Oakley Terrace Scheme Care Home Service Adults 10 Oakley Terrace Dennistoun Glasgow G31 2HX Telephone:

Oakley Terrace Scheme Care Home Service Adults 10 Oakley Terrace Dennistoun Glasgow G31 2HX Telephone: 0141 550 2344 Type of inspection: Unannounced Inspection completed on: 21 August 2014

Contents Page No Summary 3 1 About the service we inspected 4 2 How we inspected this service 6 3 The inspection 10 4 Other information 23 5 Summary of grades 24 6 Inspection and grading history 24 Service provided by: The Richmond Fellowship Scotland Limited Service provider number: SP2004006282 Care service number: CS2003000933 If you wish to contact the Care Inspectorate about this inspection report, please call us on 0845 600 9527 or email us at enquiries@careinspectorate.com Oakley Terrace Scheme, page 2 of 26

Summary This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change after this inspection following other regulatory activity. For example, if we have to take enforcement action to make the service improve, or if we investigate and agree with a complaint someone makes about the service. We gave the service these grades Quality of Care and Support 5 Very Good Quality of Environment 5 Very Good Quality of Staffing 5 Very Good Quality of Management and Leadership 5 Very Good What the service does well This service was performing very well across all four quality themes that we looked at. Involving people who use the service in decisions about their care and giving feedback about a range of aspects of the service was very good. Staff training and development was well organised and relevant to service being provided. People liked their personal space and felt safe living at Oakley Terrace. What the service could do better We have made recommendations in this report in relation to written information in participation folders, running notes and staff reading essential information. What the service has done since the last inspection The service continued to offer a very good level of care and support to residents. There have been further developments in the ways that people participate in the dayto-day running of the service and the influence the future development of the service. Conclusion Overall, this service continues to provide a very good standard of care to individuals with mental health care needs. Areas for improvement and recommendations in this report are based on a foundation of a service that is performing well. Oakley Terrace Scheme, page 3 of 26

1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Prior to 1 April 2011, this function was carried out by the Care Commission. Information in relation to all care services is available on our website at www.careinspectorate.com. This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April 2011. Requirements and recommendations If we are concerned about some aspect of a service, or think it could do more to improve its service, we may make a recommendation or requirement. - A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service but where failure to do so will not directly result in enforcement. - A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reforms (Scotland) Act 2010 and Regulations or Orders made under the Act, or a condition of registration. Where there are breaches of the Regulations, Orders or conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Inspectorate. Oakley Terrace is located in the East End of Glasgow close to local shops and excellent transport links. It provides 24 hour residential care and support to eight people with mental health problems. The property has eight single self-contained rooms with en-suite bath or shower facilities. There are two lounges, one being a designated smoking room. There are two fully fitted kitchens, two laundry rooms and communal bathrooms. Staff have an office and a sleepover room. The service's mission statement is "to develop and deliver the best personal supports that listen to what you want and achieve what matters for you" Based on the findings of this inspection this service has been awarded the following grades: Oakley Terrace Scheme, page 4 of 26

Quality of Care and Support - Grade Quality of Environment - Grade Quality of Staffing - Grade Quality of Management and Leadership - Grade This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website www.careinspectorate.com or by calling us on 0845 600 9527 or visiting one of our offices. Oakley Terrace Scheme, page 5 of 26

2 How we inspected this service The level of inspection we carried out In this service we carried out a low intensity inspection. We carry out these inspections when we are satisfied that services are working hard to provide consistently high standards of care. What we did during the inspection We wrote this report following an unannounced inspection. This was carried out by one Inspector. The inspection took place on Wednesday 20 August 2014 between 6.30pm and 10pm. It continued on Thursday 21 August from 9.30am until 5pm. We concluded the inspection on Thursday 21 August 2014 and gave feedback to the area manager on the same day. As part of the inspection, we took account of the completed annual return and selfassessment forms that we asked the provider to complete and submit to us. We sent ten questionnaires to the service to be given to staff to complete. We received five completed questionnaires back. During this inspection we gathered evidence from various sources, including the following: We spoke with: - five service users - one area manager - one senior support worker - four support practitioners. We looked at: - the participation strategy. This is the provider and service's plan for how they will involve service users in all areas of the care service - minutes of house meetings - a copy of the national evaluation tool - a copy of the net audit and action plan - copies of Glasgow East updates 2014 - a written update from "The Echo Group" - three support plans Oakley Terrace Scheme, page 6 of 26

- three participation folders - staff training records (online) - a sample of medication records - the registration certificate - certificate of public liability insurance - certificate of employers liability insurance - records of notifications/accidents/incidents and complaints. Inspection report continued Grading the service against quality themes and statements We inspect and grade elements of care that we call 'quality themes'. For example, one of the quality themes we might look at is 'Quality of care and support'. Under each quality theme are 'quality statements' which describe what a service should be doing well for that theme. We grade how the service performs against the quality themes and statements. Details of what we found are in Section 3: The inspection Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement. Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at www.firelawscotland.org Oakley Terrace Scheme, page 7 of 26

What the service has done to meet any recommendations we made at our last inspection We made four recommendations following the last inspection of the service. They were: 1. The following aspects of medication management should be addressed accordingly: a. Gaps in medication recording should identify the reason why and medication administration sheets should always include a coding system for this, for tracking purposes. b. Medication protocols should clearly show the maximum amount of as required medication that can be administered in a given period. c. Staff should follow the person's medication support plan or have the plan amended to reflect any agreed changes. National Care Standards (NCS) 5.11 Care Homes for People with Mental Health Problems - Management and Staffing Arrangements and NCS 15 Care Homes for People with Mental Health Problems - Keeping Well - Medication This recommendation has been met. 2. Where appropriate, residents who have identified nutritional care needs should have a nutritional care support plan in place to show how this area of care and support is being addressed. NCS 14 Care Homes for People with Mental Health Problems - Keeping Well - Lifestyle This recommendation has been met. 3. Staff should always sign to show that they had read and understood the contents of "must read" material. NCS 5 Care Homes for People with Mental Health Problems - Management and Staffing Arrangements. This recommendation has not been met. (See Quality Statement 3.3). Oakley Terrace Scheme, page 8 of 26

4. Staff should receive associated training to make sure they are confident in reporting serious accidents and incidents in accordance with the guidance, 'Records that all registered care services (except childminders) must keep and guidance on notification reporting'. NCS 5 Care Homes for People with Mental Health Problems - Management and Staffing Arrangements This recommendation has been met. The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The Care Inspectorate received a fully completed self-assessment document from the provider. We were satisfied by the way the provider completed this and with the relevant information included for each heading that we grade services under. The provider identified what it thought the service did well, some areas for development and any changes it had planned. The provider told us how the people who used the care service had taken part in the self-assessment process. Taking the views of people using the care service into account For this inspection we received views from five people that we spoke with during the inspection. Everyone that we spoke to said that they were happy or very happy with the overall quality of the service. We have included further comments and views from people using the service throughout the report. Taking carers' views into account There were no carers available to speak with during the inspection. Oakley Terrace Scheme, page 9 of 26

3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths At this inspection we found the performance of the service was very good for this statement. We concluded this after we spoke with service users and staff, observed practice and examined a range of relevant documentation. The provider and service provided clear procedures and opportunities for involving people in the day to running of the service and the future development of the service. Examples of the ways that people were encouraged to participate in the service included: - regular house meetings - involving individuals in person centred plans and person centred reviews - the use of a suggestion box located in the service - questionnaires and interviews. The Richmond Fellowship Scotland carried out an annual survey with people they support, their carers and relatives to get feedback on how well they are doing. The outcome of these surveys were pulled together in a written update and shared with people living in the service and other interested parties. We could see from the most recent survey results that, overall, most people were very satisfied with the quality of support they received, the quality of the staff supporting them and the quality of choice and opportunity in their day-to-day lives. We thought it was positive that people living in the service were given opportunities to feedback about the quality of staff and that this also informed staff development and appraisal. The service also engaged with the "Echo Group" which visited TRFS, Oakley Terrace Scheme, page 10 of 26

(The Richmond Fellowship Scotland), services within the Glasgow East area to get the views of people about the service they received and how this could be further improved. This group was composed of a cross-section of people being supported in services. Encouraging people who use services to seek the views of other users is a useful way promoting open discussion and feedback that might be more limited with staff led strategies. Each person living in Oakley Terrace had a PDSA, (Personal Development and Support Agreement), and Participation folder, We could see that people living in the service had contributed to their support plans, taken part in regular reviews of the care and support and that this participation was ongoing. Keyworking notes in the plans that we saw were well structured and contained very good detail on a ranges of areas such as physical health, mental health, social activities and support arrangements. This level of involvement meant that plans were meaningful to users and staff, focused on individual choices and provided further opportunities for discussion on a range of issues. Areas for improvement Some of the information in participation folders was not recent and needed to be updated. Examples included copies of inspection reports and other information about the Care Inspectorate. See Recommendation 1. The running notes in the participation folders that we looked at were often taskfocussed and did not clearly detail the outcome or benefit to individuals as a result of taking part in activities. See Recommendation 2. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 2 Recommendations Inspection report continued 1. The information in participation folders should be regularly reviewed and, where necessary, updated so that it remains relevant to users of the service. NCS 6 Care Homes for People with Mental Health Problems - Support Arrangements 2. Running notes in participation folders should clearly detail the outcome or benefit to individuals as a result of taking part in activities. NCS 6 Care Homes for People with Mental Health Problems - Support Arrangements Oakley Terrace Scheme, page 11 of 26

Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths Inspection report continued At this inspection we found the performance of the service was very good for this statement. We concluded this after we spoke with service users and staff, observed practice and examined a range of relevant documentation. People who used the service had very good access to healthcare services. The service had well established links with GP services, mental health and psychology services. Staff and service users could also access specialist advice from other professionals on topics such as nutrition, sexual health, infection control and positive behaviour. One staff member that we met was looking forward to training with the Positive Behaviour Team. The service achieved the Healthy Working Lives Silver Award in 2013 and was promoting healthy eating with people they supported. This extended to growing vegetables in a greenhouse in the garden area of the service. Staff indicated that the growing and harvesting of fresh vegetables with the involvement of people they support increased awareness of healthy options and was also an enjoyable activity. People living in the service that we spoke to told us about how staff helped them to develop independent living skills such as managing money, managing medication preparing meals and cleaning their rooms. This is important for individuals confidence, personal goal setting and in preparation for moving out of the service to more independent living, (if that is an identified goal). The provider had reviewed and updated the policy and procedures for managing medication partly in response to previous recommendations. The support that people needed to take their medication was individually assessed, regularly reviewed and well recorded. The provider used three levels of medication management ranging from staff administering medicines, staff prompting people to take their medicines and individuals self-administering their medicines. Staff training was relevant to supporting service users health and wellbeing. We comment further on the quality of staff training under Quality Theme 3 - Statement 3. We looked at a sample of PSDA (Personal Support and Development Agreement) files for people supported by the service. We could see through the content of keyworking records and records of care reviews that healthcare, social care and overall wellbeing was discussed in some detail with the participation of the person being supported. This meant that staff and people being supported could agree goals and put plans in place to promote and maintain health and wellbeing. Oakley Terrace Scheme, page 12 of 26

Areas for improvement We suggested that the form of medication prescribed eg tablet, capsule, liquid be added to the new MAR, (medication administration record), sheet. This was actioned immediately by the service. In some of the support plans that we looked at measures of body mass index (BMI) and weight were detailed. However it was not clear how this linked to other risk factors and what the desirable outcome was. See Recommendation 1. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 1 Recommendations Inspection report continued 1. Measures of body mass index (BMI) and weight recorded in support plans should be linked to a clear desirable outcome and take account of other relevant risk factors such as associated medical conditions. NCS 14 Care Homes for People with Mental Health Problems - Keeping Well - Lifestyle Oakley Terrace Scheme, page 13 of 26

Quality Theme 2: Quality of Environment Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths At this inspection we found the performance of the service was very good for this statement. We concluded this after we spoke with service users and staff, observed practice and examined a range of relevant documentation. We looked at a sample of minutes of house meetings and could see that health and safety matters were discussed in detail and was a standing agenda item in meetings. This meant that people who lived in the service were able to easily discuss matters about the environment the lived in, how to keep it safe and were supported by staff to do this. See strengths under Quality Theme 1 - Statement 1. Areas for improvement See areas for improvement under Quality Theme 1 - Statement 1. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Oakley Terrace Scheme, page 14 of 26

Statement 2 We make sure that the environment is safe and service users are protected. Service strengths At this inspection we found the performance of the service was very good for this statement. We concluded this after we spoke with service users and staff, observed practice and examined a range of relevant documentation. We arrived at the service in the early evening on the first day of the inspection and noted that the building had a secure entry system and that all visitors were required to sign in and out of the service. This meant that the service was only accessible to people who lived there or appropriate visitors. We were shown round the building by a member of staff and invited by service users to see their bedroom areas. Each person who lived in the service had their own bedroom with en suite facilities (a toilet, washhand basin and shower), a small fridge and a safe for keeping valuable items secure. The bedrooms that we saw were decorated to individual tastes and service users had items in their rooms that were important to them such photographs, musical instruments and soft toys. There were large spacious lounge/dining areas on both floors of the home. These were nicely furnished and the decor was coordinated well. The first floor lounge offered very good views over the city. As noted at the last inspection of the service, a fire safety audit had been carried out by Scottish Fire and Rescue service. Correspondence to the provider in April 2014 indicated that the existing fire safety measures appeared to be appropriate to the risk. Other measures taken by the service to make sure that people were safe in the service included weekly maintainance checks in bedrooms which was carried out by staff and service users. This was appropriately recorded and action was taken to address any concerns. Service users were also encouraged to participate in household chores. As a result people who lived in the service were encouraged to take ownership of their environment and be responsible for looking after it. Areas for improvement Inspection report continued We noted that some of the furnishings, fixtures and decor in parts of the service were old and in need of upgrading or redecorating. We advised the area manager of this at feedback who agreed to forward plans for refurbishing the service to us. The upstairs kitchen, though spacious, did not appear to be getting used. The cupboards were empty except for a few pots and pans and the fridge was grubby. We were informed that this area would be included in the refurbishment and development plans for the service. It was agreed to remove the fridge which was no longer in use. Oakley Terrace Scheme, page 15 of 26

Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Inspection report continued Oakley Terrace Scheme, page 16 of 26

Quality Theme 3: Quality of Staffing Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths At this inspection we found the performance of the service was very good for this statement. We concluded this after we spoke with service users and staff, observed practice and examined a range of relevant documentation. Areas for improvement See areas for improvement under Quality Theme 1 - Statement 1. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Oakley Terrace Scheme, page 17 of 26

Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths At this inspection we found the performance of the service was very good for this statement. We concluded this after we spoke with service users and staff, observed practice and examined a range of relevant documentation. We spoke with a number of staff during the inspection and we also received five completed questionnaires from staff, (out of ten we sent to the service). All of the feedback from staff was consistent in that they had very good training opportunities and that this helped them to do their jobs. Staff also indicated that the service was very good at providing opportunities to gain qualifications relevant to their jobs. Well trained staff meant that users of the service benefited from support from people who had a good knowledge and understanding of how to meet their needs. This meant that service users were cared for by staff that they were familiar with and who knew them and their needs. The area manager and team manager were registered with the SSSC, (Scottish Social Services Council), and those staff that needed to be registered soon had applications in process. The SSSC is the regulatory body for people who work in social care in Scotland and is responsible for regulating their education and training. Staff also indicated they had access to the SSSC Codes of Practice. This meant that staff who worked in the service had information about their rights and responsibilities, (and their employer's), as social care workers. The provider had clear processes in place for staff supervision and appraisal. Supervision meetings are important opportunities to make sure that staff are accountable for their practice when working with service users. Supervision also allows staff the opportunity to discuss any support and training needs they may have with their supervisor. Appraisal (or performance review) gives individual staff feedback about how well they are meeting key objectives in their role and to get feedback about how well they are doing. We observed staff practice when they were supporting service users and noted that this was done well. Service users were supported with dignity and respect, their views taken into account and their potential encouraged. People that we spoke who lived in the service told us that the staff were "nice" and that they felt they both helpful and supportive. Areas for improvement Inspection report continued The service kept a folder of "must read " material for all staff. This contained important information and updates that staff had to read, then sign to indicate they Oakley Terrace Scheme, page 18 of 26

had understood the contents. We made a recommendation following the last inspection that this should be kept up to date and signed by all staff in line with the provider's procedures. We have repeated the recommendation as we noted there were still some gaps indicating that not all staff had been reading this information. See Recommendation 1. We discussed with area manager how the provider plans to develop some training beyond that of introductory or foundation training in areas that were particularly relevant to the needs of the people being supported. An example was staff attending training on mental health matters that could be extended beyond awareness or mental health "first-aid" training. We will look at this again at future inspections. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 1 Recommendations Inspection report continued 1. Staff should always sign to show that they had read and understood the contents of "must read" material. NCS 5 Care Homes for People with Mental Health Problems - Management and Staffing Arrangements Oakley Terrace Scheme, page 19 of 26

Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths At this inspection we found the performance of the service was very good for this statement. We concluded this after we spoke with service users and staff, observed practice and examined a range of relevant documentation. See strengths under Quality Theme 1 - Statement 1. Areas for improvement See areas for improvement under Quality Theme 1 - Statement 1. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Oakley Terrace Scheme, page 20 of 26

Statement 4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide Service strengths At this inspection we found the performance of the service was very good for this statement. We concluded this after we spoke with service users and staff, observed practice and examined a range of relevant documentation. The area manager showed us how various aspects of the service is audited and reported on. There was a comprehensive quality assurance system in place which covered four key sections including: - Person centred Planning - Continuous Learning and Development Planning - Policies, Procedures and Documentation - Health and Safety. Inspection report continued The evaluation tool used by the provider reported in great detail on the sections highlighted above and in other areas that were relevant to the particular service. There was very good evidence of a range of areas where people being supported were included in the planning, delivery and review of their care. Examples of this were included the audit of person centred plans and the audit of health and safety in the service. We made a recommendation following the last inspection of the service that staff should receive associated training to make sure they are confident in reporting serious accidents and incidents in accordance with the guidance, 'Records that all registered care services (except childminders) must keep and guidance on notification reporting'. We noted that the service had a copy of this guidance, that reference to it was in the written NET (National Evaluation Tool) audit of the service and that we had received relevant notifications from the service. We were satisfied that the recommendation had been met. We looked at how accidents, incidents and complaints were reported, recorded and managed. The service had no recent complaints and had a clear complaints procedure that was easily accessible to people who used the service. In a sample of accidents and incidents that were logged by the service there was very good detail recorded of each event and what action was taken by staff to manage each situation. There were regular team meetings which meant that managers and staff could discuss current issues, share information and exchange ideas for improving the service. Action plans were put in place in response to items discussed in meetings, Oakley Terrace Scheme, page 21 of 26

organisational audits and external scrutiny reports such as the inspection report from the Care Inspectorate. Areas for improvement Some minutes of meetings were not written up for some time after the meetings had taken place. This could mean that information was out of date or had not been actioned in time. See Recommendation 1. We suggested that, as well as sharing and discussing inspection reports from external agencies with people being supported by the service, action plans also be shared to inform people how the service was responding to any recommendations for improvement. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 1 Recommendations Inspection report continued 1. Minutes of all meetings should be written up within agreed timescales after meetings have taken place to make sure could that information is not out of date and any actions have been addressed in time. NCS 5 Care Homes for People with Mental Health Problems - Management and Staffing Arrangements Oakley Terrace Scheme, page 22 of 26

4 Other information Complaints No complaints have been upheld, or partially upheld, since the last inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information No additional information recorded. Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in the Care Inspectorate re-grading a Quality Statement within the Quality of Management and Leadership Theme (or for childminders, Quality of Staffing Theme) as unsatisfactory (1). This will result in the Quality Theme being re-graded as unsatisfactory (1). Oakley Terrace Scheme, page 23 of 26

5 Summary of grades Quality of Care and Support - Statement 1 Statement 3 Quality of Environment - Statement 1 Statement 2 Quality of Staffing - Statement 1 Statement 3 Quality of Management and Leadership - Statement 1 Statement 4 6 Inspection and grading history Date Type Gradings 19 Mar 2014 Unannounced Care and support 4 - Good Environment Staffing Management and Leadership 8 Feb 2013 Unannounced Care and support Environment Staffing Management and Leadership 25 Nov 2010 Unannounced Care and support Environment Not Assessed Staffing Not Assessed Management and Leadership Not Assessed Oakley Terrace Scheme, page 24 of 26

6 Jul 2010 Announced Care and support 6 - Excellent Environment 6 - Excellent Staffing Not Assessed Management and Leadership Not Assessed 16 Feb 2010 Unannounced Care and support 6 - Excellent Environment Staffing Not Assessed Management and Leadership Not Assessed 5 Aug 2009 Announced Care and support 6 - Excellent Environment Staffing 6 - Excellent Management and Leadership 6 - Excellent 28 Jan 2009 Unannounced Care and support Environment Staffing 4 - Good Management and Leadership 4 - Good 10 Sep 2008 Announced Care and support Environment Staffing 4 - Good Management and Leadership 4 - Good All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Oakley Terrace Scheme, page 25 of 26

To find out more about our inspections and inspection reports Read our leaflet 'How we inspect'. You can download it from our website or ask us to send you a copy by telephoning us on 0845 600 9527. This inspection report is published by the Care Inspectorate. You can get more copies of this report and others by downloading it from our website: www.careinspectorate.com or by telephoning 0845 600 9527. Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: 0845 600 9527 Email: enquiries@careinspectorate.com Web: www.careinspectorate.com Oakley Terrace Scheme, page 26 of 26