Unit 04

Promote person-centered approaches in care settings

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Unit purpose and aims

This unit introduces the concept of person-centered support as a fundamental

principle of adult care.

The learner will:

1. Understand the application of person-centered approaches in care settings

2. Be able to work in a person-centered way

3. Be able to establish consent when providing care or support

4. Be able to implement and promote active participation

5. Be able to support the individual’s right to make choices

6. Be able to promote individuals’ wellbeing

7. Understand the role of risk assessment in enabling a person-centered approach

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1.1 How and why person-centered values must influence all aspects

of health and social care work

A person-centered approach puts the person, not their illness or condition, at the centre. The

needs and feelings of each person are the focal point around which everything revolves.

Person-centered care is a care approach which aims to help you and other care

workers to see, value and treat people as individuals who have led, and are still

leading, their own unique life.

Person-centered values acknowledge the person’s individuality, their rights and choices,

their needs for privacy, dignity, respect and independence. Person-centered care is a

partnership between the individual and their care-givers.

Person-centered care was developed in the 1990s by, among others, the late

Professor Tom Kitwood, of the Bradford Dementia Group. (“Dementia reconsidered -

the person comes first” Kitwood, 1997).

The five key elements of person-centered care

Professor Kitwood identified five key elements of positive care. It is important that you

think about an individual’s previous whole life and what was and still is important to them.

These include:

Comfort and attachment - belonging

Communication and interaction

Biography and identity - their past, who they are

Autonomy and Agency - being in control

Inclusion and occupation - doing something meaningful.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:

Regulation 9. CQC states ‘The intention of this regulation is to make sure that people

using a service have care or treatment that is personalised specifically for them. The

regulation describes the action that providers must take to make sure that each person

receives appropriate person-centred care and treatment that is based on an assessment

of their needs and preferences’. (www.cqc.org.uk)

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Holistic/whole care

It is now recognised that a person has needs beyond their physical care; therefore, it is

important that the whole care needs of the person are met. Care should be planned to

take into consideration the religious, spiritual, psychological, social and cultural as well

as physical needs. This means looking at individuals as a whole person rather than just

focusing on their medical condition and recognising that person-centered values must

influence all aspects of health and social care work.

It is easy to forget that people are all different. None of us are the same - we have all had

different experiences of life as we have grown; we all have different personalities, likes and

dislikes.

Every one of us deals with events in our life differently.

Consequently, as a care worker, it will help to think about the person first i.e. their life

history and what they enjoy. If, as a care worker, you can see the person, this will help

you to consider how you can care for the individual.

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Maintaining individuality and respect

It is the right of each person to be treated as an individual. This will make them feel

valued and respected. You can achieve this by the way you treat individuals

Always find out the name they prefer to be called. Do not assume everybody

prefers first name terms or endearments such as ‘gran’ (this may be seen as

belittling to the individual)

Talk with, and listen to individuals, key people and others, to assess, needs,

wishes and preferences

Find out about the individual’s daily routine, their family and friends, hobbies and

interests

Plan care holistically

Be polite, helpful and show empathy

Ensure individuals have contact with family and friends

Encourage personal items e.g. photographs, furnishings, ornaments etc.

Do not clothe individuals in items that belong to the care establishment

Encourage the wearing of day clothes

Give choices, uphold rights.

Rights and Choices

It is vital that individuals feel in control of their lives. Ensuring they are aware of their

rights and choices, and that these are actively promoted, will help individuals to be

confident and develop a feeling of self-worth. Individuals should be encouraged to say

what they want, express opinions and make suggestions about the care they receive.

Achievement and fulfillment

It is important that individuals are able to feel successful in their daily lives. Empowering

people, encouraging self-management and allowing them to become partners in care, will

ensure goals set are realistic. The individual can then achieve their full potential. This will

lead to a sense of fulfillment.

Active support

You must provide active support to enable individuals to use their strengths and potential.

This means setting realistic goals, giving positive feedback and encouraging (but not

forcing) self- management.

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Individuals should be supported to identify how they want you to carry out your work

activities. This upholds their right to choose and will encourage and empower them.

Privacy and dignity

The Human Rights Act states that a person has a right to privacy, dignity and respect.

Privacy may be viewed as privacy of information, the provision of private areas for

individuals and privacy that involves covering the body.

All individuals have the right to be provided with a private area to wash, dress, attend

to toilet needs, meet with visitors, receive treatment, relax or be alone.

Clothing should be of the individual’s choice and should cover the body adequately to

maintain dignity. Individuals should also be offered advice and support to choose clothing

appropriate for their personal needs and the activities they are undertaking. An abrupt,

impatient or intolerant attitude will humiliate and dehumanise the individual, and should be

considered abusive. Care settings where care practices are institutionalised, do not

maintain dignity, privacy or show respect.

Independence, freedom and being in control

Everyone needs to feel that they have independence - as a teenager, it is

something many struggle for. Try and consider:

In what ways are you in control of your life now?

How it feels to be in charge of your life.

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Why it is important to work in a way that embeds person-centered values

Individuals should be included in the planning and delivery of all aspects of their care. This

will ensure that the service provided puts the individual at the centre of everything you do.

Decisions are made and care is delivered with the individual’s knowledge, understanding,

co-operation and consent. You should actively support individuals to participate as much

as they are able.

Your aim, as a person-centered care worker, is to make sure that each day is as

positive as it can be for each person.

Care workers can show respect and preserve dignity by always supporting individuals’

choices and upholding their rights.

People entering a care home, or receiving care in their own home, may experience a

number of losses, particularly a loss of independence. There is a danger that loss of

independence will lead to loss of identity which may be a direct result of people who

need care being treated in the same way. This is particularly so in care settings or

organisations whose routines fit more closely with the needs of the organisation than that

of the individual.

As a care worker you can help an individual hold onto their sense of ‘who they are’ by

respecting their individuality, getting to know them and learning their life history.

Understanding the uniqueness of the person will promote individuality. If we look closely

at the person’s individuality we can recognise their strengths and skills, in order to

promote independence.

Privacy is not only ensuring private areas for personal care, but also the individual’s

private and confidential information. There may be other ways of promoting the privacy

and dignity of the individual. The most important aspect for you to learn is that you should

always treat the individual with the respect you would expect for yourself or a member of

your family; listen to what individuals have to say, and encourage and accommodate their

choices and personal preferences. It is vital that you ensure the individuals’ comfort. The

care team should be aware of their needs and should strive to meet these by providing the

best possible quality service. Creating a relaxing and harmonious atmosphere is as

important as having pleasant and comfortable physical surroundings.

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1.2 Evaluate the use of care plans in applying person-centered values

Policies have now become more focused on the importance of service users being in

control of the services they receive. This is about looking at what the individual needs and

wants, rather than just offering them a choice. By developing a care plan you have

identified their choices.

‘Over a number of years, different ways of including everyone in the planning

process in a meaningful way have been developed.

They include:

Advocacy

Self-advocacy

Facilitated decision making

Providing mentors and/or other support for family members

Providing training for staff and family members’.

(Health and Social Care Adults Yvonne Nolan

pg 242)

Advocacy- where another person speaks on behalf of someone else, expressing their

wishes and needs.

Self-advocacy - empowers the person to speak for themselves and to maintain self-esteem.

Recent legislation has strengthened the requirement to use a person-centered approach

and include the individual and their family carers in care planning. The Care and Support

Plans written following a care and support assessment as required by the Care Act 2014

is an example of a care plan based on person-centered values.

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1.3 How to collate and analyse feedback to support the delivery of

person centered care in line with roles and responsibilities

Your job role and level of responsibility will dictate how much you are responsible for

collating (putting together) and analysing feedback to support the delivery of person

centred care. However care workers at all levels are likely to be required to:

Report and record an individual’s needs and preferences. This may be simple

information

suchasnotingwhatfoodstheyprefertomorecomplexissuessuchasthestrategiesrelative

s have found helpful in managing the individual’s behaviour that challenges

Observe the individual and share with colleagues any significant observations, such

as the individual seems subdued today

Report and record any feedback from the individual or their relatives about their

care: what

isworkingwellandhelpfulforthem,anyunmetcareandsupportneedsandanysuggestions

they may have about how the care could beimproved.

In addition, in your job role you may be required to update an individual’s care plan as

his or her needs change or as the care team develop new ways of supporting that

individual. More senior staff will liaise with other professionals (multidisciplinary

working) and other organisations (multi agency working) and collate the information to

support the delivery of person-centered care.

Within health and social care, situations and individuals are constantly changing. This

means that new strategies are often needed to support individuals. All care workers need

to consider feedback regarding how well care and support is working for the individual

and to be prepared to change their way of working if needed.

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Sometimes an individual or relative may make a complaint about their care. A positive

way for staff to respond is to see this as a form of feedback from which lessons may be

learned. Senior staff will deal with the complaint and consider whether or not the

complaint is justified, whether something has gone wrong, what lessons can be learned

and whether new safeguards or working practices need to be put in place.

Positive feedback such as praise and thanks from individuals and relatives should always

be shared with staff. This is encouraging and motivating for the team and lets them know

what they are doing well.

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2.1 Work with an individual and others to find out the

individual’s history, preferences, wishes and needs

The meaning of life history work

This is the process of finding out who a person really is. It is not just about compiling a list

of what the person has done or where they lived etc.

Each of us is formed by our past life. We all have a life history. It is made up of the things

which have happened to us in our lives and the way they have affected, or been affected

by, our own personality. The story of our life is part of the story of our family; that is our

identity.

Ways to collect life history information

A profile may include an individual’s:

Likes and dislikes

Values and beliefs

Life experiences, events and

encounters

Significant people, places and

objects

Disappointments and achievements

Routines and habits

Talents, hobbies and interests

Work life and education.

The obvious place to start, and one which is often overlooked, is to talk to the person

themselves about their life. Many care workers have a lot of information about individual

people, but the only place it is recorded is in their heads. This means that when they are off

duty the information is not available for other staff to use in order to help the person. All

information obtained by talking and listening to the individual should be recorded. In order to

achieve this you must actively listen to the individual, following the basic principles

described in unit 01.

A life history is not something which is completed in one session on one particular day.

Information comes gradually, from several different sources. Personal care sessions, when

you are alone with the individual, will often be the time and place where they recount stories

about their life. It is important to record these.

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Friends and family are another valuable source of information. Some families will want to

pass on as much information as they can and may find that writing a mini biography about

their relative helps them over the period when the decision is made to move the person into

a care home.

Others will not. There will be many reasons for this. Care staff have to work with what life

history information is available.

Family photographs are a useful source of life story material and can be used to make life

storybooks. Involving the family and the individual in this is often a pleasant activity which

they may all enjoy. It is very important that the names of significant people in someone’s life

are known; you need to know if this is their husband/wife, their brother, their son/daughter,

their partner or their dog!

Many people in care homes have had long associations with community groups such as

churches, service associations, trade unions or professional bodies. Everyone has lived in a

street, a neighbourhood, a town or village. Local information can be very useful in collecting

life history.

This provides cues which help the care worker to meet the preferences, wishes and needs

of an individual when planning care and support.

It is important for you and other care workers to share all information you collect, to ensure

that you are working as team and promoting good quality care for the individual.

Other external members of the team could include the GP, the district nurse and social

worker who may also be included as a source of history or information.

All information gathered, from whatever source, should be recorded, and used for reference

and referral for those involved in the care of the individual.

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2.2 Demonstrate ways to put person-centered values into practice in a

complex and sensitive situation

There may be situations that are complex or sensitive. Examples are:

Conflicts within the family about the best way forward, such as whether or not

to try to resuscitate someone nearing the end of their lives if their heart

stopped

Issues relating to religion, spirituality, relationships or sexuality tend to be sensitive.

Applying person-centered values, putting the individual at the centre and approaching

their needs in a holistic way will identify how the individual may react to or deal with

complex or sensitive situations. This will enable care to be planned and implemented in

ways to put person-centered values into practice. This will include approaches, language

and communication used appropriate and supportive of the person’s specific needs.

The benefits of life history work to the individual concerned

The individual will perceive that care workers are taking an interest in them and value

them as a person. Involving them in life history work can be very fulfilling and prove

therapeutic for the individual concerned. People derive enjoyment from the relationships

formed with care staff who know them well and are able to use their knowledge of the

individual to plan care which is truly person-centered.

2.3 Adapt actions and approaches in response to an individual’s

changing needs and preferences

Individuals’ needs and preferences may change over time. This could be due to changes

in physical or mental health, spiritual, cultural, social or economic situation. It is important

to adopt actions and approaches in response to an individual’s changing needs and

preference. In order to do this the individual’s needs and preferences must be reviewed

regularly. Any changes identified and alternations made to the plan of care must be

detailed in the plan of care. The care plan must detail how care workers’ actions and

approaches can be adapted to respond to the individual’s changing needs and

preferences.

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3.1 Factors influencing the capacity of an individual to express consent

Certain individuals may lack capacity to make decisions and are therefore unable to give

informed consent. It is important that you are aware of, and have an understanding of, the

legislation relating to mental capacity.

The Mental Capacity Act 2005

The Mental Capacity Act 2005 provides a framework to protect vulnerable adults who

are unable to make their own decisions about the care and support they require:

Capacity is presumed unless proven otherwise

All available help and support is given to enable individuals to make decisions,

before a conclusion is reached that they lack the capacity to do so

An individual retains the right to make unhealthy choices and decisions, if they so

wish

Any intervention must be in the individual’s best interests and not infringe basic rights.

The Mental Health Act 1983

The Mental Health Act 1983 - identifies measures to uphold rights for those with

mental health problems.

The Health Care Professionals Council Standards states that Social Care Workers must:

Promote and Protect the rights and promote the interests of service users and carers

Strive to establish and maintain the trust and confidence of service users and carers.

Other legislation and policies that would relate to promoting rights and responsibilities:

Use of restraint

Taking risks

Preventing/managing violence

Complaints procedures.

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The Mental Health Act 2007

The Mental Health Act 2007 - provides a new revised framework which is more

applicable to the current support and services that are available.

The reasons for and aims of the Mental Capacity Act 2005

The Mental Capacity Act 2005 provides a statutory framework which aims to empower

and protect vulnerable people who are not able to make their own decisions. It makes it

clear who can take decisions, in which situations and how they should go about this. It

also enables people to plan ahead for a time when they may lose capacity.

Definition of the Mental Capacity Act

‘Mental capacity’ within the context of the Mental Capacity Act 2005 refers to ‘an

individual’s ability to make a decision’. There are various differing factors which can

affect an individual’s ability to make a decision, including conditions such as a stroke,

dementia, learning disability and physical illness, head injury, drug or alcohol intoxication,

mental health problems, trauma, loss and bereavement. In addition, conditions such as an

intimidating or unfamiliar environment can also affect capacity.

Defining lack of mental capacity

If mental capacity refers to an individual’s ability to make a decision, we can assume that

there may be times when individuals lack the capacity to make a decision; there are

several factors that can influence this. Within the context of the Mental Capacity Act 2005,

a person is deemed to lack capacity if, ‘because of an impairment of, or a disturbance in,

the functioning of the mind or brain’ (which may be temporary or permanent) they cannot

do one or more of the following four things:

1. Understand the information relevant to the decision

2. Retain that information long enough to make the decision

3. Weigh up the information available to make the decision

4. Communicate their decision (whether by talking, using sign language or other

means).

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3.2 Establishing consent for an activity or action

The importance of gaining consent when providing care or support

Consent can be defined as ‘informed agreement to an action or decision’; the process of

consent will vary according to an individual’s assessed capacity to consent. Consent

may be implied, written or verbal.

Individuals can only give consent to treatment if they understand the reasons, the benefits

and any possible disadvantages of the care planned. Withholding information about their

treatment means you are withholding their rights. They are then unable to give informed

consent to their plan of care or be involved in theprocess.

In order to identify and meet the needs and preferences of the individual, it is important to

have as much relevant information and advice as possible, which will be available

through communication and assessment of the individual. Consent should never be

considered a ‘one-off’ event.

It is important that, as a care worker, you establish an individual’s consent to the care and

support you and others provide, and you know how to do this. This is called ‘informed

consent’ and is their legal right.

The consent of the individual is gained for the sharing of confidential information within a

care setting and between care professionals who have the right and need to know.

Continued sharing of this information between care professionals is called ‘implied

consent’, as it is assumed that the individual wishes the care team to continue to share

information, unless they state otherwise. This is justified by the need to share information

that will benefit the individual’s health and wellbeing and ensure their care needs are fully

met.

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Consent can be obtained verbally. This involves clearly explaining to an individual the

reasons for a particular aspect of care and support, establishing their understanding and

receiving their consent verbally. This can be via the spoken word, sign language or by the

use of technology.

Establishing consent using the spoken word requires the care worker to ask the

appropriate question at the appropriate time; for example: ‘would you like a bath?’,

‘shall I run you a bath now?’ or ‘what time would you like your bath?’ which requires the

appropriate answer indicating consent to the activity. If the individual needs to

communicate using sign language, the same questions should be asked using sign

language or cue cards. Care workers should ensure that hearing aids are worn,

switched on and in good working order, prior to asking questions and gaining consent.

In addition, you should explain the use and purpose of the care activity, and any related

equipment, to the individual, establish their understanding and ask them directly if they

wish to proceed. This will give them an opportunity to ask questions and express

concerns or obtain information from other care professionals before deciding whether or

not to consent. You should always record consent and how it was obtained in the care

plan.

Some individuals may be able to understand information verbally, but are only able to

respond non-verbally in the form of gestures, facial expressions and other body language

such as nodding. It is particularly important that you establish the way they convey their

consent and that this is recorded. For some people who are very disabled or

incapacitated, blinking their eyes may be their only means of communication; therefore,

correct interpretation of non-verbal communication is vital.

Written consent

Consent may also be obtained in writing. This is less common in general day-to-day care

and support, but is used to obtain consent for surgical procedures, certain medications,

investigations and treatments. In this case, the individual must be provided with written

information which should be supported by clear and understandable verbal information.

Written consent forms are often used with self-administration of medication following an

assessment of the individual’s abilities. This consent would be reviewed on a regular basis or

as the need arises or where agreed compliance fails.

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Advice must be taken from management who will act on guidance contained in

legislation and organisational policies and procedures.

In certain care settings and with certain individuals, obtaining consent may be more

difficult. This may be because a person has no speech, a lack of insight into their

communication needs, such as people with dementia or those who are unable to

communicate due to an unconscious state. You will need to seek advice and support to

meet the individual’s needs.

A useful guide to consent published by the Government can be seen at:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_10

3653 1_.pdf

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3.3 Explain what steps to take if consent cannot be readily established

Communication Problems

There may be occasions where you have problems understanding an individual’s

communication, or they may have problems understanding you. It is vital that you seek

appropriate support and guidance to resolve this. You must never feel that you should be

able to communicate with, and understand, all individuals, and that if you cannot - you

have failed. All people will, at times, have difficulty communicating with others or making

themselves understood, even if there is no obvious physical or psychological barrier to

communication. If you feel that consent has not been given, or established, then do not

continue with the task, but try to establish why the individual has not given consent. You

could return at a later time and try again, or ask a colleague to gain consent. If all fails

report and record your actions to your manager.

The individual’s care needs may not be met if support is not gained to help them

make an informed decision and give their consent to the planned activity.

Advocacy

This is a process which enables those unable to fully exercise their rights, to have their

rights upheld. It is achieved by representation from a third party. The advocate may be

informal or appointed by the court. When you identify individuals, who may be unable to

exercise their rights, you may be in a position to speak on their behalf. In certain

circumstances this may not be possible, as it may be beyond your role and

responsibilities. You must then ensure that you discuss issues with your manager who

will be able to arrange advocacy services.

It may be possible to enlist the support of an independent advocate to represent the

interests of the individual. If there is conflict of interests between the individual and the

care team, an advocate can make them feel they are being listened to and have someone

on their side. This can have the effect of taking the pressure off the individual, and easing

the tensions that exist between them and the care team. This may result in the lines of

communication remaining open so that a solution, agreeable to all parties, can be

reached.

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Sharing information

Whilst you may fully understand the concept of confidentiality, deciding whether to

share the information that you receive with others, especially when it is of a serious

nature, can be a very difficult decision to make.

Confidential information can be disclosed to an appropriate health care professional, if it is

relevant to the care of that individual. It is justified on the basis that the individual may

suffer if that information is withheld e.g. not passing on the fact that an individual has an

understanding difficulty may result in their needs not being identified.

Individuals giving information in confidence, have a right to expect that it will only be

used for the purpose for which it was given, and that it will not be shared with others,

without their consent.

Care staff are not released from this responsibility, even when the person dies.

You can legitimately disclose information, if you have gained the individual’s consent. If a

person is unable to give consent, the consent of their relatives is often sought, for

justification. However, unless the individual has given a named relative that authority,

there may be little justification for this in law (Dimond 1990).

Determining capacity

A person is unable to make a decision if they cannot understand information relevant to

the decision, retain the information, use or weigh the information to make the decision,

communicate the decision.

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The assessment process

The Mental Capacity Act 2005 sets out the best practice approach to assessing capacity.

The steps taken to initially determine whether a person lacks capacity will depend on the

individual circumstances and the urgency of the decision required to be made, as the

assessment of capacity should be specific to the decision needing to be made at that

particular time. The Code of Practice sets out quite clearly the details that are involved in

assessing an individual’s capacity to make decisions.

The Code of Practice identifies a two stage process to the assessment of capacity, and

identifies two questions that need to be asked.

Stage 1: Does the person have an impairment of, or a disturbance in, the functioning

of their mind or brain?

If this is so, the assessment will move on to stage 2:

Stage 2: Does the impairment or disturbance mean that the person is unable to make a

specific decision when they need to?

The Code of Practice states that relevant information must include:

The nature of the decision

The reason why the decision is needed

The likely effects of deciding one way or another, or making no decision at all.

Assessing and reviewing capacity is not just a one-off event. It is essential that capacity

is reviewed on a regular basis, as people can experience changes in their decision-

making capabilities. Capacity should always be reviewed whenever a care plan is being

developed or amended, at other relevant stages of the care planning process and as

particular decisions need to be made.

Assessing capacity correctly is vitally important to everyone concerned with the Act. There

are a number of reasons for this:

This two stage assessment process has to be followed and the assessor must be able to

demonstrate that it has been.

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A person who is assessed as lacking capacity may be denied their right to make a

specific decision. This is particularly true if others think that the decision would not

be in their best interests or could cause harm

If a person does lack the capacity to make specific decisions, and this has not been

assessed, then that person may make a decision they do not really understand.

This could cause harm to the person or put the person or others at risk

The person who is responsible for undertaking the assessment is accountable for

his or her actions; and the person who does or does not undertake an assessment

at the appropriate time will be called to account for anything that may happen as a

consequence of their actions.

So, we can see it is absolutely essential that an assessment is carried out whenever there

is doubt about a person’s capacity. It is also vital that the person who does an assessment

can justify their conclusions.

Who should assess capacity?

The best person to assess an individual’s capacity to make a decision will usually be

the person who is directly concerned with the individual at the time the decision needs

to be made. This means that there could be different people involved in assessing

someone’s capacity to make different decisions at different times.

Where more complex decisions need to be made, a specialist opinion on the person’s

capacity may be necessary; for example, an assessment may be requested from a

psychiatrist, psychologist, a speech and language therapist, occupational therapist or

social worker. But the final decision about a person’s capacity must be made by the

person intending to make the decision or carry out the action on behalf of the person

who lacks capacity, and not the advising professional.

Any person, regardless of their professional status, who takes responsibility for

assessment, must have the skills and ability to communicate effectively with the

individual being assessed. If necessary, they must engage in professional help in order

that they can communicate effectively with the person.

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4.1 Different ways of applying active participation to meet individual needs

Active participation is a way of working that recognises an individual’s right to participate

in activities and relationships of everyday life, as independently as possible: the

individual is regarded as an active partner in their own care or support, rather than a

passive recipient. This means that the individual should be an active partner in

formulating their care and support plan in addition to participating in activities of their

choice.

Active participation is important to improve feelings of wellbeing and self-esteem. It also

provides an outlet for creativity and help to prevent boredom. Well planned activities can

also help to meet a person’s psychological needs.

Without us offering opportunities and helping people to be occupied, they are likely to

feel the following things:

Useless and worthless

Not valued

That nobody cares about them.

4.2 Working with individuals and others to agree how active

participation will be implemented

This is a situation in which it is very important to find out as much as possible about the

life history of a person in relation to their former work and the way they filled their time.

This will enable the care team to formulate a plan and discuss with the individual, their

family and others, how this will be implemented and how they can actively participate to

gain their consent.

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4.3 How active participation can address the holistic needs of an

individual

Care homes should provide opportunities for this type of occupation. This is relatively

easy for women and, occasionally, some men in the oldest age group, as they would all

have done house work - polishing, dusting, washing up, helping to make the beds,

sweeping, folding laundry, drying up - you will be able to think of a list of things which

count as occupation. The challenge is greater for most men, but it is still possible, with

imagination, to think of activities associated with former jobs - gardening, repairing objects

(e.g. clocks), washing the car, sorting papers, keeping an appointments diary, making

lists of words or numbers. It is important to learn as much as you can about the person’s

life history in order to identify ways in which to keep them busy and linked to their past

work or personal life. It is also vital not to stereotype individuals according to their gender,

e.g. assuming that women/men like certain activities and have certain skills just because

of their gender.

Active participation benefits the individual by providing opportunity for:

Variety and interest in people’s daily lives

Stimulation of specific abilities.

Enjoyment and fun

Opportunities for creative self-expressing

Opportunities to make choice.

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Some barriers to active participation are:

An activity made too easy could make the individual feel like a child

An activity that is too difficult could make a person feel inadequate

Anactivitythatdoesnottakeintoconsiderationtheperson’sculturalneedsandpreferences

An activity that is both costly in time and expense

Not making use of the skills of other people

Not assessing their current abilities

Not completing an assessment on their knowledge and life history.

4.4 Ways to promote understanding and use of active participation

Active participation should only be undertaken with a good knowledge of the

individual’s preferences, past life - including occupation, cultural background and

current capabilities. The individual should be regularly assessed and updates included

in their care plan.

In order to promote understanding and active participation by ensuring the individuals

and others understand and are involved in planning, implementation and review.

Individual’s needs, preferences, ideas and opinions should be listened and responded to

and respected. You as a care worker can act as a role model for colleagues and provide

information and support for them to understand and use active participation.

Some professionals working in health and social care are particularly well placed to

support active participation. An activities coordinator in a care home can tailor activities to

the preferences and interests of residents. A mental health recovery worker can help an

individual with long term severe mental health issues to access community facilities. A

support worker can help individuals with learning disabilities to attend events and

activities of their choice.

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5.1 Support an individual to make informed choices

Rights

A right is something you are entitled to receive. Rights and choices are a vital part of

good practice. You, as a care worker, should be aware of individuals’ rights and choices,

and ensure these are fostered, supported and promoted at all times.

The Human Rights Act 1998

This Act was introduced to comply with European law. The rights it contains were not

newly created in 1998. The rights had been afforded to us in the European Convention of

Human Rights long before that. However, before the 1998 legislation, the remedy for the

contravention of these rights was only available from the European court in Strasburg - a

very lengthy and costly procedure. Since the rights were brought into English law by The

Human Rights Act, the remedy can now be found in the courts of this country.

It is important to note that, currently, the Act only applies to public authorities. This may

change as the courts interpret the legislation or as the Government amends the legislation.

It is unclear how this Act may be impacted in the future by Britain’s exit from the European

Union. The Act contains the following rights:

The right to life

The right not to be tortured, also not to be punished in a degrading or inhumane way

The right not to have to do forced labour

The right to liberty and security of person

The right to a fair trial

The right to freedom from retrospective penalties or laws

The right to respect for family life, home and correspondence

The right to freedom of thought, conscience or religion

The right to freedom of expression

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The right to freedom of assembly and association

The right to marry and have a family

The right not to be discriminated against in respect of these rights and freedoms

The right to peaceful enjoyment of your property

The right to an education

The right to participate in free elections

The right not to be subjected to the death penalty.

Communicating effectively, and developing a trusting relationship with individuals

and those significant to them, is vital if you are to support individuals to make

informed choices.

In order to make choices, it is important that an individual has clear, accurate and

sufficient information with regard to the choice being offered. Also, that they fully

understand the implications of the choice they make and the benefits, disadvantages and

potential risks related to these. It is your role to make information available to the

individual by giving the information verbally in a clear understandable way. You may also

need to access resources, such as written materials, to reinforce verbal information.

Ensure you seek advice and guidance of other professionals to support you and the

individual. Always check the individual’s understanding of the information provided.

The person should be reassured that their right to choose will be respected and they will

be supported in their choice. They should also be given time to consider the choices

available and encouraged to discuss matters with those significant to them. Ensure you

answer questions honestly; give clear explanations and offer reassurance.

Individuals must feel in control of their lives, so being supported to make choices will

make them feel empowered.

Ensuring individuals are aware of their rights and choices, and that these are actively

promoted, will help them to be confident and develop a feeling of self-worth.

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5.2 Using own role and authority to support the individual’s right to make

choices

The right to choose

We all expect that we have a right to choose. Being cared for does not alter this right. An

individual does not lose all ability to do things for themselves, or make choices, just

because they become ‘a patient/service user’. It is important to maintain the individual’s

chosen daily activities, maintain their physical activities and keep the body exercised.

Mentally - it keeps the mind alert

Emotionally - it provides stimulation, interest, a sense of self-esteem and individuality

Socially - it keeps contact with others, and maintains social skills and identity.

Choices may vary from choosing activities associated with daily living, to major life

changing decisions. The care setting/organisation can support choice by

encouraging individuals to:

Choose recreational activities

Choose diet and fluids

Have visitors

Have a say in how the care setting is organised and the type of care they receive

Choose hygiene facilities and standards

Choose to care for themselves

Communicate using their preferred method and language

Choose a preferred place of care.

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Individuals must be supported to identify how they want you to carry out your work

activities. This upholds their right to choose, and will encourage and empower the

individual. You can use your own role and authority to support their right to make choices

by encouraging and advocating for the individual.

They should be encouraged to say what they want, express opinions, and make

suggestions about the care they receive.

The nature of caring means, that at times, you are performing very personal, intimate

tasks. People need to feel as comfortable as possible, so it is essential they feel they

have a trusting, therapeutic relationship with the care worker.

Assisting individuals to access their rights and responsibilities

You, as a care worker, have a duty of care. It is the responsibility of all the care team to

ensure that individuals obtain their rights and are aware of their responsibilities and

choices.

Monitoring, recording and reporting any problems with accessing rights is essential to

ensure individuals’ rights are upheld.

5.3 Manage risk in a way that maintains the individual’s right to make

choices

Care organisations should ensure that all individuals’ rights and choices are respected

by giving them the freedom to take risks. Every day we all take risks. This is something

we are entitled to do, as are the individuals we care for. Generally, we are aware of the

risks we take and we have sufficient information to decide whether we wish to continue

with the activity that carries that risk.

A person-centered approach allows people to have rights and the lifestyle of their

choosing. Sometimes, this may involve them making the wrong or bad choices.

‘Involvement of service users and relatives in risk assessment’: involving the person

concerned and the people that care about them most is one of the most fundamental

tenets of any person- centred approach. The process we have put together considers

carefully the people that need to be involved, using the 'Relationship Circle' to help the

person and their allies identify key people who could form the persons 'circle of support'.

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This group of people is involved from the outset, in the initial gathering of information, in

the framing of what the risk under discussion actually is, in thinking that generates ideas

and solutions, in evaluating these solutions, in decision-making around the risk, in

implementing the actions and in the learning that takes place during these actions. Bates

and Silberman suggest that ‘staff must understand what service users and others want,

how they view their own risks and what responsibilities each person has in managing

risks effectively’ (2007 p7)

(http://www.helensandersonassociates.co.uk/reading-room/how/person-centred-

practice/person-centred-risk-.aspx)

Balancing individual choice with risk

Balancing individual choice with risk is a very difficult issue to deal with, as a person is

entitled to make their own choices in life and therefore their own risks. For example, an

individual with emphysema may decide to continue smoking, despite knowing they are

accelerating the disease process. Even though the risk to the person’s health is

considerable, care professionals have to accept that the individual is entitled to make an

informed choice to take the risk and that they have no power to stop the person taking part

in the activity. The only restriction the care organisation can impose on the individual is

where they can and cannot smoke. Individuals who self-neglect or self-abuse through

choice, have a right to choose, but have a responsibility to those around them. They are

not entitled to make choices that put others at risk. Social Services and other agencies

must become involved to protect all those involved. It is important that you understand

this, as you have a ‘duty of care’ to all individuals and a responsibility to others. You must

report any concerns you have to your manager.

For those who self-neglect or self-abuse through vulnerability, it is important that health

care professionals become involved if that risk becomes so great that the health, safety

and wellbeing of the individual and others, is put at risk.

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Why personal views should not influence an individual’s choices

It is essential that the worker’s views do not influence a person’s choices. It is, as previously

discussed, the individual’s right to make choices. No two people are the same and views,

opinions and choices may differ significantly. However, these differences must be accepted

and respected.

An uneven balance of power exists between care worker and those they care for. The care

worker should never abuse this power by exerting pressure on an individual to influence

their choices.

Individuals must not be pressured into making decisions they are unhappy with, be

denied activities they find enjoyable, or be coerced into participating in

inappropriate or unsuitable activities.

The care worker should not express opinions about the care organisation which

may unduly influence the individual.

5.4 How to support an individual to question or challenge decisions

concerning them that are made by others

Individuals must be supported to challenge decisions concerning them made by

others. These may include:

Care workers

Social worker

Occupational therapist

GP

Speech and language

therapist

Physiotherapist

Pharmacist

Nurse

Specialist nurse

Psychologist

Psychiatrist

Advocate

Dementia care advisor

Family or carers.

Encourage individuals to speak with you; you may be able to discover what is worrying

them. Answer their questions and give information, explanations and reassurance. The

main message the individual will want to hear is that they are in control of what happens

to them, and the care they receive is planned in partnership with them and key people

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involved in their care (such as Social Worker, GP, Pharmacist and specialist agencies).

This will make the person feel empowered and they may be more willing to accept the

care they need.

Assist to complain

Encourage questions and comments

Be prepared to listen

Assist the individual to ask for a second opinion

Speak on behalf of the individual or refer the individual to a senior member of staff

Use and follow the complaints procedure.

Complaints procedures

It is vital that individuals are not only provided with a Charter explaining their rights and

responsibilities, but that they are provided with information about how to comment on

care services and complain, if they feel their rights are being withheld. Care workers

should also be made aware of the complaints procedure, to enable them to make a

complaint themselves, if they feel this is necessary, or to assist a person to complain.

Some individuals may benefit from advocacy services (as discussed in Unit 01). Care

workers (especially senior staff) may be involved in giving individuals information about

advocacy.

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6.1 The links between identify, self-image and self-esteem and wellbeing

Wellbeing is what we all need to make life worth living. In order to maintain wellbeing, we

need to recognise whole care needs, know the individual’s life history, ensure our

approach is person-centered and focuses on treating a person as an individual, whilst

preserving their identity and maintaining self-esteem. The person who is experiencing

wellbeing will:

Be able to communicate with others

Express their wishes

Form meaningful relationships

Show pleasure and enjoyment

Have a strong sense of self/personal identity

Have a sense of purpose

Show signs of self-respect.

Being valued and respected as an individual with a distinct identity will promote feelings of

self- worth and maintain self-esteem. This will result in the preservation and maintenance

of wellbeing. In 2008 the Government’s Foresight Project Mental Capital and Wellbeing

Project commissioned the New Economics Foundation (NEC) to identify ways in which

people could incorporate more wellbeing activities into their lives. The evidence suggest

that even quite small improvements in wellbeing can decrease some mental health

problems and help people to live more fulfilling and contented lives.

The NEC recommended that people build on the following five areas:

Connect - for example ensuring opportunities for social interactions

Be active - for example exploring the possibilities for physical activity

Take notice - finding opportunities to enable people to take notice of the environment

and what’s happening around them

Keep learning - for example finding out about something that the person is curious

about or learning to do a small daily task

Give - for example giving a smile, a compliment or encouragement to someone

As a care worker you can help those you care for to identify what is important to

their own wellbeing and discover ways of building positive actions into their daily

lives.

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You can find out more about the 5 ways to wellbeing at:

Website: www.neweconomics.org/programmes/wellbeing

Identity and self-esteem

Subjective feelings

It must be remembered that individuals do not always view things objectively and that

feelings are very subjective. It may not always be possible for individuals to view things in

the way that others see them, or experience feelings as others believe they should.

A care worker may be working very hard to meet an individual’s needs, carrying out all

care interventions to a very high standard, in a pleasant, polite way, only to be met with

anger and resentment from the individual. Even though the individual realises that the

care worker is trying their best and that they should be polite to them, all they may feel is

resentment, frustration and anger at their situation. Similarly, even though the care

worker may understand the individual’s feelings and that the anger directed at them is

not personal, they may still feel hurt, undervalued, or even angry.

Therefore, it is important to understand that feelings are subjective, even when we can

understand how we should feel, we may not feel that way. Feelings are as individual as

we are.

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Maintaining appropriate professional relationships with individuals

You must be aware of the boundaries of your relationship with individuals. Forging a

close friendship or intimate relationship, delving into their private life, or making

personal comments or remarks, is unacceptable. The person may be made to feel

uncomfortable and anxious. A relationship that is inappropriate makes individuals

vulnerable; it breaches your contract of employment and legislation. An appropriate

therapeutic relationship will enable you to carry out your work activities effectively.

There needs to be an acceptable balance of power in any relationship. Vulnerable adults

need support and not to be told what to do. The partnership begins when individuals are

encouraged to make their views and choices known during assessment. They have a

right to be listened to and to be given the opportunity to express themselves. By being

given the chance to identify their preferences, they are retaining an element of control in

their lives. This boosts self-esteem and self-worth; they have a degree of independence

and involvement in the decision-making process relating to their lifestyle and choices.

6.2 , 6.3 and 6.4 Factors that contribute to the wellbeing of individuals

When considering how to help the individual feel, think about how you make yourself feel

at home in your own house.

Physical environment

In some care homes the building looks more like a hospital or a hotel, with long corridors

and lots of doors, rather than an actual ‘home’. Although staying in a hotel can feel quite

nice for a few weeks, imagine having to spend the rest of your life in a hotel. To promote

wellbeing it is important that the environment looks homely. You can achieve this by the

following:

The environment should be well decorated and well maintained

Have a homely atmosphere

Be clean and odour free

The visual environment should be well lit, and have useful and helpful signposting

The visual decor and furnishings should be sympathetic to the building, wall

pictures and furnishings should be homely to avoid an institutional look

Have safe and secure access to the outside

Noise levels should be appropriate and allocated quiet areas should be provided.

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It is important that people are encouraged to personalise their own space. This could

include:

Individual’s own belongings in their room, with bed linen and soft furnishings chosen

by them

Cherished objects e.g. family photographs, ornaments etc.

A favourite chair

Favourite flowers from the garden.

A person can gain comfort from items which seem to have no importance to us. What

matters is not what the item is, but how it makes the person feel.

The environment in the individual’s own home should also be considered. Their home may

have undergone considerable changes to accommodate their needs. This could range

from rearranging furniture, moving their bed and bedroom furniture to a downstairs room,

to major alterations. Aids and equipment could also be in place. This may make the

individual feel that their home no longer feels ‘homely’ and that they are losing part of their

identity.

It is important that any changes involve the individual, and that they are able to give

opinions and make decisions. Fixtures and furnishings should be the person’s choice and

where the individual wishes personal items to be displayed. Access to items, such as

handbags, is extremely important, as removing these may make the person feel anxious

and insecure.

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Social and emotional environment

Life is far more pleasant and the time spent in another’s company far more rewarding, if

people feel valued and respected. Forming a good relationship will help individuals

socially, mentally and physically. Good, honest and open communication with people

creates a positive, therapeutic atmosphere, and high standards of care reflect this.

In order to create a positive social and emotional environment, it is important that you:

Maintain dignity and respect at all times

Encourage expression of needs, wishes and preferences, and endeavour to meet

these

Create relaxed, sociable occasions which will give the individual time to build

relationships

Having a cup of tea with the individual could give opportunities to build relationships

with yourself, the individual and others

Treat the person as an individual

Modify the level and pace of your communication to suit the individual

Use appropriate and respectful language.

Being cared for probably makes a person feel very vulnerable. Encourage individuals and

their family/carers to speak with you, answer their questions and give information,

explanations and reassurance. The main message the individual will want to hear is that

they are in control of what happens to them, and that the care they receive is planned in

partnership with them and key people. This will make them feel empowered and they may

be more willing to accept the care they need.

Attitudes and approaches that are likely to promote an individual’s wellbeing

Care plans should be developed in partnership with the individual and a person-centered

approach used to meet the individual’s whole care needs, wishes and preferences.

These may include:

We all need:

Physical care that is personal and offers individual choice

Emotional care that is sensitive to our feelings, individuality and past life

Social care that is relevant to how we spend our time in an individually meaningful ay

Spiritual care that is respectful of the meaning to our lives

Cultural care that respects our identity

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Religious care that respects our beliefs

Care that promotes mental health

Sexual care which recognises our sexuality in a sensitive and respectful way

Political care which is sensitive to our views and opinions.

It is important to promote the wide range of medical and social approaches that can help

maintain a person’s self-esteem.

Focusing on the Individual

The focus of all approaches is to assess an individual’s needs and preferences. A

therapeutic approach towards an individual focuses on seeing the person as a ‘whole

person’ and considers how to offer opportunities wider than meeting just their physical

needs, which will enhance someone’s wellbeing. As a care worker this is an important

part of your role and it would be useful to talk with your manager and colleagues about

how the care setting where you work aims to provide all of these approaches to meet the

holistic needs of the individual. Without being aware of it, care workers make judgments

about what the people in their care are thinking and feeling all the time. They often base

these judgments on guesses and hunches, and on what they have been told about the

person by someone else. It will be better for all concerned if care workers learn to base

their judgments on careful observation of the person.

Adopting a strength-based approach

Despite a person’s illness, disability or other limitations, they will still have many strengths

and abilities. It is the role of the care team to identify these and work with the individual to

develop a strength-based approach/plan to build on strengths and minimise weaknesses,

in order to maintain wellbeing.

Attitudes

It is extremely important to an individual’s wellbeing that care workers’ approach towards

them is supportive and that they are treated equally and with respect. The person should

be treated with unconditional positive regard. This means a person is accepted and

respected by others, regardless of their condition. It is vital you recognise that you have a

‘duty of care’ to all individuals, regardless of their race, sex, religious background and

apparent lifestyle choices. The service you provide should be delivered equally and

inclusively.

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A care worker who demonstrates a polite and willing attitude, and provides open and honest

communication, whilst maintaining privacy, dignity, confidentiality and choice will create

feelings of self- confidence and self-worth- a relationship which truly values the individual

and maintains their dignity.

7.1 Different uses of risk-assessment in care settings

A person-centre approach to care means that an individual is free to make their own

choices. Sometimes they may make risky choices (such as engaging in dangerous

activities, putting themselves in situations where they are vulnerable or declining

treatment). In care settings risk assessment is needed to balance the rights of the

individual to make choices with the organisation’s duty of care to avoid harm to the

individual. Risk assessment means identifying the potential hazards in a situation or

associated with particular behaviour and evaluating the risk of harm.

You may be familiar with different uses of risk assessment in care settings, such as

those related to infection control, manual handling and safe handling of medication.

These are general risk assessments used for everyone’s benefit in the care

environment. By contrast, a more individualised approach to risk is needed to enable a

person-centered approach to care. Different risk assessments will be needed for each

individual and for each one:

Risk assessment helps to identify risks and hazards involved in the individual’s

choices

Risk assessment helps to protect the individual by helping staff to balance the need

to respect the person’s choices with safety concerns

Riskassessmenthelpsstafftoidentifyrisksandhazardsandshowthattheyhavegivendue

consideration to enabling the individual’s choices whilst trying to avoid harm.

Pritchard (2003) has done some excellent work on risk assessment and she

advises asking several basic, but important questions:

What does the service user want to do?

What will they get out of taking the risk?

What might stop the service user getting the benefits, or cause the dangers?

What is the worst that can happen?

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Pritchard then describes the ‘principles of risk’ as being:

Self-determination - capable of making decisions, living life to the full

Independence - striving to maintain or improve

Service user focus - wishes should not be over-ridden by others

Equal Opportunities - not to discriminate e.g. on the grounds of age

Confidentiality - information may have to be shared

Staff support - must be supported by policies.

Pritchard then goes on to consider the ‘key stages’ of risk assessment. These are:

Getting to know the service user

Talking with the service user about risk-taking

Liaising with others

Completing paperwork; for example, risk assessment forms

Predicting likelihood of harm or danger

Grading the level of risk (is the risk high, medium or low)

Developing the care plan

Setting a date for review.

7.2 How risk taking and risk assessment relate to rights and

responsibilities

We have a duty of care to carry out risk assessments in order to attempt to balance risk-

taking, rights and responsibilities. We assess what the risk is and what measures can be

implemented to try to reduce the risk. There may be occasions however, when it is not

possible to reduce or eliminate the risk and the individual has to be able, and has the right,

to make the final decision regarding whether to take the risk. There are also occasions

when, following assessment, we, as health care workers, identify risks that individuals may

not have considered for themselves, including, for example, the risk of developing a

pressure ulcer. Our communication and explanations in these instances is of utmost

importance.

Person-centered care focuses on the rights of the individual to make choices. However,

individuals have responsibilities too. Within a care context, although person-centered care

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encourages individual’s rights, there is a need to respect the rights of others too. Care

workers may be involved in situations where a person’s choices adversely affect other

service users so compromises must to be made. An individual who chooses to smoke for

example might be asked to do so away from other service users and a risk assessment

would need to consider factors such as the potential fire hazard.

In practice, enabling individual’s choices as part of person-centered care is not

straightforward due to the impact of their choices on themselves and others. There can

be a conflict between the rights of one individual and the rights of others. There can also

be a conflict between the organisation’s intention to enable person-centered care and

their requirement to reduce risks and hazards.

7.3 Why risk-assessments need to be regularly revised

Risk assessments need to be regularly revised to keep up with changes in care settings.

The needs, choices, behaviour and environment of individuals in care settings can

change frequently and risk assessments need to reflect that.

In addition, employers are required by the Management of Health and Safety at Work

Regulations 1999 to assess the risks to the health and safety of their workforce. This

helps to protect workers from hazards and risks in the workplace.

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Conclusion

The information you have read within this unit should increase your knowledge and

understanding which will benefit you, the individuals you care for, key people and others.

Now complete the assessment questions for this unit in the workbook section.