Resources

Helpful Websites

Living well in care homes, a toolkit from the British Association and College of Occupational Therapists

Torbay Dementia Action Alliance

Useful Links from The Purple Angel

National Association for Providers of Activities for Older People

Article: Mattering in a dementia care home – The Butterfly Approach (pdf)

Alzheimer’s Society

Dementia Friends

Musical Reminiscence

Sing for Your Life

Animal Activity

Inner Beauty, Devon

Soprano Eventi

Carnation Films

The Daily Sparkle

 

Best practice guide: How to make the most of group work opportunities

This best practice guide is targeted at staff in elderly residential settings.

Download the pdf of the guide

 

Article: Establishing an activity culture in care homes

OT News, March 2015

Heather Manktelow explains how she is sharing knowledge, skills and best practice around activity provision in an attempt to try to raise standards of activities in care homes.

Download the pdf and read the article

 

Article: Activities In Care Homes Don’t Need To Be Costly But Are Priceless

Author: Heather Manktelow, Occupational Therapy BSc(Hons), Therapeutic Activities Specialist (Activities for Health), experienced in facilitating therapeutic activities in a range of care homes and in the community.

”Focusing on the importance of activity provision in care homes, promoting cost-effective personalised activities using a whole-team approach”

Author note

Why not download this article as a pdf and print it for a care home staff-room that you know, and help to make a change? You are welcome to contact the author to discuss the themes.

Introduction

The College of Occupational Therapy (COT) and The National Activity Providers Association (NAPA) have been working very hard for many years now to raise the profile of the importance of person-centred activity provision in care-homes. They evidence through a whole body of work that activities are beneficial to people, and now, finally the topic is gaining the recognition and attention it deserves. The Alzheimer’s Society’s “Home from Home” report states  “Availability of activity is a major determinant of quality of life and affects mortality rates, depression, physical function and behavioural symptoms” (2007,p5). The National Institute for Health and Care Excellence (NICE) states ”A lack of activity and limited access to essential healthcare services can have a detrimental impact on a person’s mental wellbeing” (2013,p1).

The COT, NAPA and Skills for Care have been collaborating and working really hard together to provide extra resources and training to promote activity provision in Social Care. They have been working with training companies to promote the vocational (QCF Levels 2 and 3) qualifications in “Supporting Activity Provision in Social Care” and recruiting Occupational Therapists to deliver, assess and mentor, carers and activity organisers through the courses. NAPA also offers these vocational qualifications and is committed to ensuring that “Activity is at the heart of care for older people” (NAPA, 2014). The COT has compiled an excellent resource “Living Well Through Activity in Care Homes: the Toolkit” which gives ideas to provide an activity service focused on residents’ needs, preferences and activity choices. It is available to download free from their website (College of Occupational Therapists, 2014).

Care Quality Commission inspectors already look for evidence that individuals’ needs are being promoted including physical, mental, social, personal relationships, emotional and daytime activity (CQC, 2010). They presently feel that there is room for improvement on finding out how people like to spend their time, provision of choices of activities and options for people to support their independence – particularly for people with dementia (CQC, 2013, p.6). The Care Quality Commission Strategy 2013 – 2016 “Raising Standards – Putting People First” proposes a number of changes to raise standards in health care. It pledges to improve inspections, ensuring that services provide a safe, effective, caring environment, are well-led and responsive to peoples’ needs. It states “We will work closely with our partners and the National Institute for Health and Care Excellence (NICE) so we are clear about the measures we use in our assessments” (Section 1, p.9). CQC has also been collaborating with NAPA on ideas for improvements of inspections of meaningful activity. NAPA have suggested that carers should be asked to explain to inspectors why residents sit where they do in a care-home, and how residents spend their day.

By working collaboratively all these organisations are now far more influential, and finally NICE has recognised the importance of their work; in December 2013 it issued a new Quality Standard (QS50) titled ‘Mental Wellbeing of Older People in Care Homes’. This calls on care homes to provide spontaneous and planned opportunities by trained staff during the day allowing residents to engage in meaningful activities of their choice, involving family and friends if the resident wishes, helping residents to express themselves and maintain their personal identity. This means that for the first time, activities in care homes will be regulated and this must be a catalyst for change.

Are commissioning agencies, owners and managers of care homes really taking it on board?

There is little doubt that some care homes are working very hard to offer person-centred activities to their residents. Since these homes believe in the importance of activity provision to keep their residents active and healthy, which ultimately promotes their independence; they employ an Occupational Therapist (OT), or Activity Organiser and allocate a specialised budget for activity provision.

There are some excellent examples of practice. In particular, David Sheard from Dementia Care Matters is helping to change culture in dementia care homes and there are currently 56 homes in the United Kingdom known as Butterfly Service Homes adopting the Feelings Matter Most model of care:

“Feeling you matter is at the core of being a person. Knowing you matter is at the heart of being alive. Seeing you matter is at the centre of carrying on in life” (Sheard, 2013 p.2)

However there is another side to the coin; in comparison, the Alzheimer’s Society’s “Home from Home” report found that the typical person in a care home spent only two minutes interacting with staff or other residents over a six hour period of observation, excluding time spent on care tasks. Also that some people with severe dementia had been left alone in their room for hours with no attempt from staff to engage with them (Alzheimer’s Society, 2007). These statistics are horrifying, but the recent policy changes will affect the way activities are inspected in care homes which will drive up standards. Training along with a whole-team approach will help raise standards of activity provision in care homes.

Funding

There are long term cost-benefits of keeping people active. NICE states “extra training of existing staff may involve additional staff costs, however it could result in decreased numbers of visits to secondary care in general which could represent an overall saving for healthcare services. Potential savings include reductions in attendances at Accident and Emergency Departments and non-elective hospital admissions” (2013, p5).  Also if a care home becomes known for good and plentiful activities, it is a good advert for the home and something that relatives look for when considering a care home for their loved-one.

Activities are just as important as personal cleanliness, comfort and safety of residents. Funding is always an issue… nevertheless, care homes must address the challenge. They must realise the importance of quality person-centred planning, delivery and documentation of a range of activities. Occupational Therapists are the experts, but not all homes can afford one and instead employ an Activity Organiser.

Care homes must provide a budget for activity provision; some care homes do not, which means that activities revolve around producing crafts, cakes and events to raise funds rather than activities specifically being planned and chosen by the residents. Therefore even homes with an OT or Activity Organiser can fall short when it comes to personalisation if they are not allocated a budget to work within.

Activity provision doesn’t have to mean large extra financial outlay if a whole-team approach is used… just a change of attitude and culture within the home. It doesn’t cost anything for staff to be regularly communicating (verbal/non-verbal) with every resident.  Activity provision doesn’t need to be expensive, but it is ‘priceless’ in terms of benefit to wellbeing. Staff and relatives need to be encouraged to share their talents for example singing, playing an instrument or other hobbies. Relatives need to know that they are welcome, and should be encouraged to join in with activity sessions and also to engage in 1:1 activities with their loved ones on visits to the care home. Also to bring in meaningful items from home such as photograph albums and memory boxes to look through together. Keeping links with the community are valuable and don’t need to cost money. Trips out walking in the locality, to art galleries and museums or visits from a local priest are examples. It may be the case that not all residents can go out on trips so it is beneficial to bring in outside entertainers (which needn’t be at great expense), in which case the OT or Activity Organiser and carers should stay in the room and help the residents to become actively involved. Some residents are not as outgoing as others and need extra encouragement to sing along or get up and dance. If residents are actively engaging it makes the cost worthwhile. Even those residents not obviously actively engaging are likely to be getting enjoyment from listening and watching others, so there is definitely value in booking outside entertainers; but they should be chosen carefully and with input from the residents.

Occupational Therapy Theory and Philosophy

The heart of Occupational Therapy philosophy is that all people share an innate occupational nature which exists in the framework of environment and time. Time reveals itself as a vacuum, inviting us to fill it with ‘doing’. Without activity time weighs heavily on us. Therapy enables people to engage in activities and occupations that provide meaning and satisfaction and that support their physical and emotional well-being (Kielhofner, 2007).

If people are bored and have no or little opportunity to engage in activities it affects their whole being: they may become depressed, give up on life, and ultimately may retreat inside themselves, withdrawing from their social network and environment. If people become depressed it affects their motivation to engage in activities, which can impact upon activities of daily living (getting washed, toileted, dressed and feeding themselves). When residents become less able through lack of motivation, it means that carers do more and more for the resident which can have an effect of de-skilling and reducing independence. Carers and other staff must use skills to motivate and encourage residents to continue to do as much for themselves for as long as possible. With the right approach from staff, even activities of daily living can be made into pleasurable activities rather than tasks. If carers are bright and cheerful, and promote the sensory aspects, any task can be a meaningful and pleasurable ‘activity’. For example encouraging the resident to notice and smell the lovely coconut aroma of the soap, singing to and with the resident, bringing some fun into it, taking the resident to the window and discussing the weather and what can be seen, encouraging them to feel the fabrics and choose what they want to wear. If residents have cognitive failings, the Pool Activity Level (PAL) Instrument is very helpful in assessment and guiding carer support at the appropriate level for each individual (Pool, 2012).

Assessment and Planning

Activity assessment and planning needs to be done in discussion with the resident, involving the family and intermittently reviewed. Every resident must have an activity plan. It should include:

  • Personal History
  • Interest Checklist
  • Medical conditions and any sensory, physical or cognitive difficulties
  • Risk Assessment
  • Outcome Measures

Putting It Into Practice

There are many aspects of therapy, the complexities of which are not always appreciated by the lay-person and the team may require training to appreciate the aims, objectives and risk assessment of activities that they deliver, and to help residents reach their full potential and well-being. Research shows that when staff are given such training from an OT it raised their understanding and interest in the importance of graded activities that are appropriate to each resident’s ability and interests (Boyd et al, 2014). Occupational therapy promotes balance, motor, sensory, perceptual, cognitive, intrapersonal and interpersonal skills, spirituality, self-confidence, self-esteem, mood, and independence to name a few. Through engagement in graded activity, it helps to keep residents mobile and flexible, thereby promoting independence and control. For example, ball games keep arms flexible which helps a resident retain the ability to raise an arm to brush their own hair.

Residents who want to, should be included as much as possible in daily routines for example folding paper napkins, laying tables, sweeping up, clearing plates away, washing up etc. Meaningful activity is all about correct activity care-planning and finding the ‘right fit’ for individuals; not everyone will want to help with domestic chores, but for a lot of ladies, this was their life role – and is still enjoyable and meaningful to them. Generally residents of all ages like to be active and feel that they are helping-out.

Participation in activities needs careful observation and documentation in the individuals’ care plans. During activity sessions carers should be helping the OT or Activity Organiser… by staff losing their inhibitions and getting enthusiastically involved in activities, it encourages the residents to do the same… nobody wants to be the only one dancing on the dance floor! Carers in care homes have a difficult job and most of their time is taken up being involved in direct care tasks and observing people to ensure safety, but if everyone in the staff team makes even a small change in the way they work, it can make a large change overall.

A skilled activity facilitator makes activity provision look easy but it can be draining, especially when giving so much of themselves to encourage and motivate residents to engage in activity. With hard work, good communication skills, determination and correct activity planning to explore graded activities that are meaningful to each individual, the most reluctant of residents can be supported to enjoy activities even if in their own discrete way. This also applies to residents who cannot verbally communicate and therefore who some inexperienced people may perceive can’t ‘do’ activities, for example in later-stage dementia or stroke. Some residents just need more patience and skill than others who readily join in. When people can no longer join in with the more complex activities on offer, sensory stimulation/therapy can still be enjoyed by all so it is a very important aspect to bring into activity planning. Some examples are aromatherapy hand massage, music, singing, rhythm, movement, taste, touch, stroking animals and use of bright colour. The environment should also contribute towards interest and sensory stimulation, providing opportunities for hands-on engagement for example ‘rummage boxes’ of items for people to explore. Some homes also incorporate rooms or ‘stations for reminiscence’ such as a pub, café, music room or book library.

Support for the Activity Organiser

OTs and Activity Organisers in care homes sometimes find themselves to be disregarded by the care home team which can be very de-motivating and de-moralising. This attitude needs to be changed in care homes, and to be cascaded down from the owners and managers. They must make clear at job interviews, in job descriptions, at staff meetings and supervisions that EVERYONE is an activity facilitator, and must work as a team to support the OT or Activity Organiser (if there is one). Activity organisers should receive ongoing training and supervision sessions to help them to define aims, objectives and outcomes of activities and to give them the underpinning knowledge and skills for their role. Those who deliver activities in care homes should be appreciated, respected and supported because they contribute so much to health, well-being, spirituality and quality of life for the residents. They need to be supported to avoid possible ‘burn-out’.

When You Get It Right…

The following two examples help to evidence the benefits of activities.

At a mental health and dementia Nursing Home in Devon the residents chose that they wanted to remember stories from the bible. They were supported by the Occupational Therapist to re-create the story of Adam and Eve. Residents helped to make the props and took parts in the play-let, and the local priest was involved. A resident’s comments demonstrate what he got out of the activity:

“Fabulous. The best bit was the way people smiled and laughed – it set people free. If you are able to smile and laugh it frees you from your troubles. People have been taught religious stories in a light-hearted way before and it works… I’m sure Jesus laughed. Singing the hymns also set me free. I have troubles, I guess everyone has but whilst I watched the show I forgot about them. It’s nice to remember the stories from the bible.”

At the same Nursing Home, a comment from the daughter of a resident demonstrates the difference that personalised activities can make to a person’s life:

“I think that activities in a home can be very under-valued by management, other members of staff and visitors. Too many people have the attitude that those with dementia aren’t worth bothering with or that ‘where’s the point they won’t remember in a couple of minutes’. Some people don’t seem to realise that when a person is made to feel ‘Happy’ even if they can’t remember why they feel ‘happy’ the wonderful feel good factor can stay with that person for a long time.

When you are just sat in a home and there is almost nothing going on around you, you switch off into a world that is a very sad and lonely place. Therefore being part of an activity is so important.

I think my Dad benefits from your visits because you bring LIFE into his life. You treat him as an individual who has needs, and who needs to know he matters. Your activities make him ‘Happy’.  They make him feel that he is ALIVE and that someone cares. 

Being part of an activity also allows him to be part of a bigger picture giving him a sense of belonging. You found out what his likes and dislikes are and provide him with stimulation to suit his needs. Besides football Dad loves music, singing and dancing. You found that out. Dad has lost the ability to have a conversation but you found that you can communicate with him and make him happy by singing with him. You always make him smile.  Thank you so much.”

Conclusion

This article has explored some of the benefits, complexities and barriers to person-centred activity provision in care homes using a ‘whole-team’ approach, and has given some sign-posting to resources promoting good practice. Activity is at the heart of the Occupational Therapy profession. Presently, there are few Occupational Therapists employed in care homes but it is an emerging role for Occupational Therapists and it makes total sense that Occupational Therapists – specialists in activities, should be playing a larger part in training, guidance and leading the way to ‘getting it right’. Every individual in every care home deserves to be given opportunities to engage in meaningful activities of their choice as a right not a privilege.

Resources

College of Occupational Therapists College of Occupational Therapy (2013). Living Well Through Activity in Care Homes: The Toolkit. Available at http://www.cot.co.uk/living-well-care-homes. Accessed on 02.02.2014.

National Activity Providers Association. Available at http://www.napa-activities.co.uk/default.asp?contentID=517. Accessed on 27.02.2014.

Pool J (2011). The Pool Activity Level (PAL) Instrument for occupational profiling: a practical resource for carers of people with cognitive impairment, 4th ed. London : Jessica Kingsley.

Sheard D (2013). Mattering in a dementia care home – The Butterfly Approach, Dementia Care Matters. Available at http://www.dementiacarematters.com/pdf/modern.pdf. Accessed on 27.02.2014.

References

Alzheimer’s Society (2007). Home from Home: A report highlighting opportunities for improving standards of dementia care in care homes, 4.1 Lack of activities and occupation, p. 5.

Boyd et al (2014). Bored to death: tackling lack of activity in care homes. British Journal of Mental Health Nursing 16 (2), 98-102.

Care Quality Commission (2010). Guidance about Compliance: Essential Standards of Quality and Safety, p.64.

Care Quality Commission (2013). Time to Listen In Care Homes. Dignity and Nutrition Inspection Programme 2012, Summary, p.6.

Care Quality Commission (2013).  Raising Standards – Putting People First – Our Strategy for 2013 – 2016. Section 1, p.9. Available at http://www.cqc.org.uk/sites/default/files/media/documents/20130503_cqc_strategy_2013_final_cm_tagged.pdf. Accessed on 28.03.2014.

Kielhofner G (2007). Model of human Occupation: Theory and Application. Fourth Ed. Edinburgh, Lippingcott, Williams & Wilkins. 

National Institute for Health and Care Excellence (2013). Quality Standard 50: Mental wellbeing of older people in care homes. Quality Statement 1: Participation in meaningful activity. London: NICE. Available at http://publications.nice.org.uk/mental-wellbeing-of-older-people-in-care-homes-qs50/quality-statement-1-participation-in-meaningful-activity. Accessed on 27.02.2014.