Facilitator Guidance and Checklist
for Portfolio Evaluation
NAME OF CARE HOME………………………………......
ADDRESS…………………………………………………………….
DATE COMPLETED………………………………………..……….
FACILITATOR/EDUCATOR………………………………………..
CARE HOME MANAGER…………………………………………..
This guide is to support the facilitator assessing the portfolio to ensure essential evidence is included. The portfolio of evidence can be used to showcase the implementation of the Six Steps to Success programme.
The portfolio clearly needs to reflect that the care home has included evidence from practice which can be directly linked to the Quality Markers and Measures for end of life care and the Care Quality Commission (CQC) standards. The portfolio remains in the care home and can be shared with commissioners, Local Authority monitors and CQC.
Creativity is encouraged; however the facilitator would need to see that essential criteria are included. It does not prohibit the care home from including other relevant information as detailed in the care home portfolio of evidence guidance.
There are no marking criteria as the assessment should be seen more as a supportive process. The aim of the facilitator reviewing the portfolio is to identify any gaps and work with the care home to implement what is needed by compiling an action plan together with identified timelines and then support the care home to implement and produce the evidence required.
Once the facilitator is satisfied the care home has implemented the programme fully and the evidence is included in the portfolio the care home certificate can be presented. The certificate confirms that at that moment in time, the home has implemented the programme and supplied the evidence. The care home manager must sign the certificate to agree the programme has been implemented and that the care home will sustain the programme in the future.
This guidance supports the facilitator assessment to ensure the essential evidence is included in the portfolio based on the implementation within the care home. There is a column for you to record all other pieces of evidence the care home has provided.
You may want to keep a final completed copy of the checklist in the portfolio as a care home record to evidence what was included at that time.
PLEASE ENSURE YOU KEEP A COPY FOR YOUR OWN RECORDS
N.B. To maintain confidentiality all examples of information in the portfolio with resident information on must be anonymous.
Step 1
Discussions as the end of life approaches
Not all care home residents are in the last year of life. The first step on the route to success is about identifying residents who are thought to be in their last year of life so that discussions around end of life care and advance care planning can be initiated.
Topic / Minimum Evidence Required / PO / Further evidence provided /1.1
There is a policy or action plan developed within the care home for end of life care / QM 5.1 Care Home Policy - End of Life Care
- Should include all components of the Six Steps Programme
- Copy of care homes Philosophy of Care
1.2
There is a system in place for identifying residents in the last year of life / QM 5.3 Supportive Care Record
- Photocopy of the populated record used in practice with patient details anonymised
- Evidence of a team approach to the Supportive Care Record – could include minutes of meeting (including MDT)
- Documentation in residents notes
- Use of the North West Model
1.3
All identified residents and their families are involved in discussions around end of life care to the extent they so wish / QM 5.2 and QM 5.6 Implementation of Advance Care Planning
- Anonymised Advance Care Plan
- Evidence of how residents and families are offered advance care planning discussions
- Examples of literature used, e.g. ‘Planning for your future care’
- Evidence of best interest decisions where the resident lacks capacity
Step 1
Discussions as the end of life approaches
Topic / Comments /1.1
There is a policy or action plan developed within the care home for end of life care
1.2
There is a system in place for identifying residents in the last year of life
1.3
All identified residents and their families are involved in discussions around end of life care to the extent they so wish
Step 2
Assessment care planning and review
The second step on the route to success is about the early assessment of a resident’s needs and wishes as they approach the last year of life. The aim is to establish their preferences and choices as well as identify areas of unmet need. It is important to explore the physical, psychological, social, spiritual, cultural and environmental needs and wishes of each resident.
Topic / Minimum Evidence Required / PO / Further evidence provided /2.1
There is a system in place to discuss, record and communicate the wishes and preferences of those approaching the end of life / QM 5.2 and 5.3 Evidence of holistic assessment (anonymised)
- Photocopy of a completed holistic assessment
- Photocopy of completed assessment tools used may include Spiritual, HAD, etc.
- Care plan reflecting holistic assessment
- Examples of completed documentation used to share information, e.g.
- out of hours
2.2
The needs of residents are assessed and reviewed on an ongoing basis / QM 5.3 Regular review
- Evidence of regular review of needs (updated care plan, documentation)
- Evidence of ongoing communication with resident and/or family
- Documentation
Step 2
Assessment care planning and review
Topic / Comments /2.1
There is a system in place to discuss, record and communicate the wishes and preferences of those approaching the end of life
2.2
The needs of residents are assessed and reviewed on an ongoing basis
Step 3
Co-ordination of care
The third step is about co-ordinating services. Once a care plan has been agreed it is important that all the services required are effectively co-ordinated. A lack of co-ordination can mean a resident’s needs and preferences are not met.
Topic / Minimum Evidence Required / PO / Further evidence provided /3.1
There is a robust communication system in place to ensure all staff members and external health and social care professionals are fully informed of the plan of care / QM 5.2 Sharing information
- Evidence of North West End of Life Care Good Practice Guide in use
- Photo copy of a completed Review Sheet used in practice with patient details anonymised
- Identified member of staff coordinating and communicating care
- List of key contacts readily accessible
- Evidence of communication with multidisciplinary team e.g. out of hours, GPs, Macmillan Nurses and District Nurses
3.2
There is a nominated key worker for each resident approaching the end of life / QM 5.4 Key worker
- Photocopy of the actual Supportive Care Record used in practice showing identified key workers
- Documentation demonstrating how the key worker has acted as a link between services
3.3
There are systems in place to respond rapidly to changes in circumstances as end of life approaches / QM5.3 Anticipatory prescribing
- Documentation demonstrating that the need for anticipatory prescribing has been identified
- Evidence that anticipatory prescribing has been addressed
- Completed North West End of Life Care Review sheet
- List of chemists stocking end of life care drugs
Step 3
Co-ordination of care
Topic / Comments /3.1
There is a robust communication system in place to ensure all staff members and external health and social care professionals are fully informed of the plan of care
3.2
There is a nominated key worker for each resident approaching the end of life
3.3
There are systems in place to respond rapidly to changes in circumstances as end of life approaches
Step 4
Delivery of high quality care in care homes
Residents and their families may need access to a complex combination of services across a number of different settings. Step 4 on the route to success is about the delivery of high quality care and the expectation that residents should receive the same level of care regardless of whether they live independently at home or in a care home.
Topic / Minimum Evidence Required / PO / Further evidence provided /4.1
How to access a combination of complex services 24/7 / QM 5.12 Contact list
- Copy of contact list and statement where the list is accessed in the care home
- Example from care home documentation of accessing services
- Examples of outcomes of accessing services in the care home documentation
4.2
There is a process in place to identify the training needs of all workers especially those involved in discussing end of life care with residents, families and carers / QM 5.3, 5.9, 5.10 and 5.11 Care home training needs
- Care home end of life care training plan.
- List of available end of life care education
- Attendance at end of life care education including ACP, Mental Capacity Act, Five priorities for care of the dying person and communication skills
4.3
The environment within the care home offers privacy, dignity and respect for individuals, families as end of life approaches / QM 5.2 Environment
- Care home policy – Dignity
- Named Dignity Champion
- Care plans respecting choice and independence
- Evidence of how the environment provides privacy, dignity and respect
- Photos (with consent if residents are portrayed)
- Thank you letters, statements
Step 4
Delivery of high quality care in care homes
Topic / Comments /4.1
How to access a combination of complex services 24/7
4.2
There is a process in place to identify the training needs of all workers especially those involved in discussing end of life care with residents, families and carers
4.3
The environment within the care home offers privacy, dignity and respect for individuals, families as end of life approaches
STEP 5
Care in the last days of life
The point comes when the resident enters the dying phase. It is vital that staff recognise the person is dying and take the appropriate action. How someone dies remains a lasting memory for relatives, friends and care staff involved.
Topic / Minimum Evidence Required / PO / Further evidence provided /5.1
Processes are in place to review all transfers into and out of the care home for residents approaching the end of life. / QM 5.1, 5.8, and 5.12 Reducing unnecessary hospital admissions
- Audit of admissions to hospital at end of life
- Statement detailing where 999 Poster is situated
- Photocopy of completed Significant Event Analysis, e.g. patient admission to hospital
-
5.2
Residents who are dying are supported with an end of life care plan / QM 5.2 and 5.5 End of Life Care Plan
- Photocopy of an individualised end of life care plan used in practice (anonymised)
- Documentation of multidisciplinary team decision (including GP) that the resident is dying and all reversible causes have been considered
- Photocopy of anonymous prescription for end of life care drugs
- Care of the dying person training undertaken by staff
- Syringe driver policy (where in use)
5.3
There is a system in place for involving families and significant others in some aspects of the care giving and in discussions as death is approaching / QM 5.6 Family & Carer involvement
- Anonymised documentation of support given to families (resident’s notes)
- Examples of supporting literature used, e.g. leaflets
5.4
There is a system in place to record any particular spiritual or cultural needs identified and recorded as part of the end of life care planning / QM 5.2 and 5.3 Spiritual care
- Information available showing different religious/cultural needs at end of life
- Contact list of religious/spiritual leaders and statement showing where stored/displayed
- Evidence from resident documentation of spiritual needs assessment and relating care plans
STEP 5
Care in the last days of life
Topic / Comments /5.1
Processes are in place to review all transfers into and out of the care home for residents approaching the end of life
5.2
Residents who are dying are supported with an end of life care plan (or equivalent)
5.3
There is a system in place for involving families and significant others in some aspects of the care giving and in discussions as death is approaching
5.4
There is a system in place to record any particular spiritual or cultural needs identified and recorded as part of the end of life care planning
Step 6
Care after death
Good end of life care does not stop at the point of death. The support and care provided for relatives will help them cope with their loss and is essential for achieving a “good death”. It is also important for staff, many of whom will become emotionally connected to the resident.
Topic / Minimum Evidence Required / PO / Further evidence provided /6.1
Systems are in place for providing good practice for the care and viewing of the body / QM 5.1 Care of the deceased
- Copy of Protocol for Last Offices
- Signatures of all staff who have read last offices protocol
6.2
Systems are in place to provide appropriate information and support to relatives, significant others and staff post bereavement / QM 5.7 Bereavement support
- Copy of information leaflets, e.g. what to do after a death? (DWP ?011)
- Evidence from the residents notes (Care after death section)
- Contact numbers of bereavement support agencies
- Thank you letters/cards
6.3
Other residents are supported following a death in a care home / QM 5.7 Support for other residents
- Evidence of bereavement support for other residents
- Evidence of remembrance for deceased residents
-
6.4
The quality of end of life care is sustained, audited, and reviewed / QM 5.8 Six Step audits
- Copies of completed audits
- Action plan to maintain ongoing audits
- Evidence of care home attendance at care home forums (where available)
- Induction for new staff members to include the Six Step Principles
Step 6