As much of a burden as it feels to be writing in care plan after care plan, they are an important aspect of the role, says Robyn Taylor, as she shares some excellent tips on writing and personalising evaluations for the CQC…
We all know that delivering activities and spending time with residents is the most rewarding part of our job. Seeing the reaction on the person’s face and knowing you are having an impact on their lives is what it is all about. However, the downside to working in care is all the paperwork that comes along with it. Initial assessments, life stories and evaluations – is there ever enough time to fit it all in? It’s easy to feel that if there wasn’t all this paperwork you could be spending more time with the actual person. But, evaluating what a person has joined in with, how they socialise and what they are doing on a daily/weekly/monthly basis means you can see how that person is improving or declining, and you can assess their needs, look at regular patterns and behaviours enabling you to design the best care for them in the future.
BE PERSONAL
When writing about what the person has taken part in, it is important to write a personalised account. The best advice I have been given – and would remember each time I wrote in a care plan – was: if a person was to pass away and their loved ones read their care plan, what would they want to read, knowing it was their last day?
Would they want to read: ‘Ethel sat in the lounge, ate dinner, had personal care, fell asleep’, or would they want to read: ‘Ethel socialised with two other ladies, Betty and Isobel, and spoke about life growing up on a farm and listened to the other ladies’ memories. She enjoyed eating sausage and mash, which she said reminded her of having to cook the same meal for over 15 people and she didn’t have enough food to go around so everyone had to fill up on bread and butter! Ethel had a smile on her face and laughed as we chose the clothes that she wanted to wear for the concert she was attending in the evening at the local village hall with a group of residents. After singing along to songs at the concert and gazing out of the taxi window on the drive home, she decided to go straight to bed rather than watching the TV in the lounge which she normally does of an evening. Ethel stated: “I’ve had a lovely day today and would like to do it again soon”.’
It’s obvious what the answer would be. When delivering activities, ask the person what their thoughts are and how they are feeling so you can document this into the care plan. Some good questions to ask yourself are:
- How do you know the resident enjoyed the activity?
- What reaction did the person have on their face?
- Were there any changes in body language, tone of voice, or comments the person made compared to previous activities?
- How did they interact with others?
RECORD AS OFTEN AS POSSIBLE
Each care home is different – one home might document daily, the other might document monthly. But to get quotes from the residents and an accurate account, it is a good idea to jot down all the information as soon as possible. The longer you leave it, the less in-depth and vivid your memory is of the event and also subsequently your evaluations.
SPEND TIME WITH EVERYONE
Normally there are one or two activity coordinators in the home, and between 20-100 residents per home. How do you know if everyone has been seen? A lot of coordinators design their own charts so they can see who has been seen that week, using a colour code and highlighting if a person has been to a group activity, had one-to-ones, been on a trip or outdoors and so on. It is very important to make time for those people who do not participate in group settings, those who are bed-bound or have later-stage dementia. With a colour-coded chart you can quickly scan to see who hasn’t been outside over the last few days. Then make the extra effort to take that person out on a one-to-one or ask another member of staff to support you.
TIME
Time is always the most important factor of evaluating. Plan what you are doing each hour of the day to ensure you have enough time for documentation.
WHAT THE CQC WANTS TO SEE
When the CQC come to visit the home – or when any senior member of the team is inspecting the home – they want to see personalisation and what you are doing for each individual; how they are involved in their own daily lives, and whether you are documenting and delivering what they are asking for. When reading through your evaluations, they want evidence of what a person has asked for and then evidence that this is in process, or has taken place. For example:
17.11.19 Ethel has expressed to me that she would like to visit her husband’s grave to place their wedding flowers there.
21.12.19 We have contacted Ethel’s family who are delighted that we are supporting their mother to do this. The family have told us where the grave is and told us that Ethel and Bob had white roses for their wedding (as Ethel was unsure when we asked). We have organised a florist to deliver the flowers, as Ethel has stated she may become too tired to go shopping and to visit her husband on the same day, and that she wants fresh flowers.
24.12.19 The florist delivered the flowers today for Ethel who came down to the reception area to thank the reception staff for organising the delivery. We wrapped up warm and went in a wheelchair to the crematorium where Ethel placed the flowers on the grave and had a few moments to think. Ethel didn’t speak out loud during the experience but spent a few moments looking at her feet and then at the headstone. On the way home, we sat on a bench and Ethel held my hand and told me stories of when she met her husband and how she will always love him. Ethel has stated she would like to take flowers more often as she feels she has neglected this recently.
13.1.19 We have arranged for a local flower company to deliver white roses once a month for Ethel to take flowers to her husband’s grave. It is written on her diary in her bedroom and Ethel has said she is so grateful for this.
General activities in care homes are nice social experiences for people to engage in, but making things personal and doing things for the individual can be life-changing.
