision is of exceptionally high quality Outstanding: this aspect of the provision is strong Good: this aspect of the provision is sound Satisfactory: this aspect of the provision is not good enough Inadequate: 3 of 13 Inspection Report: SC036019

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Brief description of the service

The children’s centre was opened in 1976. Set in its own grounds it is one of a number of children's residential facilities. The building complex houses three separate units with five, six and six placements respectively. The service provides placements for young people aged between 10 to under 18 years of age in medium to long-term placements. Each unit may also take emergency admissions. There are 15 young people currently accommodated, 10 of the young people participated in the inspection. There is a lounge, dining area and utility room on each unit. All bedrooms are single. The home is within easy reach of facilities and amenities which may be accessed by public transport.

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Summary

This unannounced full inspection monitors all of the key National Minimum Standards and in addition standard 23 relating to the location, design and size of the home. The recommendations made at the last inspection in December 2008 were also looked at. These related to records of restraints and sanctions and records of supervision of staff and these have both been addressed. At the last full inspection the centre was assessed as satisfactory. Following this inspection the overall judgement remains the same. However, there are four new actions and seventeen recommendations on this occasion. These cover each of the outcome areas but predominantly the staying safe and achieving economic wellbeing outcomes. Most significantly many of these relate to the premises and the impact of the environment on the quality of care provided to young people. The overall quality rating is satisfactory. This is an overview of what the inspector found during the inspection.

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Improvements since the last inspection

The recommendations from the previous inspection have been addressed. Each unit has a record of restraint and sanctions held in separate dedicated bound and numbered books. Generally progress has been made with staff receiving more regular planned supervision sessions with a written record being completed and agreed by staff. Supervision is monitored during Regulation 33 visits and Regulation 34 monitoring. However, new members of staff do not receive regular fortnightly supervision and a new recommendation has been made in respect of this.

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Helping children to be healthy

The provision is satisfactory. Young people are generally provided with healthy meals through varied menus. Whilst young people’s preferences and dietary needs are recorded it is generally accepted that the main kitchen is unable to address the individual preferences of all young people, however, each unit is able to address this issue during evening and weekend food purchase and mealtimes. Young people said that, ‘most of the time we have balanced meals’. The young people‘s health and dietary needs are clearly identified and met.

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Helping children to be healthy

Basic health care plans for young people are included within placement plans. Young people are encouraged to establish good routines for regular health care checks at local health services. This includes attendance at a range of medical appointments with the support and encouragement of staff. Where young people are reluctant to access medical services staff 4 of 13 Inspection Report: SC036019 provide information and look for suitable alternatives with specialist agencies. The Children in Care nurse assists staff and young people in networking with other health professionals and positively engages the young people. Staff promote healthy lifestyle choices in daily routines, personal care, exercise and activities for young people. However, whilst there are notices around not smoking and young people are informed of the dangers to their health, older young people are to be seen openly smoking throughout the grounds.

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Helping children to be healthy

The children’s centre has policy and procedures in place for the safe storage and administration of medication. The majority of staff are trained in the safe handling and administration of medication and first aid. The staff generally record the administration of medication appropriately. However, on some units the receipt and disposal of medication is recorded on individual sheets rather than in a bound book providing a description of the amount and name of the medication returned and how and where it is disposed. Young people’s health is safeguarded as staff are informed and aware of the appropriate procedures to follow.

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Protecting children from harm or neglect and helping them stay safe

The provision is satisfactory. Young people’s records are kept secure and confidential. However, there are systems where the recording of personal and confidential information is made on multipurpose documents, such as, the staff meeting book, a special log for feelings and concerns. Personal information is also wall displayed in staff offices, whilst a useful quick reference for staff this information is not held discreet and confidential. Following a risk assessment young people are issued with keys to their own rooms and a lockable safe to store personal valuables. There are arrangements in place to protect young people’s privacy and confidentiality. This is balanced against the need to protect both the individual and other young people. Whilst young people may have their own mobile phone or may access the office telephone supervised by staff, the centre does not provide young people with access to a telephone on which to make and receive telephone calls

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Protecting children from harm or neglect and helping them stay safe

Young people are informed and understand how to raise a complaint, however, staff will usually try to address this at first stage rather than process formally. For example, some general concerns raised by young people about the locking of doors or menus choices are discussed one-to-one or in group discussions with explanations given by staff rather than processed formally. The relationship with staff is very important to facilitating effective use of complaint processes and this is variable on each unit. A small number of complaints have been addressed in an appropriate manner within timescales with verbal feedback given to young people. The VOYCE project worker usually visits the centre once a month for independent meetings with the young people providing them with an opportunity to express any issues or concerns they may have.

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Protecting children from harm or neglect and helping them stay safe

The centre has policies and procedures for all safeguarding practices in respect of Child protection, Countering, Bullying, Absence of a child without authority and Notification of significant events. The home provides care for vulnerable young people with a wide range of high risk factors. The management and staff receive training in safeguarding and child protection, however, ancillary staff have not all received basic training in these topics. The centre has established working relationships with social work teams and the safeguarding board. All allegations and suspicions of abuse are reported and addressed appropriately.

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Protecting children from harm or neglect and helping them stay safe

The young people are aware that bullying is a serious issue and state they, ‘See people get bullied; try to help and sort things out.’ Staff provide young people with advice and support 5 of 13 Inspection Report: SC036019 regarding prevention of bullying and how to keep themselves safe. Individual risk assessments are completed and include strategies to manage oppressive and aggressive behaviour. The premises are large with many hallways and communal areas which have the potential to be difficult to monitor and supervise at all times. The size and layout of the premises and grounds provides areas that are potentially hazardous and may facilitate bullying to take place. The centre does not have a recorded risk assessment for the premises in respect of prevention of bullying.

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Protecting children from harm or neglect and helping them stay safe

The centre has a high level of incidents recorded and reported of young people that are absent without authority or missing persons. The young people are protected in accordance with written guidance and responded to positively by staff on their return. Comprehensive risk assessments are held within the care plan. Staff follow agreed police protocol of when to report young people missing. There is regular liaison with police officers who visit the centre and individual units to make ‘safe and sound’ checks and work with staff and young people to keep them safe in the community. Due to the design of the premises there are many different entrances and exits that can be used by young people to exit the building without the knowledge of staff. The staff will lock external doors at times to restrict movement and prevent comings and goings from the premises. Similarly, staff will remove the footwear of a young person as

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Protecting children from harm or neglect and helping them stay safe

a precautionary measure at times of high risk or potential for harm to a young person or others. These measures are not recorded in the risk assessments or care plans of young people. Management identify patterns and trends of absence without authority.

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Protecting children from harm or neglect and helping them stay safe

Staff make appropriate, timely notifications to Ofsted with 17 events received in the past 12 months. Notifications are generally detailed with all relevant information provided. Six of the notifications related to and instigation of a protection enquiry involving a young person at the centre. Strategy meetings are held and notified to the relevant agencies.

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Protecting children from harm or neglect and helping them stay safe

Staff receive training in managing behaviour and there is a policy of early intervention to prevent escalation of behaviour. The home has behaviour management strategies in place and these are included in the placement plan. Staff response to young people does vary throughout the units, though, is generally fair and helpful. Records of restraints and sanctions are completed appropriately with relevant details. Young people are asked to make their comments and record their views, however, this is frequently refused. Young people have made a number of allegations against staff members regarding inappropriate restraints with subsequent safeguarding investigations. The staff use a range of sanctions and where possible make these reflect the incident. However, there are a lot of occasions where pocket money is withheld and whilst this has been recognised as ineffective and inappropriate, by the management team, the practice

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Protecting children from harm or neglect and helping them stay safe

The centre is a large building with other premises also on site accessible to and accessed by young people. Young people are informed of the importance of keeping themselves safe through provision of information and discussion of health and safety topics. All staff complete training in safe working topics. One of the deputy manager’s takes the lead on the health and safety aspects of the centre. There are monitoring systems in place and regular maintenance checks and the required certificates are completed and updated as necessary. The staff maintain the accident records and ensure young people receive medical assessment and treatment as needed. Nominated First Aid is provided appropriately. The Fire Safety in the home was not fully inspected on this occasion. However, it was evident that individual risk assessments of young people were not always updated or cross referenced to the centre health and safety files for

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Protecting children from harm or neglect and helping them stay safe

6 of 13 Inspection Report: SC036019 example where there are fire safety issues. Staff state that, ‘Risk assessments are provided when needed to ensure staff and young people are kept safe.’ The kitchens were found to be clean and hygienic, however, some food stuffs are stored without date labels potentially causing a hazard the health of young people. Young people are generally aware of health and safety issues and strategies to keep themselves safe.

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Protecting children from harm or neglect and helping them stay safe

The centre has clear practice and procedures for visitors signing in and out of the building. Visitors may enter the grounds and premises without the knowledge of staff and young people. Management recognise this as a potential hazard and precautions are taken to secure the premises with locking of external doors to ensure the safety of those living and working in the centre. The premises have metal guards attached to the facia boards and roof of the building to prevent people accessing the roof. Whilst this provides a security and safety measure, it also projects a hostile institutional aspect of the centre.

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Protecting children from harm or neglect and helping them stay safe

There is an established recruitment process. On this occasion not all of the required clearance records and identification of staff information was available at the centre to demonstrate the suitability of staff, such as, date of criminal record clearance, start date, no photo identification and no evidence of qualification. Staff files are held secure and confidential. The system for staff clearance is generally effective in ensuring suitable staff are appointed to provide care for young people.

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Helping children achieve well and enjoy what they do

The provision is satisfactory. The young people are given help to develop their self confidence and fulfil their individual placement plans. Staff can generally meet the needs of young people accommodated at the home. Such needs include disability, race, gender, belief, religion, sexual orientation, language and culture. Young people are encouraged to make choices and participate in daily activities and routines. Staff access learning opportunities for young people, such as, 'Peer mentoring, two young people have attending this training'. This helps to develop the self image of young people whilst promoting social skills. Specialist services are accessed, such as, the Enhanced Care Project. A mental health practitioner works directly with individual young people and provides guidance to staff on behaviour management and strategies. This worker is supervised by a Consultant Child Psychologist. Staff receive training in therapeutic theories, such as,

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Helping children achieve well and enjoy what they do

attachment theory and use of strategies and resources, such as, coping diary worksheets and behaviour modification programmes.

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Helping children achieve well and enjoy what they do

Young people are provided with opportunities to develop education and social skills. The young people did not have personal education plans held on file to inform educational objectives and learning. Individual timetables are set up weekly for each young person, these can be quite limited with hourly sessions booked at the enhanced care project through to full time education in mainstream school. A wide range of different educational programmes and resources are accessed to meet the varying ages, abilities and stage of development of individual young people. There is clear progress for some young people with educational attainments in mainstream school and others being successful in their applications to the armed forces or college entrance. For a number of other young people progress is not so evident with very limited educational timetables and little or no structure to the school day.

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Helping children achieve well and enjoy what they do

The centre has activities resources, equipment and facilities for use indoors and in the grounds, such as, table football, tennis, pool, art and crafts, computer games and books. Placing social 7 of 13 Inspection Report: SC036019 workers state, 'young people have attended workshops and activities in the community; well-dressing, the Buddhist centre, RSPCA, local museums and garden centres'. Although young people are encouraged to take part in leisure activities and personal hobbies or interests, it would seem there is limited involvement as they choose not to participate, insufficient staff with appropriate skills to facilitate activities or due to sanctions depriving them of the activity. Young people appear to have a lot of unstructured time including during the school day and in their leisure time.

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Helping children make a positive contribution

The provision is satisfactory. Young people’s care plans are generally based on the assessment of their individual needs and wishes and are regularly reviewed and updated. Basic information in looked after children documents has the potential to present difficulties for placement planning when the young person does not have an allocated placing social worker or their availability for sharing information is limited. Staff provide placement plans which outline the individual needs and wishes of the young people and try to engage the young people in contributing to this process. However, these do vary in their quality and detail of how the objectives are to be met on a day-to-day basis.

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Helping children make a positive contribution

Young people are encouraged to contribute to the review process and be involved in decision making about plans for their future. Reviews appear to be taking place within timescales with the exception of 72 hour reviews which may overrun the timescale. Generally, placing social workers will visit to discuss and prepare for the review with the young people.

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Helping children make a positive contribution

The centre generally supports and nurtures positive relationships with relatives, friends and the placing authority workers. Staff are generally very supportive of young people in meeting contact arrangements. Recording shows a good understanding of the potential to disrupt emotional wellbeing of young people and subsequent behaviour management issues following contact or changes to these arrangements.

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Helping children make a positive contribution

Staff provide young people with verbal and written information at the time of them moving into the unit giving them facts which they need and wish to have. The centre receives both planned and emergency admissions with 15 of the latter being made in the last 12 month period. Emergency admissions can be of short duration and are potentially extremely disruptive to resident groups of young people. However, the group risk assessment is not being completed or implemented in the placement planning process to ensure that any shortfalls in service delivery are being identified and addressed.

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Helping children make a positive contribution

Young people are regularly consulted, formally and informally regarding their needs and wishes and given an opportunity to influence the day to day matters on the units. Young people’s meetings take place regularly and young people are able to call extra ones if they have an issue they wish to discuss. Other professionals are aware that, ‘There is a young person’s consultation group which meets regularly to discuss any issues, their views are then relayed to the managers meeting for consideration.’ A range of issues are discussed for example, leaving care allowances, behaviour management, leisure time and how to fill it. Occasionally visitors are invited to attend meetings, such as, the CIC nurse to talk about sexual health advice and purpose of health care medicals, smoking and giving up smoking, the health care plan and recommendations that staff follow up with young people. Whilst the centre will generally liaise with the placing authority

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Helping children make a positive contribution

social worker, not every young person has an allocated worker, or, they have limited availability 8 of 13 Inspection Report: SC036019 for consultation regarding the overall operation of the centre. The local authority has a participation officer in post to encourage and engage young people in a range of events and opportunities to share their views.

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Achieving economic wellbeing

The provision is inadequate. A number of young people approaching 16 years of age do not have pathway plans or leaving care plans. The children’s services make a commitment to care for young people until the age of 18 years unless their care plan is for them to leave care at an earlier age. However, young people are not transferred to the leaving care team at an early stage to enable adequate preparation for leaving care. There are no pathway plans or leaving care plans seen on young people’s files even though a number of young people are approaching 16 years of age. Whilst young people are finishing formal education and may have places to move on to there is no formal written leaving care plan for independence to be working towards.

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Achieving economic wellbeing

Young people are provided with personal and clothing allowances and are aware of the personal money that is available to them. Staff maintain records of monies given and clothing provided. Young people are encouraged to save and have a bank account. Staff accompany young people to shop for suitable clothing and instruct them in use of laundry equipment and personal cleanliness and hygiene. Young people state, ‘Staff make me take the bus, cooking sometimes and doing my own washing.’

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Achieving economic wellbeing

The premises do not provide adequate good quality domestic style facilities, neither are they maintained in good order throughout. The centre is a detached property in its own grounds. It is located in an urban area; this makes for easy access to a range of community facilities and resources for health, education, recreation and leisure. Whilst staff make every effort to create a pleasant, safe environment for young people to live in, the children’s centre is not domestic in size or homely in ambience and the premises and layout remain large and institutional. The building complex consists of management and administration offices, meeting room, recreation hall and three units providing placements for young people. There is a range of centre facilities including; the enhanced care project building, forum, fitness room, art room, sports store and considerable grounds. Safety and security of the young people and premises is a primary feature

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Achieving economic wellbeing

of the physical aspects of the building and the ethos of care within the home. Some of the individual bedrooms are very small with room for a single bed and wardrobe and bedside cupboard. Generally, bathroom and shower facilities are basic in small rooms with regular damage to shower units placing them out of order.

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Achieving economic wellbeing

At the time of the inspection there is a building in the grounds awaiting demolition. The basic fabric and structure of the premises are worn, damaged and continuously in need of repairs to wall plaster, ceiling tiles, door frames and fire doors, glazing in doors and windows. In addition plumbing and water supply in the units is variable for hot and cold water.

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Achieving economic wellbeing

Due to limited space on the individual units there are not always rooms available in which children can meet privately with visitors or space for private activities, play and recreation which do not affect other children’s routine activities. There are communal facilities and resources shared between the three units and arrangements can be made to book use of these.

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Achieving economic wellbeing

Some young people choose to personalise their own rooms within the unit. Two of the individual bedrooms do not have carpets on the floor and in others furniture is damaged or removed from 9 of 13 Inspection Report: SC036019 rooms. Some of the bedrooms are very small with room for a single bed and wardrobe and bedside cupboard. Generally, bathroom and shower facilities are basic in small rooms with regular damage to shower units placing them out of order. The staff work hard to provide a pleasant environment for young people including some tiling and decoration in bathrooms and young people’s rooms. Young people and staff plant pots at the front of the building to brighten the institutional frontage and exterior of the building with metal barriers on the flat roof. Staff and young people are very pleased with a successful fund raising project to purchase outdoor seating which appears to be frequently used by individuals and groups of young people.

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Achieving economic wellbeing

However, the premises are not very well maintained, repaired or decorated. The management are aware of the unsuitability of the premises and there are plans for refurbishment of the premises to improve the facilities for young people being looked after. The space, facilities and grounds do not meet the requirements for accommodation and in their present condition they do not provide a safe secure environment for young people.

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Organisation

The organisation is satisfactory. The promotion of equality and diversity is satisfactory. Staff are generally aware of diversity issues and the cultural needs of individual young people are identified and addressed. Staff have received training in these topics which informs their practice. For example; the specific dietary and personal care needs of young people are addressed as they arise. Where necessary interpreters are accessed and written material can be translated. Generally staff engage young people in discussion, challenge prejudice and raise awareness.

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Organisation

Staff are usually well supported through individual supervision. The staff say it is of good quality, they discuss any issues and also appreciate access to informal supervision. However, new staff are not receiving regular fortnightly supervision to support them in their new roles. Staff confirm that staff appraisals have recently been completed and find these useful for their personal development. There are regular staff meetings with minutes recorded and available to all staff. Meetings are useful with an update regarding each young person, general unit issues and specific projects, such as, the garden design project. The management team has increased to incorporate three deputy managers with specific areas of responsibility. This includes support to a nominated unit. Staff confirm managers are available and approachable.

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Organisation

Staff are encouraged and well supported to attain qualifications and the majority of staff have the National Vocational Qualification Level 3 or are supported to work towards this. The staff group vary in their levels of competence, abilities and skills. Both staff and young people state that ‘there are some good staff who really get engaged with the young people but there are several others who are not really bothered’.

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Organisation

There are a sufficient number of staff employed at the centre with regular recruitment of new staff to vacant posts. Young people receive care provided by a diverse staff group in terms of gender, ethnicity, age and experience. There is a good percentage of male staff and generally three staff on duty on each unit. Additional staff are placed on shift to address needs identified in risk assessments. Usually permanent will cover shifts and may move between the units, however, regular relief staff will be used if needed.

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Organisation

There is an extensive training programme available to all staff with some core training to cover safe working topics, child protection and behaviour management. Staff attend training to 10 of 13 Inspection Report: SC036019 achieve and maintain competency in their care practice and ensure young people are cared for by competent staff.

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Organisation

The children’s centre and each unit are monitored in all aspects of service delivery and action is taken to maintain quality of care within the home. The format for monthly visits and reporting has been reviewed and revised to ensure the monitoring systems are purposeful and meaningful. The feedback remains variable in content and quality at the present time with a wide range of different visitors completing the monitoring visits. Some useful constructive feedback to managers was reinforced with action plans which were reviewed for progress at the following visit. The deputy managers have begun to complete the Regulation 34 monitoring of each unit and confirmed that many of the issues raised as actions and recommendations during the inspection had been previously identified through the monitoring systems, however, clearly are still to be addressed satisfactorily or consistently.

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Organisation

Children’s files contain the information detailed in the Children’s homes regulations 2001 and are confidentially stored. The files are reasonably well organised with index and clear sections holding relevant information. Young people generally know they can access their files and are encouraged to read, contribute to and sign various records.

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Statutory requirements

This section sets out the actions, which must be taken so that the registered person meets the Care Standards Act 2000, The Childrens Homes Regulations 2001 and the National Minimum Standards. The Registered Provider must comply with the given timescales.

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Due date Action Standard

30 September 2009 ensure premises are in a location, and of a physical design and layout, which are suitable for the purpose of achieving the aims and objectives set out in the home’s Statement of Purpose Regulation 31 31 July 2009 provide sleeping accommodation which is equipped with furniture, storage facilities, lighting, bedding and other furnishings including window and floor coverings suitable to his needs Regulation 31(8)(b) 30 September 2009 ensure that children accommodated in the home are provided at all reasonable times with access to a telephone on which to make and receive telephone calls in private Regulation 15(4)(a) 30 June 2009 ensure children accommodated in the home are provided with such sums of money in respect of their occasional personal expenses as is appropriate to their age and understanding. Regulation 14(2)

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Recommendations

To improve the quality and standards of care further the registered person should take account of the following recommendation(s): 11 of 13 Inspection Report: SC036019 • ensure young people are actively discouraged from smoking, alcohol and illegal substance or solvent abuse and under-age sexual activity (NMS 12.6) • ensure a written record is kept by the home of the receipt and disposal of medication including when medication ceases and how and when medicines are disposed of (NMS 13.2) • ensure children's privacy is respected and information is confidentially handled (NMS 9.0) • ensure the provision of training for all staff, including ancillary staff, agency staff and volunteers, in the prevention of abuse, recognition of abuse, dealing with disclosures or suspicions of abuse and the home’s child protection procedures (NMS 17.8) • ensure recorded risk assessments are regularly carried out of the times, places and

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Recommendations

circumstances in which the risk of bullying (including bullying amounting to abuse by other children) is greatest, and takes action where feasible to reduce or counteract the risk of bullying (NMS 18.5) • ensure when a child is considered likely to go missing, the registered person has agreed procedures to monitor the child and to specify how the child may be prevented from leaving the home. Any such measures such as the locked door policy, proactive removal of a young person’s shoes must be used as agreed in the child’s placement plan and where applicable care plan (NMS 19.18) • ensure risk assessments are carried out, recorded in writing and regularly reviewed. Such risk assessments are carried out in relation to the home’s premises and grounds and children’s known and likely activities (NMS 26.2) • ensure the environmental health service has assessed the food storage and preparation provision of the home and any recommendations are implemented within the timescales

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Recommendations

given, for example, labelling of foodstuffs and ventilation (NMS 26.4) • ensure there is a written record of the recruitment process which is followed in respect of all staff and volunteers who work with children in the home, including evidence that all requirements of Schedule 2 have been met in every case (NMS 27.1) • ensure each child’s file contains a copy of their Personal Education Plan (NMS 14.2) • ensure there is a proper balance between free and controlled time in the structure of the day. Activities reflect the choices of the children and children are allowed to do nothing in particular at times (NMS 15.4) • ensure the placement plan for each child sets out clearly the assessed needs of the child, the objectives of the placement, how these are to be met on a day to day basis, the contribution to be made by staff of the home and how the effectiveness of the placement is to be assessed in relation to each major element of the plan (NMS 2.1)

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Recommendations

• ensure both the needs of the child concerned, and the likely effects of his/her admission upon the existing group of residents, are taken into account, and recorded, in decisions on admission to the home (NMS 5.7) • ensure staff regularly and frequently seek the views of the relevant contact officers in the children’s placing authorities on the care of the children concerned, and the overall operation of the home; this is of particular importance where young people do not have an allocated worker (NMS 8.10) 12 of 13 Inspection Report: SC036019 • ensure there is a comprehensive plan for young people preparing to leave care and to move into independent or semi-independent living and contributes to any Pathway Plan (NMS 6.1) • ensure there are rooms in which children can meet privately with visitors and space for private activities, play and recreation which do not affect other children’s routine activities

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Recommendations

(NMS 24.15) • ensure all new staff receive one to one supervision at least fortnightly during the first six months of their employment (NMS 28.2) 13 of 13 Inspection Report: SC036019

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