Case Scenario

We hear all sorts of myths about what we can and can’t do as we age.  Many of those myths are associated with living in a care home. It’s quite frustrating when we hear those stories because it paints a false picture of care home life. The progressive care services enable their people to live as normal a life as they can possibly manage. We acknowledge there are risks and we work flexibly to find a way for each person to live their life as they would wish.

Take a moment to pause and consider your responses to the scenarios below. 

Sylvia

Sylvia, who has a diagnosis of dementia, lives in a care home.  She wants to make herself a cup of tea and piece of toast with jam.  The home has a blanket rule that this is not allowed on health and safety grounds.  Only staff members are able to make tea for residents at set times or as able.

• What are the risks that Sylvia might harm herself with hot or sharp implements?
• Does she understand these risks?
• Are these risks greater than the risks to her of inactivity and loss of skills / independence?

There is nothing in law or, more specifically, Care Quality standards that requires care homes to restrict people in such a controlling way. On the contrary quality standards measure how someone can be `enabled’ to feel safe, `empowered’ to be involved in decisions about risk taking and `supported’ to do things in a way that minimises restriction or freedom. Quality Standards guidance comes from the point of view of managing and minimising risks rather than eliminating them.

Most care providers write their policies in a manner that ensures they comply with quality standards – for obvious reasons. So whilst, someone has said that, this home has a blanket rule it seems more likely that the rule is locally implemented; either by a care home manager who perhaps hasn’t had an opportunity to develop his or her learning or, more likely, a care home team who have implemented the rule as a means of controlling the behaviour of the people for whom they take responsibility.

If indeed it is the care home manager who has implemented the rule he/she may find it helpful to read through the quality standards and their supporting documents which provides essential detail on how to ensure each home meets the regulatory standard.

It is often the case though that policy and guidance on risk and safety is translated by busy care teams into `no you can’t do that’, `that’s our job’, `you will hurt yourself’ and `we are not allowed to let you do that’ language. The risk to the people living in the care home is that this type of dialogue becomes so ingrained into everyday practice that eventually everyone believes it to be true.

Usually, the motive for implementing such a rule comes from a place of good heart. The staff working in this way usually do not appreciate the hurt and damage they are causing to the person; the staff don’t fully understand the consequences of their actions.

One of the biggest difficulties that care home managers and owners experience is translating policy into practice. Writing the policy for any area of care home management is only the first step to compliance. The real work is training the team to understand the policy and helping them translate policy into person centred practice.

So, for Sylvia

• What are the risks that Sylvia might harm herself with hot or sharp implements?

We can’t assuredly answer this question unless we examine the impact of the action for Sylvia. It might be a low risk or a high risk and judged to be acceptable or unacceptable. But judged by whom and acceptable according to what standard?

To establish what the risks may be specifically for Sylvia we can conduct and Positive Risk-Taking assessment. This will help us to consider the Likelihood, the Consequences, and the Level of risk. Those factors will be determined by many other factors including Sylvia’s, past and present experiences.

• The positive risk assessment. Risks identified. Scalding, injury, cross contamination. The associated risks are rated according to their likelihood and level of injury. The assessment identifying the potential high risk of scalding and we could have stopped there. But that would have disempowered Sylvia. Why should she be disadvantaged in such a way? Instead a plan is implemented which empowers Sylvia by helping her achieve her aim whilst mitigating the risk.  
• The Control / Reduction of Risk Measures: identifies how we may consider ways of enabling Sylvia to make her own tea and toast. It identifies the advantages and disadvantages of her becoming involved in the activity. See positive risk assessment for Sylvia

• Does Sylvia understand these risks?

The scenario says Sylvia has dementia. But we know that is quite a broad statement. Simply naming the disability (dementia) doesn’t tell us any more than that Sylvia may be impacted, to some degree, by a form of cognitive loss. There are many forms of dementia and each impacts each person individually.  By completing a mental capacity assessment (MCA), we can determine a better idea of how Sylvia’s dementia impacts her understanding of certain aspects of her life. See mental capacity assessment for Sylvia

• Mental Capacity assessment completed with the outcome that Sylvia understands the risk associated with making herself a drink. ( I’m sure like me you have met many people like Sylvia during your work. I can imagine her raising her eyes to the ceiling at the prospect of any risk associated with her participating in this lifelong task). Nevertheless, to keep her safe we have shown due diligence by assessing the risk from a very rounded perspective.

• Are these risks greater than the risks to Sylvia’s inactivity and loss of skills / independence?

It would be easy to simply answer NO the bigger risk is in Sylvia’s loss of skills, independence, dignity etc. But, because there is a diagnosis of dementia, it would be difficult to answer the question without knowing more about Sylvia; something about her

• life history –perhaps Sylvia has familiarity or memories of making her own food, work skills in cookery?
• Neurological Impairment -let’s find out a little more about this label of dementia and how it impacts Sylvia’s daily life
• Social activities – what is Sylvia’s normal routine
• Personality -shy, outgoing, suggestable, disagreeing, cheerful?
• Physical health -robust, frail, experiences pain, sleeps well?

• By completing a positive risk taking assessment, supported by the information from the person centred care plan and the mental capacity assessment we learned that for Sylvia the greater risk would be in being denied the opportunity to make her own tea and toast which she would see as a loss of independence and self-determination. 

John

John has had a stroke and was admitted to an acute hospital.  He has been transferred to a rehabilitation unit.  He has been assessed as lacking capacity and told to stay in bed due to the risk of falling.  He is becoming increasingly frustrated with this as he is a retired farmer and is used to being outside and moving around.  The hospital wants him transferred to a care home as they don’t feel he is safe to return to living back at home.  John and his family want to see if he can return to his own home.  

• What are your initial thoughts about this situation?
• What assessments could be helpful?

This is a familiar tale of someone experiencing a fairly common and life changing health episode. So often the demand on all hospital beds, rehab included, puts pressure on hospital staff to discharge someone if it is considered that they no longer have rehab potential (following 28 days treatment). That sounds very un-person centred but, we acknowledge the pressure on the NHS and the reality that other solutions are needed for someone in the position that John finds himself. Remaining in the Rehabilitation bed won’t provide long term solutions.

Another familiarity with this scenario is the conflict of opinions between the professionals and the family. It’s important to understand the reasons for the conflict and the hospital teams are usually quite forthcoming with this information. The social worker is usually the best starting point.

So, for John

• What are your initial thoughts about this situation?

The scenario doesn’t tell us much about John other than he is a retired farmer. It does not say whether he still lives on a farm or elsewhere, with his family or alone. It does not say what he can do but only what he can’t do. He has had a stroke, but apart from not being able to walk we don’t know what mobility he has. He is being discharged from Rehab which must mean he has received the standard 28 day rehab support and the Rehab team feel he has achieved his limit. The description about John becoming restless could mean he has been trying to climb out of bed. We know people sometimes do try and stand or get out of bed without understanding that they are unable to maintain their own weight. That would certainly have implications for supporting his care if he were to go home.

One positive consideration is that John appears to have a supportive family who wish to see if he can return home. But, why are the care professionals against him going home? These are all things we need to understand more fully.

• What assessments could be helpful?

We know John is becoming restless and has been assessed as lacking capacity. But the scenario does not specify capacity in what? Mental capacity is decision specific so lacking capacity about one thing does not mean lacking capacity in something else. John’s Mental Capacity assessment will identify which decision/s he has been assessed for. E.g. It may have been answering questions about going home, staying in bed, moving to a care home or anything else. Further complication is that the scenario says `John and his family’ want him to go home. But if John has been assessed as lacking capacity how was he able to make the decision that he would like to go home? We need further information, from the person who did the mental capacity assessment, to discover what was assessed.

• Preadmission assessment. Our first assessment using the home’s usual preadmission assessment document is done during the visit to meet John whilst he is in the Rehab Unit. This visit will confirm that we can provide the care and support that John needs and wants. The visit will also be the beginning of our preparation for a person centred care plan.

Organisations use their own care plan template, but all person centre care plans should include information about the following:

Life History – we know John has been a farmer and what else? It would help us to know more about his life experiences. 

Neurological Impairment –More information from the hospital will help us understand John’s current cognitive ability.

Social activities – It would be good to know how John lives his life, pre and post the stroke. Knowing more about John will tell us about his views on life. E.g. his spiritual and political views, how does he see the world, what he likes and doesn’t like doing.

Personality -shy, outgoing, suggestable, placid, cheerful?

Physical health -robust, frail, experiences pain, sleeps well, former health conditions?

• Mental capacity assessment. Because our information says John lacks capacity the next assessment will be a mental capacity assessment, if not already done, about living in a care home. After that, if capacity in that area is absent, we need to complete a Deprivation of Liberty application.  See mental capacity assessment for John

• A Positive risk assessment will help us understand what John can do rather than, as we are told now, what he can’t do. We can explore his restlessness and see what we can do to help him. He’s experienced a dynamic life change and who can wonder why he must be feeling so restless, possible abandoned and lost.

John’s care is not without some significant risk, his reduced mobility, his reduced capacity in one area or another, his experience of loss which must be extreme, access to farm land even if he hasn’t been working his farm recently. It seems reasonable that he may feel comfortable in the familiarity of a farm like environment. Also, possible loss of any relationships that he has had with friends nearby and of course loss of the comfort he may have from any pets, and family?  Using a Positive Risk-taking assessment, we may hope to improve John’s circumstances. See positive risk assessment for John

The positive risk taking assessment identifies that with creative thought we can reduce John’s risk of declining emotional health from high to low. We know very little about him now but there is potential for providing this man with new experiences and encouraging him to adjust to this change in lifestyle.