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Case notes

Practitioner: Maureen Sweeney district nurse, and Debbie Harrison senior home safety adviser, community older persons' team (Copt)

Field: Older people

Location: Knowsley, Merseyside

Client: Bobby Elsworth, an 89-year-old retired docker, and his wife, Betty, 85, live in a high-rise flat, where they have been for 40 years. Their son lives away but their daughter, who is their main carer, lives close by but may have to move. The family was previously unknown to social services.

Case history: Bobby, an ex-serviceman, was referred to the community older people's team by the soldiers, sailors, airmen and families association (Ssafa) - the national charity helping serving and ex-service men, women and their families in need - because of his poor mobility. On the day he was visited by district nurse Maureen Sweeney he had fallen while trying to get out of bed. As he had not seen his GP for some time Sweeney carried out a full health check. She realised that Betty also had needs and that if they were to remain safely in their home, a series of referrals for them both was required.

Dilemma: Despite their isolation, poor access and mobility, and imminent loss of their main informal carer, Bobby and Betty wish to remain in their home.

Risk factor: Serious falls could see either or both of them being hospitalised and moved to some form of staffed accommodation.

Outcome: With preventive support from Copt Bobby and Betty continue to live independently without a care package.

The old proverb that "prevention is better than cure" may seem a tired clich' to us, but to be so over-used it must have a strong element of truth and relevance behind it. And it could easily be the motto of the Knowsley community older persons' team (Copt), as the case of Bobby and Betty Elsworth testifies.

Following referral to Copt, district nurse Maureen Sweeney visited to assess Bobby's needs. "He communicated very well and was a very independent man," she says, but a full health check sparked a round of referrals that were needed to improve his safety and quality of life. "I referred him to Copt's senior therapy assistant because his mobility was poor and he was walking with a stick. I worked closely with the well-being project social worker, Elaine Pugh, because of his social isolation caused by his poor mobility and the location of his accommodation. He also needed a bathing assessment and pensioners' advocacy for some benefits advice as he didn't appear to be receiving all the benefits he was entitled to. I also wrote to the GP to outline that I had done the health check so that this wasn't duplicated by someone else."

Although primarily visiting Bobby, Sweeney realised that Betty would also benefit from an assessment. "I noticed that Betty had an unusual gait and referred her to the senior therapy assistant as well. She also struggled to get into and out of the bath and because she had a skin condition she was very concerned about her ability to bathe. The daughter, Petra, was concerned because she was being re-located to a different town and worried what might happen as she had been her parents' main carer," says Sweeney.

Given their desire to remain at home another Copt member, senior home safety adviser Debbie Harrison, carried out a home safety assessment. "We got the handyman to fit an extension socket high on the wall by the television because the plugs were quite low and Bobby and Betty were at risk of falling when bending down to plug and unplug the television. And under each socket is a hook so when they take the plug out they can rest it on the hook - and don't have to bend down to pick the plug up again," she says.

Other simple help included a perching stool in the kitchen to take pressure off their legs while cooking or making a cup of tea, and a trolley to save having to carry meals and from the kitchen into the lounge, which is difficult when using a walking stick.

Fire safety was also checked by Harrison. "The Elsworths were cooking with a chip pan, which was worrying because of their mobility and the fact that they lived in a high-risk, high-rise tower block, so we gave them a deep fat fryer," she says. Importantly, Harrison has the authority to issue or order all safety improvements instantly, and impressively, they are all free to users.

"Also, because of their difficulties with the bath we had grab rails fitted, which made them feel a lot safer getting in and out of the bath. Although they had a bath lifter - a device which lowers you to the bottom of the bath - I noticed it was faulty. I referred on to the social services occupational therapist who, following assessment, exchanged the lifter," says Harrison.

With the health checks complete and practical home safety solutions in place, the next task for the team is to tackle the Elsworth's social isolation. Sweeney had already set those wheels in motion: "Bobby had been an active member of his church for many years and had not been able to attend for some time. This distressed him. So I asked a priest to visit to administer communion - and discovered that the church runs an over-50s club on Tuesday afternoons and they were quite interested in that," she says.

However, detailed follow-up will be left to Pugh. "What I did was take a step back while all this practical help was being sorted - because if I went in as well they could easily feel overloaded," she says.

This simple case highlights the effectiveness of preventive work. "The normal route would be a fall, followed by A&E and then a hospital ward, and then a social services care package with a social worker to monitor," says Sweeney.

Never having had services before Sweeney recalls how anxious the Elsworths were at first. "But in the end they thought it marvellous that all this help was available - and they are more confident now. They are both over the moon." Proverbially speaking, of course.

Arguments for risk 

• The Elsworths want to stay in their flat. Falls were proving to be the largest barrier to this. But the team was able to equip the flat to minimise risk of further falls. 
• With some low-tech improvements the Elsworths have had their wishes met without recourse to expensive care packages. 
• The multi-agency nature of Copt ensured that all aspects of the Elsworths' well-being were professionally covered.  
• Although, apart from social worker Elaine Pugh's work, there are no more plans to visit - save a six-month follow-up from Harrison - Copt members always leave a contact number. "So, if any time in the future they need anything we tell them to ring us. If we can't help personally we'll put them in touch with someone who can. And this gives people confidence knowing that if they have a query we can direct them appropriately. It's what many people want, really: it's a bit of back-up," says Sweeney.   

Arguments against risk 

• There is a concern over the practical loss of daughter, Petra, as main carer. While the immediate environment may have been made safer and connections made with luncheon clubs, church and shopping companions, it's unclear who will be fulfilling most of those informal tasks that  Petra undertook in the future. Who will run errands, fetch the papers and so on? Also now that both their children have moved many miles away, this can only enhance their feelings of isolation.  
• The risk of falls remains high when coupled with the social isolation that both Bobby and Betty find themselves in. It could be argued that, what the team describe as the normal procedure - fall, A&E, hospital ward, care package and monitoring - is simply waiting to happen. 
• They are both old and frail. One cannot but worry what might become of the other when one of them is taken ill is hospitalised or dies.

Independent comment    

Two elements of this story particularly impress me with the progress made over recent years: the confidence with which professionals within health and social services work together; and the ability of front-line workers to mobilise resources without having to go through cumbersome bureaucracy, writes Jef Smith. Both factors have contributed significantly to giving this vulnerable couple more time to be able to go on living together. 

It was the home environment as much as their disabilities which presented threats to their safety, and the team were right to focus on practical matters. A new bath seat, grab rails, a safer pan for chips, a high stool, a food trolley, an additional plug and a hook on the wall to hang it on - these are not the sort of expenditures to breach any agency's budget; indeed they probably cost less than the staff time it would take to administer a financial assessment.   

Older people are certainly at risk of falls, but so are residents in homes, and in this case every sensible precaution seems to have been taken. At least Bobby and Betty have each other, so if an accident does occur, help can be quickly summoned. 

Petra's move remains the biggest worry and the social worker will need to keep the Elsworths' welfare under review. Perhaps the church has access to volunteers - another member of the over-50s club? - who could help with shopping, errands and possibly also transport to services, as well as providing informal surveillance.  

Jef Smith is a writer, trainer and consultant in care for older people.