A Vision for the future Rosemary Hurtley MSc Dip COT Consultant Occupational Therapist

1. A Vision for the futureRosemary Hurtley MSc Dip COTConsultant Occupational Therapist/Advisor Restoring Hope and Passion: A Life Worth Living in Relationship Centred Communities

2. Trends Over the next 20 years 2/3 increase needed for over 85�s There will be a 57-59% increase in older people who are sick or disabled Laing & Buisson project 45% growth over the next 20 years Moving towards more emphasis on dignity and quality of life in care homes �Merger Mania� Regulation changes � CSCI Change to Health Commission 30% increase in incidence of dementia over next 25yrs More resources will be needed to meet the needs of the over 85 population Change of emphasis from property to service delivery Regulation change (CSCI) including self audit, improvement plans, risk assessment, less annual inspection and themed inspections, traffic light system of quality indicators (KLORA) More resources will be needed to meet the needs of the over 85 population Change of emphasis from property to service delivery Regulation change (CSCI) including self audit, improvement plans, risk assessment, less annual inspection and themed inspections, traffic light system of quality indicators (KLORA)

3. The vision � Dignity in Care People�s �higher� human needs for enrichment, fulfilment and recognition are met in care homes A meaningful life until the end; and peace of mind Valuing those that work closest to residents Bringing care homes out of the cold

4. The potential of care homes As being a positive choice for older people As Learning organisations As being at the heart of the community Helping to deliver the vision of �Our Health Our Care, Our Say�.

5. An Adventure in Living

6. Relating - Engaging It may be more meaningful for older people to embed activation and therapeutic activity within the wider context of wellbeing and independenceIt may be more meaningful for older people to embed activation and therapeutic activity within the wider context of wellbeing and independence

7. factors affecting function Lack of motivation/ powerlessness/ hopelessness Lack of daily structure and roles Limited social opportunities Low self esteem and lack of confidence Unchallenging and limited opportunities Restricted autonomy/control Lack of opportunities for positive risk taking

8. What Resident�s want Receiving person centred care Opportunities for social/occupational activity Influencing meals and nutrition Meeting spiritual needs Resolving concerns and complaints 1. Receiving person-centred care Enabled to discuss and agree help with personal care needs Enabled to exercise rights in giving consent to treatments Receiving care perceived by the client to be desirable, and of an acceptable standard 2. Taking up opportunities for social/occupational activity Given opportunities to identify and agree personal social/occupational needs Enabled to undertake meaningful social/occupational activities as planned Feeling included as a valued member of the community of the Home 3. Eating, drinking and nutrition Enabled to agree nutritional requirements as part of own care plan Enabled to influence variety and choose meals from a menu Receiving needed assistance with eating and drinking as identified in care plan 4. Receiving spiritual care Enabled to follow his/her usual religious practices Enabled to find meaningfulness in his/her life Receiving end of life care in accordance with own wishes and best practice 5. Concerns and complaints Knowing to whom to speak to about concerns Enabled to raise concerns and complaints without fear of retaliation of any kind Able to access an advocate 1. Receiving person-centred care Enabled to discuss and agree help with personal care needs Enabled to exercise rights in giving consent to treatments Receiving care perceived by the client to be desirable, and of an acceptable standard 2. Taking up opportunities for social/occupational activity Given opportunities to identify and agree personal social/occupational needs Enabled to undertake meaningful social/occupational activities as planned Feeling included as a valued member of the community of the Home 3. Eating, drinking and nutrition Enabled to agree nutritional requirements as part of own care plan Enabled to influence variety and choose meals from a menu Receiving needed assistance with eating and drinking as identified in care plan 4. Receiving spiritual care Enabled to follow his/her usual religious practices Enabled to find meaningfulness in his/her life Receiving end of life care in accordance with own wishes and best practice 5. Concerns and complaints Knowing to whom to speak to about concerns Enabled to raise concerns and complaints without fear of retaliation of any kind Able to access an advocate

9. What relatives want Encouraged to contribute Enabled to be partners in care with staff Structured opportunities for involvement/engagement Enabled to influence practice Access as desired: Interacting with staff Fully informed: positive questioning RELATIVES 1. Encouraged to contribute Enabled to be partners in care with staff Structured opportunities for involvement/engagement Enabled to influence practice 2. Access as desired Welcomed to feel part of the Home Enabled to know who is who and who does what Welcomed to adapt to and develop the role of visitor 3. Interacting with staff Enabled to work through feelings linked to loss of role as main carer Welcomed to share family background and other information pertinent to the resident�s life in the Home. Being heard and trusted as a person who knows the resident 4. Fully informed Informed about good and bad news in a timely way Kept in the picture about changes in care, and staff changes affecting the resident Enabled to contribute to finding solutions to problems. 5. Positive questioning Encouraged and enabled to raise issues of concern Knowledgeable about who to speak to/ write to about concerns Suggestions for improving Home life taken seriously RELATIVES 1. Encouraged to contribute Enabled to be partners in care with staff Structured opportunities for involvement/engagement Enabled to influence practice 2. Access as desired Welcomed to feel part of the Home Enabled to know who is who and who does what Welcomed to adapt to and develop the role of visitor 3. Interacting with staff Enabled to work through feelings linked to loss of role as main carer Welcomed to share family background and other information pertinent to the resident�s life in the Home. Being heard and trusted as a person who knows the resident 4. Fully informed Informed about good and bad news in a timely way Kept in the picture about changes in care, and staff changes affecting the resident Enabled to contribute to finding solutions to problems. 5. Positive questioning Encouraged and enabled to raise issues of concern Knowledgeable about who to speak to/ write to about concerns Suggestions for improving Home life taken seriously

10. What Staff want Enjoying the work Time to do things properly Equipped to do the work Being valued Listening and relating STAFF 1. Enjoying the work (Sense of achievement in fulfilling care�giving roles) Enabled to deliver good care Enabled to build positive relationships with resident, relatives and colleagues Working in a supportive though challenging environment 2. Time to do things properly Time to listen to and communicate with residents about the things that matter to them Time for building partnerships with relatives and residents in providing care and building the home as a community Time to learn good practice and enable learning in others. 3. Equipped to do the work Receiving proper induction to the job Continuous learning opportunities provided and pursued Supervision and feedback aimed at developing resident focused practice 4. Valued Feeling valued and supported by organisation�s owners, managers and colleagues. Receiving recognition for commitment to improving resident�s experience of care Enabled to work flexibly compatible with well-being of residents 5. Listening and relating Residents and relatives are integrated partners in the care planning process. Social living decisions and associated activity are fully represented in care plans. Residents, relatives and staff have opportunities to undertake projects aimed at improving life in the Home. Pat Duff/R Hurtley � 2006  STAFF 1. Enjoying the work (Sense of achievement in fulfilling care�giving roles) Enabled to deliver good care Enabled to build positive relationships with resident, relatives and colleagues Working in a supportive though challenging environment 2. Time to do things properly Time to listen to and communicate with residents about the things that matter to them Time for building partnerships with relatives and residents in providing care and building the home as a community Time to learn good practice and enable learning in others. 3. Equipped to do the work Receiving proper induction to the job Continuous learning opportunities provided and pursued Supervision and feedback aimed at developing resident focused practice 4. Valued Feeling valued and supported by organisation�s owners, managers and colleagues. Receiving recognition for commitment to improving resident�s experience of care Enabled to work flexibly compatible with well-being of residents 5. Listening and relating Residents and relatives are integrated partners in the care planning process. Social living decisions and associated activity are fully represented in care plans. Residents, relatives and staff have opportunities to undertake projects aimed at improving life in the Home. Pat Duff/R Hurtley � 2006

11. Observations Confirm the Belief that: The wellbeing of residents is commensurate with the wellbeing of staff. Their human experience is interdependent and interconnected Tom Kitwood 1997 High proportion of people in care homes with dementia � and increasing challenges / complexities. There has been a sea change in attitudes towards people with dementia in terms of attitude and New Culture thinking and the potential of the individual receiving care. Staff are now expected to help people to express themselves further and to understand the finer nuances of communication/ individual engagement as part of a new approach to consultation, thus requiring different attitudes and new more sophisticated skills and self awareness/understanding. In addition an move towards more enabling practices to promote independence and autonomy, challenging task orientated practice.High proportion of people in care homes with dementia � and increasing challenges / complexities. There has been a sea change in attitudes towards people with dementia in terms of attitude and New Culture thinking and the potential of the individual receiving care. Staff are now expected to help people to express themselves further and to understand the finer nuances of communication/ individual engagement as part of a new approach to consultation, thus requiring different attitudes and new more sophisticated skills and self awareness/understanding. In addition an move towards more enabling practices to promote independence and autonomy, challenging task orientated practice.

12. Emotional health at work Staff do not work separately from their emotions. Emotional health in the workplace works best if there are: Shared organisational values Skilled staff Management style is participative, developmental, inclusive in decision making Management style and emotional health of the staff is linked to the experience of person centred care

13. Research Findings- Job satisfaction and motivation The individual, team and organisational health is interdependent A Listening management, asking the right questions, along with the development of a learning environment for both staff and residents is necessary to person centred care and optimal wellbeing of both.

14. Continued Key values, roles and knowledge and skills must not be assumed Wellbeing of residents and staff is interdependent Releasing empowerment and creativity within the workplace can negate the negative effects of stress and burnout Open relationships and proactive management styles are required for person centred practice Realistic rewards needed to reflect task significance to raise self esteem and the status of the work

15. Person centred to relationship centred care model A sense of security A sense of continuity A sense of belonging A sense of purpose A sense of fulfilment A sense of significance (Nolan et al 2002) PCC needs to be seen in the context of relationships and is only possible when there is a partnership between staff, relatives and residents (Eales 2001)PCC needs to be seen in the context of relationships and is only possible when there is a partnership between staff, relatives and residents (Eales 2001)

16. 3 Types of Community Controlled Cosmetic Complete

17. The New Benchmarks Use biography to ensure PC activity Care plans to include activity needs/outcomes Individual risk assessment involve choice/relatives Dining experience/ADL/Spiritual needs PC Resources for activity in business plans Staff taught relationship centred approaches/community development Basic gerontology/ageing/conditions/ communication Managers take a lead in developing activity culture

18. Building human habitats- Eden Alternative The three plagues of the human spirit are: -loneliness -helplessness -boredom

19. Eden Principles States the problem Human habitats Companionship Care balance Spontaneity/unexpected encounters Meaningful activity Medical treatment serves Culture change � elder centred Wise leadership � enabling/learning Loneliness helplessness and boredom Human habitats that nurture the spirit as well as the body- habitats nurture and grow vs. the control of an institution Loving companionship is the antidote to loneliness � emphasis on relationships and including animals plants and children using close and continuing contact Care balance � giving and receiving care as an antidote to helplessness Unexpected interactions Medical treatment serves human caring and quality of life, not its master Culture change- moving decision making down and turning round top down culture � ongoing process Leadership is lifeblood of any struggle against the 3 plagues Loneliness helplessness and boredom Human habitats that nurture the spirit as well as the body- habitats nurture and grow vs. the control of an institution Loving companionship is the antidote to loneliness � emphasis on relationships and including animals plants and children using close and continuing contact Care balance � giving and receiving care as an antidote to helplessness Unexpected interactions Medical treatment serves human caring and quality of life, not its master Culture change- moving decision making down and turning round top down culture � ongoing process Leadership is lifeblood of any struggle against the 3 plagues

20. Activity at the Centre of CARE �Man does not cease to play because he grows old, he grows old because he ceases to play� George Bernard Shaw �Purposeful activity is an essential component of quality of life for older people and is needed throughout life� Green et al 2000 The trend is towards Relationship centred activities which involves a multidimensional challengeThe trend is towards Relationship centred activities which involves a multidimensional challenge

21. Old Culture Disengagement Value-added luxury �anything will do�just look busy� Focus on leisure alone (retirement model) Stereotyping � �all older people are the same� No need for training Group v. individual Sedentary lifestyle not challenged One person does everything �within these walls�

22. On with the New Integral to the care plan/process of care Activity Activator: initiate function/wellbeing Leadership role within the team Co-ordinating community opportunities Team development �Change agent� role within the team Quality of life specialist- �personalising lifestyle within setting

23. Activate Opportunities Physical Recreational Relaxation Cognitive Communication Creative Cultural Reminiscence Social Esteem Spiritual Community Family/relatives Learning �Once we create a world on which we can presume, we stop learning��.a vaccination against neurodegeneration�

24. Principles of activation A= activity range C= creative opportunities, challenge T= teamwork I= including V= Variety to meet a range of preferences A= activating learning opportunities T= together with residents, relatives and staff E= enjoyment and well being. Long Term Care Settings Same principles, but concentrate teaching staff �enabling� approaches with realistic long term and short term goal setting. Utilise the family and carers to inform this process. Consider previous lifestyle, biography, preferences, motivation, interests etc Splinting, positioning and seating to prevent pressure sores and asymmetry- using cushions, wedges, towels. Encourage the care environment to be active, enabling and stimulating. Encourage working with retained skills and abilities rather than taking over the task to save time in the short term ( de-skilling).Long Term Care Settings Same principles, but concentrate teaching staff �enabling� approaches with realistic long term and short term goal setting. Utilise the family and carers to inform this process. Consider previous lifestyle, biography, preferences, motivation, interests etc Splinting, positioning and seating to prevent pressure sores and asymmetry- using cushions, wedges, towels. Encourage the care environment to be active, enabling and stimulating. Encourage working with retained skills and abilities rather than taking over the task to save time in the short term ( de-skilling).

25. Restorative Care promoting health C= correct level of support given to maximise abilities. Promote communication (carer/ resident) to promote greater mutual understanding. Choice of a wider range of activity and enabling/learning opportunities. A= appropriate activities, promoting abilities, providing appropriate levels of support. Assistance to point of need. R = restoration of function ( rehab programme / re-ablement approaches). Realistic goal setting in care plans. Roles developed for both staff and residents. E= enabling independence, learning/ interdependence / empathy. APPLICATION OF REHABILITATION PRINCIPLES TO THE CARE PROCESS; Opportunities to learn and practice new ways of performing skills. New learning should be taught in non-stressful setting. Need for rest periods and enough time to complete tasks. Positive attitude of care and nursing staff towards effort as negative attitudes limit rehabilitative approaches to care (Phipps 1992) Need for actively motivating an older person. (Hesse , Campion 1983 in Phipps). Residents often show low expectations of their abilities /potential along with ageist attitudes among health professionals. Negative attitudes towards individuals� potential for improvement can impose �learned helplessness� in the older person. Dependent behaviour in nursing home residents is frequently maintained by the nursing home staff. (Avoron & Langer 1982 in Phipps). Fear of pain, treatment processes, perceived decline, and loss of control can result in depression and dependent behaviour. INDUCTION Understanding Rehabilitation Philosophy- to enable independence Creating the Right Environment � team building Communication Skills training- assertiveness, report writing, care planning, listening skills. The role of the multi-disciplinary Team � physiotherapy, nursing, occupational therapy, speech and language therapy dietician roles within the team. Carers and relatives. Mobility Principles of Movement � maximising independence in transfers, walking, proper use of equipment. Common Conditions- Principles and Precautions � stroke, Parkinson�s, arthritis, orthopaedics, falls etc. Promoting Independence in Daily Living Skills � personal and domestic ADL; use of different devices, equipment and techniques for different functional difficulties. Reframing the meaning of care by meeting the care challenge ie.over protective, controlling practices, task orientation, overemphasis of medical model to detriment of adequate emphasis on psychosocial needs.APPLICATION OF REHABILITATION PRINCIPLES TO THE CARE PROCESS; Opportunities to learn and practice new ways of performing skills. New learning should be taught in non-stressful setting. Need for rest periods and enough time to complete tasks. Positive attitude of care and nursing staff towards effort as negative attitudes limit rehabilitative approaches to care (Phipps 1992) Need for actively motivating an older person. (Hesse , Campion 1983 in Phipps). Residents often show low expectations of their abilities /potential along with ageist attitudes among health professionals. Negative attitudes towards individuals� potential for improvement can impose �learned helplessness� in the older person. Dependent behaviour in nursing home residents is frequently maintained by the nursing home staff. (Avoron & Langer 1982 in Phipps). Fear of pain, treatment processes, perceived decline, and loss of control can result in depression and dependent behaviour. INDUCTION Understanding Rehabilitation Philosophy- to enable independence Creating the Right Environment � team building Communication Skills training- assertiveness, report writing, care planning, listening skills. The role of the multi-disciplinary Team � physiotherapy, nursing, occupational therapy, speech and language therapy dietician roles within the team. Carers and relatives. Mobility Principles of Movement � maximising independence in transfers, walking, proper use of equipment. Common Conditions- Principles and Precautions � stroke, Parkinson�s, arthritis, orthopaedics, falls etc. Promoting Independence in Daily Living Skills � personal and domestic ADL; use of different devices, equipment and techniques for different functional difficulties. Reframing the meaning of care by meeting the care challenge ie.over protective, controlling practices, task orientation, overemphasis of medical model to detriment of adequate emphasis on psychosocial needs.

26. Benefits to the Home Potential to change the image � healthy lifestyles v. decline Increased sense of teamwork Expanding the meaning of care �reduced task orientation to holistic care Improved reputation Extended lifespan with greater opportunity for social integration and interest

27. Benefits to the Residents Raised life satisfaction �choice, opportunity and involvement Greater confidence � improved function Improved health status Greater sense of personal significance and worth Sense of identity, purpose and control

28. Benefits to Staff Raised job satisfaction/ retention Job retention � relationships developed, purposeful goal-orientated care, interest Broadens understanding of delivery of care � more dynamic and purposeful Observe change, growth, development Satisfaction- active engagement, challenge, novelty.

29. Keys to Success Enjoyment Challenge ��fit� Help older people to learn, to transform experience into knowledge, skills, attitudes, values, beliefs, senses and emotions in order to respond to challenges and change Help them to wear age with dignity Supportive manager � creative, flexible to involve staff beyond normal roles to enrich activities within their home Training route � NVQ 2, NVQ 3 CREATING A COMMUNITY Understand the significance of relationships recognise roles, rights and responsibiltities creating opportunities for giving and receiving Create opportunities for meaningful activities Create an environment thea supports community Maximise contribution and involvement Encourage reciprocity Be commited to shared decision making TYPE OF ACTIVITIES Reminiscence and life review Purposeful organised events Informal spontaneity Music based activity Social ( physical IQ sensory stimulation) Learning and challenge Enjoyment and fun EDEN PRINCIPLES To negate boredom, helplessness and loneliness. A whole systems and comprehensive approach to negate sterility, staff empowering and relationship centred model. Flat management, team model introducing new elements into the daily experience of residents (plants, animals and children) NB Understand the significance of relationships Recognise roles, rights and responsibilities Create opportunities for giving and receiving Create opportunities for meaningful activities Build an environment that supports community MUTUAL GOALS ( Residents and staff) TO FEEL SAFE PHYSICALLY COMFORTABLE EXPERIENCE A SENSE OF CONTROL FEEL VALUED EXPERIENCE OPTIMAL STIMULATION EXPERIENCE PLEASURECREATING A COMMUNITY Understand the significance of relationships recognise roles, rights and responsibiltities creating opportunities for giving and receiving Create opportunities for meaningful activities Create an environment thea supports community Maximise contribution and involvement Encourage reciprocity Be commited to shared decision making TYPE OF ACTIVITIES Reminiscence and life review Purposeful organised events Informal spontaneity Music based activity Social ( physical IQ sensory stimulation) Learning and challenge Enjoyment and fun EDEN PRINCIPLES To negate boredom, helplessness and loneliness. A whole systems and comprehensive approach to negate sterility, staff empowering and relationship centred model. Flat management, team model introducing new elements into the daily experience of residents (plants, animals and children) NB Understand the significance of relationships Recognise roles, rights and responsibilities Create opportunities for giving and receiving Create opportunities for meaningful activities Build an environment that supports community MUTUAL GOALS ( Residents and staff) TO FEEL SAFE PHYSICALLY COMFORTABLE EXPERIENCE A SENSE OF CONTROL FEEL VALUED EXPERIENCE OPTIMAL STIMULATION EXPERIENCE PLEASURE

30. Innovation in dementia care Activating Restoring Developing Enriching Releasing Empathising Connecting Activating ability focused meaningful activity, adapted to abilities whether spontaneous and planned. Restoring relationship of a person to their former self and to others around them by building an image of a person through activities and roles which match the former life style, individual preferences and current cognitive level of an individual through a range of therapeutic media using the biography to inform these with accurate ongoing assessment thus providing a mutual and �complete community�. Developing an environment where novelty and new experiences gently challenge and stimulate individuals, probing for improved function thus ongoing learning experiences can take place. Communicating an approach to activities in a way which includes an imaginative approach to how daily activities are presented and the potential of them to be appreciated by all those involved in their delivery thus to create a positive experience of the �small� day-to-day opportunities. This will involve an intense understanding and effective communication skills which need to be taught throughout the home. Enriching � the environment to maximise wellbeing aims to be stable and peaceful and offer a range of targeted meaningful activities and sensory enrichment which foster an interdependent social living experience, including access to animals, children, nature and the outdoors and wider community where possible. Releasing the creativity within the relationship triangle (Staff, relatives, residents) for their mutual support and benefit. Empathising by validation and support of the emotional experience of the world lived in by the resident, by those within the relationship triad. Connecting with the wider community and the Relationship Centred Care model (Kitwood model, Nolan model)Activating ability focused meaningful activity, adapted to abilities whether spontaneous and planned. Restoring relationship of a person to their former self and to others around them by building an image of a person through activities and roles which match the former life style, individual preferences and current cognitive level of an individual through a range of therapeutic media using the biography to inform these with accurate ongoing assessment thus providing a mutual and �complete community�. Developing an environment where novelty and new experiences gently challenge and stimulate individuals, probing for improved function thus ongoing learning experiences can take place. Communicating an approach to activities in a way which includes an imaginative approach to how daily activities are presented and the potential of them to be appreciated by all those involved in their delivery thus to create a positive experience of the �small� day-to-day opportunities. This will involve an intense understanding and effective communication skills which need to be taught throughout the home. Enriching � the environment to maximise wellbeing aims to be stable and peaceful and offer a range of targeted meaningful activities and sensory enrichment which foster an interdependent social living experience, including access to animals, children, nature and the outdoors and wider community where possible. Releasing the creativity within the relationship triangle (Staff, relatives, residents) for their mutual support and benefit. Empathising by validation and support of the emotional experience of the world lived in by the resident, by those within the relationship triad. Connecting with the wider community and the Relationship Centred Care model (Kitwood model, Nolan model)

31. New Culture workforce Manager as prime mover/ positive enthusiastic leadership Care assistant induction/role review Staff empowered Shared learning Professional staff as consultants Team ownership of activities (housekeeping, maintenance, catering) Encourage more participation of relatives

32. Challenge How do we help people maximise their last years? Those promoting activities need to be in a position to help residents to claim all the living they have done and can still do, offering hope and encouragement and provide experiences to enable opportunities for growth and development activating interest as the key to engagement. Enjoyment Challenge �fit� Help older people learn, to transform experience into knowledge, skills, attitudes, values, beliefs, senses and emotions in order to respond to challenges/change Help older people wear their age, not as a burden but as a crown. Enjoyment Challenge �fit� Help older people learn, to transform experience into knowledge, skills, attitudes, values, beliefs, senses and emotions in order to respond to challenges/change Help older people wear their age, not as a burden but as a crown.

33. The potential of care homes As being a positive choice for older people As Learning organisations As being at the heart of the community Helping to deliver the vision of �Our Health Our Care, Our Say�.

34. MY Home Life: Quality of Life in Care Homes A Programme of research, practice development and changing fixed beliefs Help the Aged and National Care Forum With our high-level steering group Residents, providers, commissioners + Launched report and gained funding Now in the first stage of development

35. Contact details Rosemary Hurtley Enterprises hurtley@btinternet.com 01483 272052 Eden Alternative june@eden-alternative.co.uk My Home Life -Help the Aged NAPA info@napa-activities.co.uk 0207 078 9375