Co-ordinating care and support for individuals living in their own homes Cydlynu gofal a chymorth i unigolion ay’n byw yn eu cartrefi eu hunain
Supporting the delivery of services that support individuals to live in their own home Cefnogi darparu gwasnaethau sy’n cefnogi unigolion i fyw yn eu cartref eu hunain

Social Care Wales have produced guidance for all domiciliary care workers in order to:

• Describe what is expected of workers
• Support workers to deliver a good service

The guidance can be used to let individuals, families and the general public know what they can expect from the service they are receiving. All care workers must follow the guidelines within this document which include:

• Knowing their limits – Care workers must be willing to recognise and work within the limits of their competence, taking advice from managers and colleagues, as appropriate.

• Personal plans – Care workers must:
• understand the plan and their role in it
• make every effort to work well with others in the plan (such as colleagues, social workers, other professionals)
• contribute to reviewing the plan.

• Delivering care and support – Care workers must:
• work with the individual to understand the level and type of support they need
• maintain safety, comfort, respect and dignity
• support the individual to understand the reasons for safety and hygiene precautions
• know how to use relevant aids and assistive technology
• follow risk assessments
• seek feedback from the individual on how well their needs are being met
• use agreed ways to monitor, record and report progress
• observe changes or difficulties and report these.

• Tasks delegated by another professional – Care workers must:
• complete the required training
• under assessment of competence
• receive on-going supervision.

• Working in people’s homes – Care workers must show respect and care for the individual’s home and belongings.

• Working at a distance from manager – Care workers must use the systems set up to support being managed at a distance.

• Working in teams – Care workers must make every effort to:
• understand roles and responsibilities
• communicate well
• respect colleagues’ skills and contributions
• prepare for and contribute positively to meetings
• manage disagreements constructively.

• Records and reports – Care workers must make sure records and reports:
• are factual, clear, complete and up-to-date
• reflect the individual’s views and wishes
• are stored and shared in a way which meets the organisation’s requirements, including data protection requirements.

• Comments and complaints – Care workers must:
• act professionally and co-operate with the investigation, if a complaint is made about them
• follow the organisation’s procedures, if they are responsible for investigating the complaint.

Social Care Wales - Practice Guidance: https://bit.ly/30vjUGS

Mae Gofal Cymdeithasol Cymru wedi llunio canllawiau ar gyfer pob gweithiwr gofal cartref er mwyn:

• disgrifio'r hyn sy'n ddisgwyliedig gan weithwyr
• cefnogi gweithwyr i ddarparu gwasanaeth da.

Gellir defnyddio'r canllawiau er mwyn rhoi gwybod i unigolion, teuluoedd a'r cyhoedd yr hyn y gallant ei ddisgwyl gan y gwasanaeth maent yn ei dderbyn. Mae'n rhaid i bob gweithiwr gofal ddilyn y canllawiau yn y ddogfen hon sy'n cynnwys:

• Cydnabod ei derfynau – Mae'n rhaid i weithwyr gofal fod yn fodlon cydnabod a gweithio o fewn terfynau eu gallu, gan dderbyn cyngor gan reolwyr a chydweithwyr fel y bo'n briodol.

• Cynlluniau personol – Mae'n rhaid i weithwyr gofal wneud y canlynol:
• deall y cynllun a'u rôl ynddo
• gwneud pob ymdrech i weithio'n dda gydag eraill sy'n rhan o'r cynllun (fel cydweithwyr, gweithwyr cymdeithasol, gweithwyr proffesiynol eraill)
• cyfrannu at adolygu'r cynllun.

• Darparu gofal a chymorth - Mae'n rhaid i weithwyr gofal wneud y canlynol:
• gweithio gyda’r unigolyn i ddeall faint a pha fath o gymorth y mae arno ei angen
• cynnal diogelwch, cysur, parch ac urddas
• cynorthwyo’r unigolyn i ddeall y rhesymau dros fesurau diogelwch a hylendid
• gwybod sut i ddefnyddio cymhorthion perthnasol a thechnoleg gynorthwyol berthnasol
• dilyn asesiadau risg
• ceisio adborth gan yr unigolyn ar ba mor dda y mae ei anghenion yn cael eu bodloni
• defnyddio ffyrdd cytunedig o fonitro, cofnodi ac adrodd ar gynnydd
• sylwi ar newidiadau neu anawsterau ac adrodd ar y rhain.

• Tasgau a ddirprwywyd gan weithiwr proffesiynol arall – Mae'n rhaid i weithwyr gofal wneud y canlynol:
• cwblhau'r hyfforddiant gofynnol
• asesu eu cymhwysedd
• cael eu goruchwylio'n barhaus.

• Gweithio yng nghartrefi pobl – Mae'n rhaid i weithwyr gofal barchu a gofalu am gartref ac eiddo'r unigolyn.

• Gweithio ar wahân i'ch rheolwr – Mae'n rhaid i weithwyr gofal ddefnyddio'r systemau priodol i gefnogi cael eu rheoli o bell.

• Gweithio mewn timau – Mae'n rhaid i weithwyr gofal wneud pob ymdrech i wneud y canlynol:
• deall rolau a chyfrifoldebau
• cyfathrebu'n dda
• parchu sgiliau a chyfraniadau cydweithwyr
• paratoi ar gyfer cyfarfodydd a chyfrannu atynt yn gadarnhaol
• ymdrin ag anghytundebau mewn ffordd adeiladol.

• Cofnodion ac adroddiadau – Mae'n rhaid i weithwyr gofal sicrhau bod cofnodion ac adroddiadau yn:
• ffeithiol, yn eglur, yn gyflawn ac yn gyfredol
• adlewyrchu safbwyntiau a dymuniadau'r unigolyn
• cael eu storio a'u rhannu mewn ffordd sy'n bodloni gofynion y sefydliad, gan gynnwys gofynion diogelu data.

• Sylwadau a chwynion – Mae'n rhaid i weithwyr gofal wneud y canlynol:
• gweithredu'n broffesiynol a chydweithredu â'r ymchwiliad os gwneir cwyn amdanynt
• dilyn gweithdrefnau'r sefydliad, os yw'n gyfrifol am ymchwilio i'r gŵyn.

Gofal Cymdeithasol Cymru - Canllaw Ymarfer: https://bit.ly/2XQ06Bd

In order to co-ordinate care and support for individuals living in their own homes, it is important to consider the individual and their needs and assign an appropriate member of staff. Things to consider are:-

• The care worker is trained and experienced in dealing with the needs of the individual they are caring for.
• If possible, the care worker should have similar interests and preferences to the individual.
• The care worker is familiar to the individual so that they have continuity of care.
• The care worker is reliable so that the individual can build up a level of trust.
• The gender of the care worker may need to be considered to meet the cultural requirements of the individuals.

Er mwyn cydlynu gofal a chymorth unigolion sy'n byw yn eu cartrefi eu hunain, mae'n bwysig ystyried yr unigolyn a'i anghenion a phennu aelod priodol o staff ar ei gyfer. Ymhlith y pethau i’w hystyried mae'r canlynol:

• Mae'r gweithiwr gofal wedi'i hyfforddi i ymdrin ag anghenion yr unigolyn y mae'n gofalu amdano ac mae ganddo brofiad o wneud hynny.
• Os yw'n bosibl, dylai fod gan y gweithiwr gofal ddiddordebau a hoffterau tebyg i'r unigolyn.
• Mae'r gweithiwr gofal yn gyfarwydd i'r unigolyn fel ei fod yn cael parhad gofal.
• Mae'r gweithiwr gofal yn ddibynadwy fel y gall yr unigolyn ennyn ymddiriedaeth ynddo.
• Efallai y bydd angen ystyried rhyw'r gweithiwr gofal er mwyn bodloni gofynion diwylliannol unigolion.

When individuals find themselves in need of home care they could be experiencing a range of emotions and will therefore find it difficult to take in a lot of information.

For this reason, it is important that they are given an accessible delivery that is simple for them to understand.

These plans are important because:

• the plan provides the individual, their family and the multi-disciplinary team involved in their care all of the information they need in order to make informed decisions
• it lets the individual and their family know what to expect from the service
• it makes them aware of their rights and what they can do if they are not happy with the service they receive
• it ensures a consistent, reliable service that individuals and their family can trust.

Pan fydd angen i unigolion gael gofal cartref, gallent fod yn profi amrywiaeth o emosiynau ac felly bydd yn anodd iddynt ddirnad llawer o wybodaeth.

Am y rheswm hwn, mae'n bwysig eu bod yn cael cynllun cyflawni hygyrch sy'n hawdd iddynt ei ddeall.

Mae'r cynlluniau hyn yn bwysig oherwydd:

• mae'r cynllun yn cynnwys yr holl wybodaeth y mae ei hangen ar yr unigolyn, ei deulu a'r tîm amlddisgyblaethol sy'n ymwneud â'i ofal er mwyn iddo/iddynt wneud penderfyniadau gwybodus
• mae'n rhoi gwybod i'r unigolyn a'i deulu yr hyn y gallant ei ddisgwyl gan y gwasanaeth
• mae'n rhoi gwybod iddo am ei hawliau a'r hyn y gall ei wneud os nad yw'n fodlon ar y gwasanaeth mae'n ei dderbyn
• mae'n sicrhau y darperir gwasanaeth cyson a dibynadwy y gall unigolion a'u teuluoedd ymddiried ynddo.

Care plans need to be updated regularly in order to ensure they meet the changing needs of the individual.

During this process it is important to:

• ensure that the individual is regarded as an equal partner in reviewing and specifying the support services needed
• ascertain whether the individual wants family, carers or advocates involved in their home care planning and support
• ensure that the updated plan is informed by the experience, skills and insight of carers
• take account of feedback from the individual and their family
• ensure that the updated plan continues to meet the needs of the individual.

Mae angen diweddaru cynlluniau gofal yn rheolaidd er mwyn sicrhau eu bod yn diwallu anghenion newidiol yr unigolyn.

Yn ystod y broses hon, mae'n bwysig gwneud y canlynol:

• sicrhau bod yr unigolyn yn cael ei ystyried yn bartner cyfartal wrth adolygu a nodi'r gwasanaethau cymorth y mae eu hangen
• nodi a yw'r unigolyn am i deulu, gofalwyr neu eiriolwyr gael eu cynnwys yn y broses o gynllunio a chefnogi ei ofal cartref
• sicrhau bod y cynllun wedi'i ddiweddaru yn cael ei lywio gan brofiad, sgiliau a dealltwriaeth gofalwyr
• ystyried adborth gan yr unigolyn a'i deulu
• sicrhau bod y cynllun wedi'i ddiweddaru yn parhau i ddiwallu anghenion yr unigolyn.

Integrated care requires clear communication to ensure that the service that is provided continues to meet the needs of the individuals.

There should be an agreement between all involved in the care of the individual about which communication systems will be used, such as daily logs etc., and these should be used consistently. The use of encrypted messaging services such as WhatsApp can be used to share information between the homecare team in line with organisational policy.

Multi-disciplinary review meetings might be required if there are other agencies/professionals involved in providing a care service to those individuals living in their own homes.

All relevant services should discuss and share information in relation to the care needs of the individual. Identifying a lead practitioner from among the agencies involved in delivering support, to coordinate care for the individual will ensure continuity of care and safeguard the individual.

Mae gofal integredig yn gofyn am gyfathrebu clir er mwyn sicrhau bod y gwasanaeth a ddarperir yn parhau i ddiwallu anghenion yr unigolion.

Dylid pawb sy'n ymwneud â gofal yr unigolyn gytuno ar y systemau cyfathrebu a ddefnyddir, fel cwblhau cofnodlyfr yn ddyddiol ac ati, a dylid defnyddio'r rhain yn gyson. Gellir defnyddio gwasanaethau negesu amgryptiedig fel WhatsApp er mwyn rhannu gwybodaeth ymhlith y tîm gofal cartref yn unol a pholisi y sefydliad.

Efallai y bydd angen cynnal cyfarfodydd adolygu amlddisgyblaethol os bydd asiantaethau/gweithwyr proffesiynol eraill yn ymwneud â darparu gwasanaeth gofal i'r unigolion hynny sy'n byw yn eu cartrefi eu hunain.

Dylai pob gwasanaeth perthnasol drafod a rhannu gwybodaeth am anghenion gofal yr unigolyn. Bydd nodi ymarferydd arweiniol o blith yr asiantaethau sy'n ymwneud â darparu cymorth, er mwyn cydlynu gofal yr unigolyn, yn sicrhau bod parhad gofal ac yn diogelu'r unigolyn.

When organisations or agencies plan schedules for workers they need to ensure that:

• Fulfil delivery plans and contractual obligations
• they have enough suitably qualified staff to cover all of the care needs agreed in the care plan
• contracts allow staff enough time to provide a good quality service, including having enough time to talk to the individual and do their job without being rushed or compromising the dignity of the individual
• staff are able to deliver home care in a way that meets the individual’s cultural and language needs.

• Meet legislative requirements for terms and conditions of workers
• staff’s travel times are included in their rota and paid for
• staff are given an 11-hour rest break between working days
• staff are given a 24-hour rest break each week or 48 hours every two weeks.

• Allow flexibility to be able to respond to emergency situations or changing needs/situations
• contracts and delivery plans offer flexibility to ensure the individual can identify what is a priority for them. This might include, allowing providers to use time flexibly, with the agreement of the individual.
• have enough staff that can be called on in an emergency situation or to increase an individual’s support if the need arises.

Pan fydd sefydliadau neu asiantaethau yn cynllunio amserlenni ar gyfer gweithwyr, bydd angen iddynt sicrhau'r canlynol:

• Cyflawni cynlluniau a rhwymedigaethau cytundebol
• bod ganddynt ddigon o staff cymwysedig i ddiwallu'r holl anghenion gofal y cytunwyd arnynt yn y cynllun gofal
• bod contractau yn caniatáu digon o amser i'r staff ddarparu gwasanaeth o ansawdd da, gan gynnwys cael digon o amser i siarad â'r unigolyn a gwneud eu gwaith heb orfod rhuthro na pheryglu urddas yr unigolyn
• o bod staff yn gallu darparu gofal cartref mewn ffordd sy'n diwallu anghenion diwylliannol ac ieithyddol yr unigolyn.

• Bodloni gofynion deddfwriaethol o ran telerau ac amodau gweithwyr
• bod amseroedd teithio staff yn cael eu cynnwys yn eu rota a'u bod yn cael eu talu amdanynt
• bod staff yn cael egwyl 11 awr rhwng diwrnodau gwaith
• bod staff yn cael egwyl 24 awr bob wythnos neu 48 awr bob pythefnos.

• Caniatáu hyblygrwydd i allu ymateb i argyfwng neu

• anghenion/sefyllfaoedd sy'n newid
• bod contractau a chynlluniau cyflawni yn cynnig hyblygrwydd i sicrhau bod yr unigolyn yn gallu nodi'r hyn sy'n flaenoriaeth iddo, gallai hyn gynnwys caniatáu i ddarparwyr ddefnyddio amser yn hyblyg, gyda chytundeb yr unigolyn.
• bod digon o staff y gellir galw arnynt mewn argyfwng neu i gynyddu'r cymorth a ddarperir i unigolyn os bydd angen.

If a service provider needs to make schedule changes to an individual’s care then this needs to be communicated clearly to all those involved.

Firstly the service provider will need to work with the individual to negotiate any changes to their care plan, for example, when visits will be made.

If staff involved in an individual’s care need to be changed then this needs to be communicated to the individual and the reasons explained.

Os bydd angen i ddarparwr gwasanaethau newid amserlen gofal unigolyn bydd angen cyfleu hyn yn glir i bawb dan sylw.

Yn gyntaf, bydd angen i'r darparwr gwasanaethau weithio gyda'r unigolyn i drafod unrhyw newidiadau i'w gynllun gofal, er enghraifft amseroedd ymweliadau.

Os bydd angen newid y staff sy'n ymwneud â gofal unigolyn bydd angen cyfleu hyn i'r unigolyn ac esbonio'r rhesymau dros y newid.