DAY CENTRE ATTENDERS’ CHARACTERISTICS, REASONS FOR ATTENDING, ACCESS TO CENTRES AND CONTEXTS OF ATTENDANCE
Participant characteristics
Most attender participants were widowed, divorced or single, and two-thirds lived alone (see Table 2). Their average age was 83.3 years (range 68-101 years), three-quarters were women and one-quarter were educated beyond secondary school. All identified as heterosexual and as not having changed gender. Three-quarters held religious beliefs. Ethnic minority groups accounted for a quarter of the total number, but were only in two of the four centres, reflecting local demography. Indicative of relative deprivation, two-thirds lived in rented homes while just under one-third were owner-occupiers. Although similar numbers received means-tested benefits as those who did not, almost two-thirds self-funded their centre attendance (n=14). Self-funders included people whose financial assessment, after being assessed as eligible for services, required them to pay for themselves (n=3) and people not mentioning any assessment (n=11). Others reported being fully local authority (LA) (means-tested) funded (n=6), sharing payment with the LA (n=1) or being unaware of who paid (n=2).
All reported having health conditions or disabilities that impacted greatly on their life, with half reporting at least two forms of these. All, except two, had some levels of Apparent Vulnerability or frailty when measuring general health status with the EFS. Levels of health conditions were under-reported by attenders; some did not report certain health conditions in the interview that the researcher was later made aware of in family carer interviews, by centre staff during discussions or by the attenders themselves, for example, that one participant had dementia and another had terminal cancer and had survived a stroke. Three-quarters of attenders had average or good wellbeing as measured by the SWEMWBS.
Two-thirds were at greater risk of isolation, depression, loneliness and other mental ill-health because of their PANT social network type. Only one-third had a stronger social network type.
Apart from marital status and living arrangements, the profiles of attenders varied between centres. DCLA was most age-diverse. DCHA was the least gender diverse. People who could be classified as having Severe Frailty were highest in number at DCHA, despite its younger profile; levels of Apparent Vulnerability were matched across the remaining three centres. DCHA and DCLA attenders had the highest levels of mobility difficulties and more long-standing health conditions, while deafness was most prevalent at DCV1 and DCV2. Owner-occupiers prevailed at DCV1 and DCV2 and renters at DCLA and DCHA.
Table 2: Attender participants’ characteristics (n=23)
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Reasons for attending
Circumstances when starting to attend a day centre mainly related to loss and a desire for something different in life. These were classified into six themes: 1) social isolation (mainly due to bereavement or having lost existing social networks), 2) loss of mobility (declining physical health, sometimes suddenly, or no longer driving their car), 3) activity-related (stopping attending another day centre or club due to closure or changed entry criteria, stopping volunteering or retirement, wanting ‘something to do’ for stimulation or a change, or ‘somewhere to go’), 4) mental health or emotional problems (feeling depressed or very low, lonely, having lost confidence or reporting a diagnosed anxiety disorder), 5) feeling ‘stuck’ at home or not getting out enough, and 6) carer-related (recognising the need for family to have a break, feeling isolated as a spousal carer, accompanying cared-for to a day centre).
Principal motivations for starting to attend a day centre reflected these circumstances in that participants had wanted social contact, something to do, to get out of their home or to improve their mental health. Additional motivations were to meet goals for better physical health through exercise and meals, to improve mental health and to accompany a partner for whom the participant provided care. Although length of attendance ranged from a few months to decades, these motivations are likely to reflect attenders’ marital status, living arrangements and health. Behind one principal motivation for attendance were different clusters of circumstances which interacted and overlapped, often triggered by an event or a series of interlinked events. Table 3 illustrates the complexity of two attenders’ circumstances when they started thinking about attending a day centre.
Table 3: Examples of two pseudonymised attenders' circumstances prior to attending a centre
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Accessing day centres
Despite having lived in their areas for an average of 40.5 years (range 10-84 years), only two had known of their current centre. Half (n=11) had never heard of day centres before attending one.
Attenders had accessed their day centres through different routes. Almost half (n=11) reported starting attendance following contact with social care or health professionals (social workers=7, district nurse=1, hospital rehabilitation service=1); the tenth was unsure of the professional’s identity and the eleventh had spoken to a GP, then a social worker. Six had found out about centres from family (n=4), from its manager who was an acquaintance (n=1), and by another attender’s recommendation (n=1). Some paths were less straightforward. Two had been told by a local councillor (politician) and a GP, and had subsequently had social work involvement. The former received a social worker assessment after starting to attend. The latter, after a ‘bad’ first experience at another centre she had been referred to by her GP, had asked her family to find an alternative centre. In the event, the LA-provided home care worker had linked them to a social worker who arranged the current centre place. Two had proactively approached social workers about centres. Four participants were unsure how they found out about their centres.
Contexts of current day centre attendance
Average weekly centre attendance was for 1.8 days. Overall, just over half (n=13, 56%) attended once weekly, one-third (n=8, 35%) for two (n=4) or three (n=4) days and two (9%) for four or five days a week. It was the only weekly outing for 5 participants (22%). Participants had been attending their centres for anything between six months and 32 years.
Attenders’ regular activities outside their day centres varied, but most seldom went outside the home. Table 4 provides examples of six attenders’ typical weeks at the time of data collection. Additional File 3 shows examples of two usual weeks.
Table 4: Six attenders' typical weeks
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The following paragraphs provide an overview of the whole sample’s contexts.
In addition to their day centre days, the number of days attenders left their homes each week ranged from none to three (average 1.3 days), plus monthly outings. Three-quarters saw family at least once weekly. While two saw family fortnightly or monthly, three saw family irregularly, not at all or had no family. A handful reported at least twice weekly telephone conversations with adult children. Two-thirds had no regular unstructured non-familial social events, such as seeing friends. Those who met with friends relied on friends or family providing transport. Two-thirds had no regular structured non-familial social events. The one-third who did either also attended another day centre, a social club or bingo session weekly, or went on monthly outings or ‘tea parties’ run by the day centre provider or a national charity. Two were enrolled at a skills centre for the visually-impaired. One-third undertook weekly or fortnightly food shopping outings, mostly with support from family, friends, dial-a-ride (mobility service for disabled people) or a voluntary organisation’s support worker. Two attended church regularly, and two received weekly or monthly Holy Communion at home from a visiting priest. One visited a gym weekly.
Two-thirds managed their personal care without paid support, including a handful who had weekly or monthly hairdresser home visits but no other personal care help. Most of the one-third who had personal care received this every day. Just over half of attenders had no paid home care. One-third received once weekly help with housework from home care workers, cleaners or neighbours and, for two, this was daily. Two attenders’ family members undertook housework for them. A handful of attenders had regular medical appointments.
Some participants provided further context about their lives more broadly and their characters. Home maintenance and self-care had become, or was becoming, increasingly effortful for many. While some talked about how independent they had always been, one was still mourning her recent loss of independence. There was a sense of resignation to the situations in which they found themselves, in that some had adjusted to these. A small number mentioned how helpful neighbours were. While some considered themselves to be ‘joiners’ of activities, others said they were not.
OUTCOMES OF DAY CENTRE ATTENDANCE
ASCOT scores and the ten themes identified from the qualitative and/or quantitative data domains are now presented. Six of the eight ASCOT domains overlapped with the eight themes identified from the qualitative data. Overlaps are covered under the relevant theme headings. Verbatim quotations illustrating commonly expressed or contrasting perspectives (underlining indicates participants’ own emphasis) and ASCOT scores are included where relevant.
The themes are: 1) social participation and companionship, 2) the way time was spent, 3) getting out of the house, 4) improved mental wellbeing and health, 5) practical support, information and access to other services, 6) physical wellbeing and safety, 7) having a meal, 8) accommodation cleanliness and comfort, 9) personal cleanliness and comfort and 10) process outcomes, that is those which pertain to the way services are accessed and delivered.
In qualitative interviews, attenders reported benefiting from attending their day centres. Attendance had added something unique to the lives of all but one attender who later added that the cost was worth it for the change of environment. For one, it had not just ‘added’ something to her life, it had changed it:
‘It changes your life.’ (Wilma)
Qualitative outcomes themes (1-7) and process outcomes (10) were reported across socio-demographic and health characteristics, social network types and day centres and across both self-funding and publicly-funded source sub-groups. Themes 1, 4 and 10 were reported by attenders across different marital statuses, ethnicities, age groups, genders, living arrangements, accommodation types, education levels, finances, number of days spent at the centre, number of operational days, EFS frailty levels, PANT network types, groupings (devised for this study) of ASCOT gain (0.00-0.09, 0.10-0.19, 0.20-0.29, 0.30-0.39, 0.40-0.49, 0.50-0.59 and 0.60-0.69) and SWEMWB scores (metric) (15.00-19.99, 20.00-25.99, 26.00-29.99 and 30.00-35.00). Themes 2, 3 and 5 were reported by participants with most of the afore-mentioned characteristics sub-groups, with the following exceptions. Activity-related outcomes were not reported by participants with further education or with highest ASCOT gain score grouping (0.60-0.69). Theme 5 was not reported among married, five-day or attenders with four types of health conditions or disabilities. Getting out of the house was not an outcome reported by attenders with ‘No frailty’, according to the EFS, those whose PANT network was on the borderline between family dependent and locally self-contained, by those aged 70-74, those living with a family member other than spouse or adult child or in private rented accommodation, the single/never-married, those with further education or five-day attenders. Themes 6 and 7 were outcomes gained by fewer than half of the participants, therefore were not represented across all characteristics. Themes 1-7 and 10 were reported by both self-funding and publicly-funded/unsure of funding source sub-groups
Completion of ASCOT INT4, by 22 attenders, also indicated that quality of life improvements were directly attributable to day centre attendance, covering themes 1, 2, 4, 6, 7, 8 and 9. Figure 1 shows average ASCOT current and expected SCRQoL score in each domain as a percentage of the total possible score (unweighted), gain in each domain and numbers of attenders saying that centres made a difference to their lives in each domain). It shows that the difference between the with and without scores (of a maximum of 100) was 34.85 for social participation and involvement and 27.27 for occupation; that is almost one-third higher with than without the service. These impact scores are statistically significant (chi-squared test).
Figure 1: Average unweighted current/expected scores, gain scores and numbers of attenders reporting centres made a difference to them in individual domains.
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Overall average preference-weighted SCRQoL scores were 0.88 (current) and 0.70 (expected), with a resulting overall quality of life gain of 0.18 resulting from day centre attendance. The gain of 0.18 is a preference-weighted score (gain can be -0.17 to 1 where 1 is the ideal situation). Thus 0.18 is not statistically significant but is an indication. Average gain varied between centres (0.13, 0.15, 0.16, 0.24) and between individuals (individual gain score range 0.00-0.62). Gain scores may have undervalued attendance’s actual impact on some participants’ quality of life. For instance, a small number of attenders’ answers did not always correspond with their qualitative interviews, and clarification of questions’ meaning was needed in some cases. Furthermore, participants reported attendance making a difference to their lives when responding to ASCOT questions even when gain scores were low or nil. Notwithstanding socio-demographic and health variations between centres, in three centres, overall expected SCRQoL, in the absence of day centre attendance, was 0.69 and 0.75 in the fourth. Average gain was higher for publicly-funded attenders (0.24) than for those self-funding (0.15).
Theme 1: Day centre attendance provided access to social participation and companionship
‘Social participation and involvement’ was one of two ASCOT domains in which centre attendance made a significant impact (p-value <0.001, 99% CI) on participants as a group. Centre attendance was said to address the problem of not meeting people when physically unable to get out of one’s home. Companionship was one of the unique contributions that participants reported centre attendance made to their lives. There were different facets to this most talked-about outcome.
Many valued having social contact which contrasted with usually being alone:
‘It's like, if somebody is married and they are not happy in their marriage, they look for a way out. Well I am not happy being at home on my own and so that's my way out.’ (Tina)
‘I get conversation instead of talking to myself… And I’m mixing with human beings.’ (Nellie)
Attenders enjoyed doing things in company:
‘We sit together and play together, like cards or any other games or … the memory class, and of course, the exercise.’ (Mariana)
The group environment enabled the opportunity for laughter or fun. There was a good deal of banter in some centres, sometimes group-based, or one-to-one between attenders or one-to-one with staff or volunteers:
’I think that's one of the things that I like about it. You have heard [female attender] and I roar with laughter before now, haven't you? …I can make her laugh so easily. I love it. I know when she laughed her head off one day when one of the questions was what did Richard II lose in the bushes and I called out, “his virginity.” She said, “for God's sake.” I don't know. I just like laughing anyhow.’ (Kaye)
Participants highlighted how they looked forward to regular contact with day centre friends:
‘You look forward to seeing friends again, you know.’ (Elizabeth)
There was mostly no contact between attenders outside centres on non-attendance days; some considered it unnecessary as they saw each other regularly at centres. For others, co-attenders were simply acquaintances whom they saw regularly at centres:
‘They are just Friday people.‘ (Thomasina)
Around half of the participants mentioned that increasing proportions of cognitively impaired attenders, either due to dementia or a learning disability, impacted negatively on levels and quality of connection possible. Although one attender referred to a co-attender living with dementia as ‘a sweet little thing’ (Jenny) and was impressed how well she joined in with games, she considered that the latter’s poor memory had hindered the development of friendship. Another reported that she was not able to build a relationship with some of her co-attenders was because ‘you are talking to them and they are just looking at you’ (Olive).
A small number also commented upon conversational faux pas and what they described as ‘annoying’ or disruptive behaviours, such as constant rocking, swearing or making unintelligible burbling noises which ‘would be frightening to some people’ (Francine) or showing aggression:
‘Some are a little bit annoying (…) One time she started smacking people with her stick’ (Elizabeth)
Two of the five male participants expressed a preference for higher numbers of men since they maintained that men and women chat about different things.
Theme 2: Day centres provided something (different) to do
The second ASCOT domain in which centre attendance made a significant impact (p-value <0.001, 99% CI) on participants as a group was that of ‘occupation’, or meaningful activity. This was also a unique contribution centre attendance made to participants’ lives. Attendance was an activity which meant doing something instead of doing nothing at home:
‘…just quite different to what you are doing at home’ (Kaye).
‘I just sit here from when I get up to the time I go to bed.’ (Ruby).
Having regular day centre days gave some attenders purpose within their week:
‘…something to wake up in the morning to do’ (Nellie).
It also gave them something to think about, something also benefiting family relationships:
‘It’s enriched my life (…) Well I suppose it gives me an interest, doesn’t it? It’s a big interest. And it gives me something other to talk about and to think about.’ (Jenny)
Attenders enjoyed being occupied or they enjoyed specific activities they did at their centres. In most centres, activities were varied although not all attenders’ (mainly sensory impairment) needs were always catered for. Joining in these was said to be enjoyable, stimulating, and, in some cases, satisfying:
‘I like to be doing something.’ (Lenny)
‘I enjoy the art. I enjoy the singing. I love to sing. I don't mind whether there is one or two singing.’ (Wilma - emphasis underlined and emboldened).
Activities cited as particularly enjoyable were art, craft, cooking, computer classes, charades, discussion groups, memory exercises, raffle/tombola, singing and music sessions, sweet shop, trips out, poetry reading, food tasting, table games, listening to background music, reading the paper, sitting in the garden, visiting speakers, therapy dog visits and performances by folk and belly dancers. Quizzes, bingo, card games, and exercise provoked mixed reactions.
Theme 3: Day centres provided the opportunity to go out and have a change of environment
A qualitative theme, being enabled to ‘get out of’ their home, another of centre attendance’s unique contributions to their attenders’ lives, was framed in two ways.
Firstly, it was tantamount to escaping from their home in which they felt they were ‘stuck’, or even imprisoned:
‘It's like being a prisoner in my house now … That's how it feels now and again, because you don't see nobody there now.’ (Olive)
Others did not feel imprisoned and were more concerned with having a change of scene:
‘Well, it gets me out of my four walls for a start.’ (Nellie)
‘Well, it gets me out once a week, which I wouldn't do otherwise.’ (Ruby)
Secondly, the day centre was somewhere to go when you had ‘nowhere else to go’ (Nellie). It was also a place to go and gather; saying hello to an acquaintance in passing was ‘not the same as actually going to a function with the people’ (Bob).
There was much stoicism and acceptance of current situations in which some attenders said they would never have imagined themselves. For some, centres appeared to be a good substitute for what they may have preferred to do had their abilities been different:
‘I used to like going here, there and everywhere. Now I can't do that so I don't mind coming here…I am happy with it…It gives me a chance to come out. (…) if I could go round and do things that I would like to do and so I’d go shopping and maybe walk around.’ (Dorothy)
Theme 4: Improved mental wellbeing and health
Participants reported improved mental wellbeing and health as a further unique contribution of attending their centres. Not only did participants enjoy certain aspects of what was provided by centres, but many enjoyed the whole experience.
‘Oh, I love going. Oh yes. Yes.’ (Kenneth)
‘Well it’s my life. It’s all I’ve got. It literally is my life.’ (Nellie).
They gained a sense of purpose, felt like they belonged, felt in control or more independent and ‘felt better’ generally. The ASCOT domain of control, the third highest scoring, falls within this theme.
They had something to look forward to that they enjoyed – and some found fun. Enjoyment was derived from social contact, the activities, getting out of the house, feelings of freedom, the meals and additional extras linked with a centre’s location, transport to it and to attending a centre as an activity in itself. Attendance also counteracted boredom and life’s monotony, helped participants gain a better perspective of their own situations and feel more relaxed, less lonely or depressed or more confident, mentally stimulated or energised. Centres were also referred to as a ‘lifeline’.
‘I just enjoy it there. Because I am alone. I am on my own. Sometimes I feel sad. I feel better when I go to the centre I have a little bit of talking, conversation and some socialising. (…) I enjoy it very much. To tell you the truth, before Monday I had been waiting for Monday to come. (…) I feel happy and it helps my depression.’ (Miguel)
Furthermore, participants felt valued and respected as individuals which reflected centre staff’s and volunteers’ personalities, behaviour and their delivery of the service (see Theme 10). The ASCOT domain of dignity, the second a highest scoring, falls within this theme.
Theme 5: Practical support, information and access to other services
A qualitative theme, practical support, information and access to other services were either provided as part of the day centre service, via occasional or regular visiting professionals, speakers or other centre visitors, or were other services offered by the day centre providers. Most mentioned were the supply of hearing aid batteries or maintenance, and useful talks. Other examples provided were lunch clubs, holidays, shopping trips, hairdressing, fingernail filing and painting, help with arranging health or other appointments, referrals to, for example, occupational therapy to get a shower installed at home, or to the local authority to get a personal falls alarm installed, help to claim taxi vouchers (discounted taxi fares) and visiting chiropodists or massage therapists or clothes-sellers. Benefits gained included, for instance, feeling safer or having peace of mind, enjoying trips out, saving or having more money:
‘Before that I was buying the batteries because… I could get them free from the hospital but I'd have to take a taxi to the hospital to get them. So I used to buy them from [pharmacist]. But [day centre manager] said “oh no, don't buy them. We'll give them to you.” … That's another thing that's been a great help. (…) I can clean part of it but I can't take the things apart and clean it properly.’ (Francine)
Not only did Ruth feel more settled at her day centre after a group holiday with other attenders, which she accessed through the centre, but it also helped reduce her depression:
‘And then eventually heard about the holiday (…) I made myself go and it did me the world of good because since then, my dark side seems to have lifted. Although I’ve physically got all these problems, mentally I’m fine now, really.’ (Ruth)
Co-located facilities were a bonus. At one centre, the short, midweek religious service was attended by some participants. At another, the library was appreciated by a keen reader who also enjoyed occasional contact with babies at the mother and baby group, as was an advice service.
Theme 6: Physical wellbeing, health and safety
This theme comprised three parts.
First, attenders reported benefiting from informal health and wellbeing monitoring and follow-up undertaken by day centre personnel, such as being asked how they were or if something was the matter, which they appreciated. Staff, and volunteers, listened to attenders talk about continence or pain, for example, and, with attenders’ consent, spoke to named relatives about health concerns:
‘They come around asking “Are you alright? What's the matter?”’ (Thomasina).
They also measured blood pressure, made GP appointments, reported safeguarding matters (e.g. about possible elder abuse) to the local authority and replaced a screw in one attender’s reading glasses.
Second, exercise was felt to help maintain mobility and alleviate depression:
Interviewer: ‘So what is it about being here that helps you feel less depressed?’
Denzel: ‘Well, I do exercise three times a week.’
Attenders felt they were more likely to exercise in a group than alone at home:
‘I think I quite enjoy it when there is people come and give us exercises and things, you know, make us to do things. (…) I think it's good for us. (…) I can sit here all day and not move. [Laughs] I could move, but I think it's good to make you do a few exercises. If you’re all doing it, you do it.’ (Ruby)
Third, some attenders felt physically safer and less vulnerable at centres compared with at home. ASCOT’s third highest scoring domain of gain, personal safety, although broader in scope, falls within this sub-theme. One attender spoke about feeling vulnerable at home after a doorstep incident with rogue traders, and another, suffering from vertigo, said:
‘Well, I come to the club when I not in hospital. You feel more safer. If I here and anything happened to me, they will call the ambulance.’ (Norma)
Theme 7: Having a meal (food & drink)
Although a minor outcome theme arising from qualitative findings, almost half the participants said that day centre attendance made a difference to them in the ASCOT domain of food and drink, and most shared their, mainly positive, views of the meals provided. Reasons for reporting having a meal as an outcome included being unable to stand for long periods when cooking, closure of a lunch club, wanting ‘a meal put down in front of me without having to cook it myself’ (Isobel). The opportunity for conversation over lunch was welcomed. Negative comments, concerning one centre only, included long waiting time, lukewarm food, feeling rushed, poor variety and disliking the meals. Meals are categorised separately from physical wellbeing and health since people would be eating lunch at home on non-day centre days.
Theme 8: Accommodation cleanliness and comfort
A theme emerging from quantitative data only, centre attendance was reported to make a difference to just under one-third of participants in this ASCOT domain, but the average gain score was very small.
Theme 9: Personal cleanliness and comfort
Another theme emerging from quantitative data only, centre attendance was reported to make a difference to just under one-third of participants’ quality of life in the personal cleanliness and comfort ASCOT domain, but average gain was zero. However, while responding to the tool’s questions, two participants implied that attendance did impact positively on them: one commented that attendance affected how clean he felt since he bathed and wore his best shirt on attendance days and the other said she took care of her appearance as she knew men would be present.
Two of the day centres had bathing facilities (suitable for people with disabilities), but managers reported attenders using these only in emergencies.
Theme 10: Process outcomes
While certain experiences contribute to the overall centre attending ‘experience’ (e.g. activities offered), others contribute towards ‘process outcomes’. Examples include feeling valued and respected, being treated as an individual, having a degree of control over the way a service is delivered, the extent to which a service fits with other support received and value for money.(54) Some of these outcomes (identified from both datasets) have already been alluded to, particularly under Theme 4, Improved mental wellbeing and health.
Overall, reported experiences and feelings about day centres indicated that attenders experienced mainly positive process outcomes. All planned to continue attending and would recommend their centre to friends, family or somebody in the same situation as themselves. Many considered their centre offered good value for money.
‘Yes, its good value for money.’ (Miguel)
Although a very small number of attenders reported mixed feelings on centre attendance mornings and making themselves get ready as they knew they would enjoy it once there, feelings of positivity were widespread, with many enjoying the whole experience, looking forward to or loving it.
‘I think it's the best thing they have done, [local authority], make this place (…). they do a wonderful job here. I don't think I'd rather be anywhere else but here. I really do enjoy being here (…) I am glad I come.’ (Isobel)
‘All I can say is that, anyone who doesn't go there is missing out on something. I like it there and I think it's wonderful.’ (Kathleen)
Comments on centre personnel were overwhelmingly positive. The few criticisms related to attenders exhibiting unpleasant or disruptive behaviour not being dealt with, certain staff very occasionally being a bit domineering or lacking understanding of sight loss. In one centre, three attenders but were less enthusiastic about one staff member than others but did not ‘dislike’ her.
The ASCOT domains of dignity (personal sense of significance) and control, the second and third highest scoring, fall within this theme. It is likely that less positive feelings, a judgement that attendance may not have been such good value for money and, perhaps, fewer attenders planning to continue attending may be been more apparent had attenders not found themselves feeling valued, respected, treated as an individual or with a degree of control over service delivery (see Theme 4):
‘The staff of [day centre] are the salt of the earth. (…) They are always there to help. No matter what, they are always there, ready. Nothing to fault them for. They are very ordinary, very friendly and they are wonderful.’ (Tina)