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Chapter 5 Findings
themselves. In 76% (n=29) of notes all that was documented was “needs
assistance”, “minimal assistance required”, “full assistance required” or
“independent in activities of living”. It was judged that this lack of specificity
made it more difficult to promote resident capacity. Twenty-four per cent (n=9)
of the residents’ sets of documentation were judged to have evidence (Chart
5.11) of promoting independence, as detail was present of what a resident could
or could not do for themselves. However, there was no care plan to support how
this could be maintained.
Chart 5.11: Element 3
Residents delegate care needs
76%
5.7.4 Element 4: An Atmosphere of Openness, Motivation and Flexibility
This was judged to be present if a resident’s requests in relation to care were
documented and acted upon. Documentation of how decisions were reached,
including risky decisions, and how staff responded to this in a flexible way
needed to be evident. Analysis of the documentation revealed mainly two
documented issues: cot-side use and use of mobility aids. In order for this
element to be judged as evident, the documentation needed to reveal decision-
making processes and actions taken as a result of these decisions.
Analysis of documentation revealed that 78% (n=30) of residents’ documentation
had no evidence (Chart 5.12) of resident requests, openness for receiving
24%
Evident
Not Evident