Person-Centred Well-being Care Planning Tool Resident Name: Gwen Parker Date: 04/05/1937 Review number: 1 Any initial concerns to be highlighted/discussed in the review: Gwen is very quiet during the day, and does not seem to be very engaged with her environment, but she does enjoy chatting to family and care staff. Providing personal care can also be challenging.

WELL-BEING

CRITERIA

DESCRIPTION OF THE CRITERIA

STAFF PERCEPTIONS ABOUT THE RESIDENT’S ABILITY TO ENGAGE IN THE CRITERIA

FORMULATION/ REASONS FOR BEHAVIOURS

POSSIBLE WAYS TO IMPROVE

WELL-BEING

ACTIONS

Personal Care

Washing, dressing, bathing, toileting/

continence

Preferences

Done independently or level of assistance needed

How concerned are you about the resident’s ability to keep him/herself clean e.g. washing & bathing?

A lot Quite a bit A little Not at all How concerned are you about the level of assistance the resident needs with personal care?

A lot Quite a bit A little Not at all How concerned are you about the resident’s ability to get to the toilet in time? A lot Quite a bit A little Not at all

Gwen currently needs two people to assist her with washing and dressing in the morning, because staff report she will physically hit out at them

During personal care, Gwen shouts a lot, and this distresses other people in the area

Before coming to the unit, her husband said he was able to manage her personal care with no problems, so he is very upset at hearing about her distress around personal care, and this is compounding his guilt over his decision for her to go into care

Gwen needs prompting about going to the toilet, but once in the bathroom, she is able to use the toilet appropriately

Are Gwen’s preferences for personal care being met?

Is the routine she had at home being mirrored in the care setting, and if not why?

Are we aware of this previous routine?

Was there any aggression previously, and if so, how did her husband manage this?

What tasks is Gwen able to complete herself, and what does

Ensure Gwen is empowered to do as much of her own personal care as possible, rather than it being done for her

Provide Gwen with choices about her personal care and clothing

Ensure her previous routine is taken into consideration within the care setting

Gwen is able to complete personal care tasks, but does

Staff to ask Gwen when she would like her bath and ensure this is scheduled in the shift plan

Staff to wake Gwen with a cup of tea at 8.30am as she enjoys a cup of tea to help her wake up

Prompt Gwen to use the bathroom, and to wash her face with a pink flannel

Mr Parker (Bill) reports that she prefers baths to showers, and that she likes to use a pink flannel. She apparently likes to have a bath in the evening, and has said that this has always helped her to sleep

she need assistance with?

Overall: Are staff empowering Gwen to do what she is able to for herself, or are they are carrying out care task for her? Gwen is used to being a decision maker and really values this, so is she being included in decision making?

forget what she needs to do, so staff should prompt her

Ensure staff have access to her preferred pink flannel and towels

in the morning

Ask Gwen what she would like to wear, and ensure she has a choice e.g. by putting two outfits on the bed for her to choose from

Prompt Gwen to complete her own personal care by offering her the flannel rather than doing it for her

Meal Times Food choices

Ability to communication preferences

Nutritional supplements

How concerned are you that the resident is eating a balanced diet?

A lot Quite a bit A little Not at all How concerned are you that the resident is able to communicate his/her preferences for food/food choices?

A lot Quite a bit A little Not at all

Gwen really enjoys her food and eats well

The housekeeper has sat down with both Gwen and her husband to ask about her food preferences so she has good knowledge of these

Gwen has a sweet tooth and always likes a pudding after her main meal, especially with custard or cream

Ensure Gwen is given a choice of meals and allow her to select

Staff to be mindful of her fish allergy and food she does not like

Make sure to offer Gwen a pudding after meals, but not

Continue to offer Gwen choices of meals

Ensure she has a pudding when wanted

Gwen likes a cup of tea before getting up and during the day

She does not have any nutritional supplements and has no problems with eating or swallowing

She likes to choose her meals from available options

She does not like sweetcorn, and swede, but does enjoy green vegetables

She likes meat (red and white), but is allergic to fish

yoghurt as this is her preference for breakfast

Before bed, Gwen likes a milky hot chocolate

Sleep Amount of sleep

Quality of sleep

Day time naps/bed rest

Aids to sleep

How concerned are you about the amount the resident sleeps? A lot Quite a bit A little Not at all

How concerned are you about the quality of the resident’s sleep?

A lot Quite a bit A little Not at all

In the main, Gwen sleeps well

She may wake to use the toilet, and this seems to be about 3.30am, but she does not use the call bell to seek help

Gwen is assisted to change for bed, and likes her milky hot chocolate once in bed

Staff report that when they fetch her hot chocolate, on several occasions, they have returned to find Gwen trying to get into the bath. When they intervene, she shouts at them

Gwen does not have any sleep medication, or aids for sleeping

Gwen appears to welcome a nap after lunch at about 2pm and likes to sit in the reclining chair for this

Gwen is currently continent, and does not wear pads – her continence will be monitored, and action taken re incontinence when needed/necessary

Gwen’s attempts to get in the bath before getting into bed, and her shouting when this is prevented, may indicate her preference for having a bath before sleeping. Evening baths have been a longstanding part of her evening routine, and Gwen herself has said that a bath before bed helps her sleep.

Offer baths in the evening

Prompt Gwen with her evening routine as to what she needs to do, how and when; she is then able to complete the tasks herself

Help Gwen into bed, then offer her a milky hot chocolate. About an hour later, once the drink has been consumed, prompt Gwen to use the toilet and brush her teeth

Enable Gwen to have an afternoon nap by encouraging her to sit in the reclining chair after lunch

Staff to check on Gwen from about 3am until 4am as this is typically when she wakes to use the toilet

Ensure Gwen is offered a bath as part of her evening routine

Ensure Gwen has her preferred milky hot chocolate in an evening

See whether Gwen has a preference for music, TV, audio-book, radio etc when drinking her hot chocolate and to help

settle her for bed

Social Contact & Confidence

Interactions – with other residents, staff & family

Quality of the interactions

Companionship

Attachments

Shows warmth and affection

Disliked/feared by others

Responds appropriately to others’ emotions

Co-operative & helpful with staff & other residents

How concerned are you about the resident having enough company? A lot Quite a bit A little Not at all

How concerned are you about how the resident gets on with people close to them? A lot Quite a bit A little Not at all How concerned are you that the resident does not get the affection he/she wants? A lot Quite a bit A little Not at all How concerned are you that the resident feels excluded by others?

A lot Quite a bit A little Not at all

Gwen seems to spend most of her time sat on her own in the lounge in the reclining chair. Staff report that she is quite subdued for most of the day, and pays little attention to the TV, or others around her

She likes to talk to people when they sit next to her and chat, or when her family visit, however, others always initiate these interactions. Her husband tries to visit every morning, and Gwen appears to really like it when he hugs and kisses her, but she is upset when he has to leave, and this distresses him also

Gwen has always had a beautiful garden and liked tending her flowers, she likes to look out at the garden, and to talk about the flowers

She does not have much interaction with other residents at present, so there are no concerns about her being disliked or feared, but residents do back away from her in the morning having heard her shouting during personal care

Apart from during personal care, Gwen appears a very warm and friendly person, and is very pleasant and smiley with staff during the day. She will co-operate with tasks and will come into the dining room when prompted. She likes to help lay the tables for meals

Gwen does have some difficulties hearing so she may not be aware when others are speaking to her

Her hearing difficulties may be limiting her interactions with staff and other residents, so ensure she is wearing her hearing aids, and try to include her in group conversations or activities

Gwen is new to the unit, so she may not have got to know other people yet, hence she feels uncomfortable talking to them

Spend more time talking with Gwen when possible

Try to encourage her to participate in conversations with other people

Try to approach and talk to Gwen from her right-hand side as this is her better ear

When Gwen’s husband leaves just before lunch, try to distract Gwen from her distress by asking her to help lay the tables for lunch

Staff to try and spend a few moments talking with Gwen whenever possible, especially about the garden and flowers, and about her family

Make sure staff are on Gwen’s level when talking with her and try to sit on her right

Try to encourage Gwen to participate in conversations and activities with people who have similar interests to her in the hope of fostering relationships

Encourage Gwen to feel

The resident has a sense of belonging within their current relationships Strongly agree Agree Not sure Disagree Strongly disagree Gwen does have strong relationships with her family, and she very much enjoys their visits. When carers are busy and unable to speak with Gwen or when she is unable to assist them, Gwen is very quiet and withdrawn. It is still early days for Gwen in terms of her settling in on the unit, as she has only resided here for 2.5 weeks. It is hoped that with the suggested actions, Gwen will develop relationships with other residents and staff.

more at home by helping out with tasks around the unit

Engagement, Occupation & Stimulation

Previous occupation

Previous/current hobbies & interests

Activities he/she enjoys currently

Participation in groups

Enjoyment in activities

Signs of boredom

How concerned are you about the level of stimulation the resident is getting? A lot Quite a bit A little Not at all How concerned are you that the resident is not actively involved in pursuing interesting activities?

A lot Quite a bit A little Not at all How concerned are you that the resident is unable to pursue their own interests? A lot Quite a bit A little Not at all

Gwen has always been a house wife, and has taken pride in her home and her family

She has always liked a clean and tidy home, and her husband has said that everything has always had a specific place, so she is quite a particular lady

Her husband has taken a more active role in running the home, and Gwen has not really been aware of this, as he has supported her to complete tasks

Gwen used to attend the local knitting circle, but has only ever had a few close friends, as she has always been very family-orientated

Gwen’s interests have mainly centred around her home and her garden; she particularly liked to grow roses

She is subdued when on her own in the lounge, and just sits in the reclining chair looking out at the garden, but staff are not sure whether Gwen is bored at these times

Gwen may avoid group activities owing to the number of people, and her only ever having a few friends

Gwen may be unable to do activities she previously enjoyed, so staff may need to help her explore new interests

Gwen may avoid being part of a group owing to worry about her hearing difficulties and not being able to hear clearly above group noise

Know more about activities Gwen likes and ensure these are provided

Try involving Gwen in activity groups, but perhaps start with smaller groups, as she may not like bigger numbers of people around her

Involve Gwen in gardening activities and encourage her to have a stroll around the garden and to talk about flowers

To discuss with Gwen about opportunities

Find out more about Gwen’s preferred hobbies and interests now

Gwen liked knitting, but seems to find this difficult now; perhaps staff could support her with knitting or try crochet

Ensure regular gardening activities and that Gwen has access to the garden

Gwen does appear to like music activities, so ensure she

or not – this needs further monitoring, and staff to ask Gwen how she is feeling

When engaged in gardening tasks, and activities with flowers, Gwen seems very happy and to be enjoying herself. She enjoys these activities when they are 1:1 with a staff member or with the OT

She appears to really likes helping staff with tasks around the unit, e.g. to lay tables, to put things away.

Gwen has enjoyed talking about her family with the psychologist, and may really enjoy life story work and reminiscence activities

for life story work and reminiscence and see whether she would like to be involved in these activities

has a seat where she can hear these clearly

Comfort Physical health problems

Medication

Any physical pain?

Ability to express discomfort & pain

Alertness

Responsiveness

How concerned are you about the resident’s physical health? A lot Quite a bit A little Not at all

How concerned are you that the resident is unable to express their physical pain and discomfort?

A lot Quite a bit A little Not at all

Gwen is in good physical health generally

She has high blood pressure and takes medication for this every morning – see drug chart

Gwen’s medication needs must be met daily

Monitor Gwen’s health, and ensure she has regular full medical health reviews

Gwen is able to say when she is feeling unwell or in pain, and will tell staff

If Gwen is quiet and withdrawn, ask if she is feeling ok

Ask Gwen how she is feeling

If Gwen reports feeling unwell, seek a doctor’s review ASAP

Monitor Gwen’s blood pressure regularly and record this to inform her medication and dosage

When Gwen has a headache, she benefits from a soluble aspirin

Monitor Gwen’s physical health and carry out regular health checks with the unit medics

Ensure Gwen has her regular medication for her blood pressure as per the drug chart

Hope Feeling valued

Feeling loved

Interest in new activities/events

Aspirations for the future

The resident is actively enjoying life - Strongly agree Agree Not sure Disagree Strongly disagree The resident needs other people to make him/her feel good about him/herself - Strongly agree Agree Not sure Disagree Strongly disagree The resident does not feel valued by others - Strongly agree Agree Not sure Disagree Strongly disagree

Gwen is described as the “matriarch” of the family, and has always been at the heart of family life. Her move into care has meant she no longer has the daily

Consider home visits and visits to her family

Gwen likes to go to flower shows, so these should be continued.

Encourage Gwen’s family to visit as often as they can

Help Gwen to develop new

As a result of this review, how would you rate the resident’s quality of life overall? Very good Good Fair Poor

She is clearly very loved by her family, and really enjoys physical touch from them i.e. kisses and hugs, and she holds her husband’s hand throughout his visits

She is very proud of her family when she talks about their accomplishments, and they clearly value and love her too, referring to her as the matriarch of the family. She is able to tell you about all members of her family, and really enjoys her grandchildren’s visits on Sundays

Unsure about Gwen’s aspirations for the future at present, as we are just building our relationship with Gwen and her family and this will be a gradual process

contact with her children, and she is likely to be missing this at present. It will be important to ensure Gwen has much contact with her family as possible, and staff should encourage their visits and their involvement in care planning.

Gwen would be accompanied by family, but would need support of a member of care staff

Ensure Gwen has a space to meet privately with her family when they visit if she, and they, would like this

interests through encouraging her to try new activities on the ward

Enable Gwen to continue to go to flower shows and visit her family

Find out more about Gwen’s wishes for her future, and about things she would like to do or continue doing

Gwen likes to do her own clothes shopping, so staff and family to support her with shopping trips and by selecting clothes from catalogues

Negativity Mood

Signs of anger, frustration etc.

Behaviours which challenge

Agitation

Anxiety

Self harm

Psychosis

How concerned are you that the resident is frustrated or angry? A lot Quite a bit A little Not at all

How concerned are you that the resident is low in mood? A lot Quite a bit A little Not at all

How concerned are you about the resident’s behaviour? A lot Quite a bit A little Not at all

Gwen may be a little low in mood owing to staff reporting she is subdued during the day, but she is very animated and pleasant when she talks with staff

Gwen is also new to the unit and adjusting to life here, and no longer within her family home, so this will affect her mood, and continues to need monitoring

Gwen is not exhibiting any signs of anger or frustration during the day

No signs of self-harm or frustration

As discussed in personal care section, this is the only time Gwen appears to be non-concordant and will hit out and shout at staff

This appears to be very time- and location-specific to personal care tasks, so suggests issues with the way personal care has been provided so far

Ensure Gwen’s preferences for personal care are adhered to

Adhere to recommendations in personal care section on prompting Gwen to complete personal care tasks, providing pink flannel and towels, and ensuring a bath before bed to reduce Gwen’s current behaviour that challenges

Identity, Personal Involvement & Agency

Sense of humour

Given choices

Cultural issues

Personal history

Expression of wants & needs

Decision making ability

Ability to take action

Using remaining abilities

How concerned are you about the resident’s ability to get help when needed? A lot Quite a bit A little Not at all How concerned are you about the resident’s ability to make him/herself understood? A lot Quite a bit A little Not at all How concerned are you that there are things the resident wants to do but is unable? A lot Quite a bit A little Not at all

Gwen is white British, and a Christian, although she is not practising at present – her family report no specific cultural or spiritual needs

Gwen is able to express most of her wants and needs, usually this is achieved by offering her a choice, and encouraging her to point to choose

As Gwen was a homemaker and very family-orientated, she is likely to benefit from having a role of the unit, and feeling she is able to be part of unit life. Staff could involve her in washing up, laying tables, putting things away, making tea, baking etc.

Consider what local Lancashire specialities can be included on the menu

Use seaside bits and bobs to stimulate reminiscence of childhood memories at the seaside

Regular hearing checks

Enable Gwen to make her own decisions by offering her choices

Gwen should be prompted to do things for herself to ensure she

well/can make things happen

Gwen may struggle to understand some staff members’ accents owing to her hearing difficulties, so staff should try to speak as clearly as possible. If Gwen continues to find it difficult to understand what is being said, she may be best supported by showing her a picture

Gwen has a good sense of humour and clearly enjoys having a laugh with people, and staff report she can have quite a cheeky streak which makes them laugh. She does like comedy shows on the TV like the Two Ronnies

Currently, she is adjusting to lots of change having moved into care recently - she has lost her role as a home-maker, and as the matriarch at the centre of family life

She is now adjusting to also sleeping on her own, and this may explain why she find it hard to settle and get to sleep at present

She is comforted by having her toy cat, Jess, at hand, and throughout her life, Gwen has always had cats as part of the family. They still have a cat now, Tommy, and her husband may like to bring him in to visit her

Gwen is also a sister to Marie and they are close. Marie is unwell, but would like to visit Gwen. She would need support to make arrangements to do this – consider Ring and Ride provision

Little is known about Gwen’s early life at present – more information needs to be found out

Empower Gwen whenever possible by giving her choices and enabling her to have a role to increase her sense of purpose. Gwen is a “Lancashire Lass”, and she loves Lancashire hotpot and other local specialities. She likes looking at local photos, and remembering her childhood holidays at the seaside.

Ensure Gwen can watch her comedy shows

Jess is very important to Gwen and makes her feel more relaxed

Gwen says she misses Tommy, so ensure that she can continue to see him regularly.

Gwen might also enjoy visits from the donkeys and pat dog, Budd – this to be discovered

Learn more about Gwen’s early life

Gwen likes to hear her husband or daughter’s voice on the phone when she is distressed, so telephone calls at these times might be supportive

remains as independent as possible for as long as possible

Gwen can ask for what she wants, but her speech is becoming more difficult to understand – speech and language therapy input to be sought regarding speech and communication aids

Encourage Gwen’s family to bring in some personal items to personalise her room e.g. photos, pictures, trinkets so Gwen might feel more at home

Ensure Gwen has access to Jess when she feels

upset or distressed

OT to consider whether Gwen might enjoy doll therapy also, and trial this with the support of care staff

Speak to Gwen’s sister, Marie, to find out more about her childhood and her parents

Previous experiences

Trauma/traumatic experiences

Abuse

Grief

Significant life events

Significant mental health problems

Longstanding issues

Likes & dislikes

Personal preferences

Ability to express these

Gwen’s family report that she has not experienced any abuse or trauma during her life.

She doesn’t have a history of mental health difficulties, but she was diagnosed with vascular dementia five years ago and her abilities have gradually declined. Her husband’s increasing ill health bought her into care

Gwen had a hysterectomy following complication after her son’s birth, but she has not had any other operations, and her health is good. Her high blood pressure needs regular monitoring

Gwen likes to be busy and have a sense of purpose and this is important for her identity as a homemaker and family orientated person

She has always been the decision maker, so she values having choices and being able to make her own decisions and this should be encouraged

Gwen has some food preferences listed in the meals section

She also has some preferred activities listed in the occupation section

Staff are still developing their relationship with Gwen and getting to know her, but they all report that she is a very likeable lady, and believe she will settle in well on the unit and develop relationships with other residents who enjoy gardening

Continue to build a relationship with Gwen, and facilitate opportunities for her to develop a relationship with other residents

Continue to find out more information about Gwen and about her life

Are you concerned about the resident’s quality of life? A lot Quite a bit A little Not at all but Gwen is still relatively new to the unit and is still settling in. We need to help her further with this by promoting friendships with people who have similar interests

What do you think/feel was most helpful about the discussion for informing your clinical practice? Sharing the information we have recently learnt about Gwen’s personal care routines and preferences, and how this might be underlying her challenging behaviour at times of personal care. Recognising how we can empower Gwen and increase her independence, and reduce the number of distressing periods she has. Need to encourage Gwen’s husband, Bill, and her children, David and Sarah, and their families to continue to be part of Gwen’s life and to help care planning through regular discussion and seeking information from them.

Staff’s ability to recognise these

Any other issues

Risk

Finances

Visiting times

Accessing the community

If these recommended actions are not implemented, Gwen may become more withdrawn

Gwen’s husband manages her finances with support from her family. He will provide money for her to go clothes shopping or to purchase her chosen clothes from catalogues, and her daughter will also help with this

Gwen would like a plant in her room – she will chose this with a member of staff and will be supported to care for it

Her husband is keen to take her out to places, but he is worried about how she will respond when he brings her back to the unit, and thinks she might became very distressed. He has not done this whilst she has been settling in, but would like some advice from staff about when he could try this, and support to actually facilitate it happening

Bill will continue to visit daily at 11a.m until lunch. He should be asked if he would like to stay for lunch on his arrival. On days when there is a concert, or major activity happening in the afternoon, he should be made aware of this and asked if he would like to be part of it with Gwen. This also applies to Gwen’s children and grandchildren

Staff to be mindful of how Bill is feeling at present with regarding to his involvement in Gwen coming into care, and staff should offer him space to talk about his feelings and offer appropriate support at these times. The psychologist is available to speak with Bill if he would like this.

Implement all actions as soon as possible

Add details to this care plan as they are discovered and amend action

Re-review in 3 months at next scheduled well-being review

Contact Gwen’s sister, Marie, and support her with making arrangements to visit

Any other comments: By carrying out these actions, we hope Gwen will be more settled in her new home, and develop some relationships with staff and other residents, while also ensuring her family continue to visit as often and as much as they can. If Gwen can become more settled, this will have knock-on benefits on her husband by reducing his own anxieties about her being in care and his guilt at placing her here. This tool has been devised by Nicola Wheeler (Assistant Clinical & Research Psychologist), Rachael Gardner (Senior Occupational Therapist), and Andrew Papadopoulos (Lead Psychologist for Recovery & Well-being), for use within Birmingham & Solihull Mental Health NHS Foundation Trust. It is a culmination of various well-being and quality of life measures including: Kitwood’s (1997) mindsets of well-being and psychological needs, Kitwood & Bredin’s (1992) well-being framework, Bradford Well-being measure, DEMQOL & proxy, QOL-AD, Well-being Assessment Schedule Older People, and the Warwick-Edinburgh Mental Well-being Scale.

Note This completed Tool for ‘Gwen Parker’ does not contain any confidential information about any of our residents. The information included is a clinical example we have specifically devised to illustrate how the tool can be used, and how it has improved Gwen’s care, empowered staff, and enhanced their care practices.