Is home the safest place?

Lisa Hovey had to decide whether an older
woman with dementia and a serious skin condition could be cared for
by her husband at home, or whether her extensive needs would be
best met by her being placed at a care home. Graham Hopkins
reports.

With the emphasis on keeping people in their
own homes, it could be argued that sometimes placing clients into
care homes counts as a failure. And yet residential care is still
very much part of the community equation. It may be a last resort
option, but can still be a positive one.

If
anything, social services departments probably battle more with
families who want their relatives to go into care than with those
who want to keep them at home. But this was the situation faced by
the specialist dementia team in Poole, Dorset. Lisa Hovey, who
manages the home care services provided to older people with
dementia, is proud that her team have only placed three clients
into care homes in the team’s two-year existence. However, the case
of 89-year-old Marie McGurk showed that keeping people in their own
homes is not always the safest option.

Hovey
visited McGurk, who had been admitted to hospital acutely
distressed by her painful skin condition. “Initially we thought
once they cleared up her skin condition it would be possible to
continue supporting her at home. But I noticed a huge difference in
her. She looked as if she had almost had a stroke or something,”
says Hovey. McGurk was now unable to sit up and had a catheter
fitted.

However, there were worries over
her husband’s ability to care, which Hovey discussed with social
worker Paul Clayton. “His behaviour gave us grave concerns,” says
Hovey. “On one occasion, after his wife spat her medication out, he
slapped her around the face.” Although there were no further
allegations, “if this was what he did in front of carers, what
might be going on behind closed doors?” adds Clayton.

“A
further concern was that she was being turned two-hourly,” says
Clayton. “Her husband reckoned that he could do that regardless of
his own mobility problems and that it was taking two nurses to do
the job in hospital. He couldn’t see the reality of what he was
getting himself into.”

The
family remained convinced that McGurk was coming home – and with
the same level of support as before admission. “While we have to
take into account the family’s wishes, we also have to make sure
that McGurk wasn’t being put at risk,” says Hovey. It was decided
that a nursing home placement was the most appropriate and a case
conference would be called to put that to the family. Indeed, if
necessary, the department would section McGurk under the Mental
Health Act 1983.

Shocked at this intended outcome,
the family asked if more support in the home was possible. At least
this showed that they were being more realistic about the
consequences of McGurk coming home. “We drew up a care plan
detailing the minimum care required, replicating the basic care
that was being carried out by the hospital,” adds Clayton. “It
amounted to 73 care hours a week, including night service. This
could only be provided through self-funding, and would cost about
£700 per week.” The department was willing to part-fund the
support up to the amount of a nursing home placement – just over
£300.

The
family was shocked by the number of hours required and the cost,
and suggested cuts in the proposed service. “We also had serious
concerns that even if we put this care plan into practice that the
family will either cancel calls or not let the carers in, because
already they were deciding what they could do away with,” says
Hovey.

“For
example, McGurk needed a special cream to be applied to her entire
body to help soothe and treat her skin condition,” adds Clayton.
“The son-in-law said this should only take 10 minutes, which again
shows the unrealistic nature of the whole thing.” This just made
the case for a nursing home stronger, adds Hovey.

Unconvinced that the family would
meet McGurk’s needs, Clayton called them to say a nursing home
placement would be made. “I was aware that it could be seen as the
power of the social worker, but I let them know as tactfully as
possible. But they agreed that she could go to a nursing
home.”

Ten
years previously her husband had suffered a horrific car accident
and McGurk had nursed him back to health. “He had promised his wife
that if he ever had to look after her, he wouldn’t let her go into
a residential or nursing home,” adds Clayton.

Nonetheless, within days of
agreeing, the family found McGurk a “very attractive, very good”
home. Her husband visits every day, and now accepts that she is in
a safe and secure environment. The son-in-law also agrees: “She’s
in the best place.”

The names of the family have been changed.

Case notes

Practitioner: Lisa Hovey

Field: Home care organiser, dementia care
team, older people’s services

Location: Poole, Dorset

Client: Marie McGurk, an 89-year-old woman
with dementia

Case history: McGurk lived at home with her
husband of more than 60 years, Patrick, also 89, and had received
home care support for two years.

She had become very frail following the onset
of dementia and lost her communication skills – she could no longer
talk but would communicate through squeaks and noises. She also had
a serious skin condition that was deteriorating and causing great
discomfort, to such an extent that she had begun to cry out in
pain. Despite this, McGurk’s GP refused to come out and visit, on
the grounds that she was being booked in to see a dermatologist
consultant at the hospital. Nonetheless, because of the distress
for McGurk and, indeed, the home carers, on three occasions the GP
was phoned, but still he refused to attend. However, another call
found the GP out and the on-call doctor agreed to visit, and
immediately had McGurk admitted to hospital.

Dilemma: By assessing the need for nursing
care, against the wishes of the family, there was a danger of
appearing high-handed and overpowering.

Risk factor: By leaving McGurk in the care of
the family at home, there was a risk that her needs would not be
met.

Outcome: McGurk was finally placed into a
nursing home with the family’s consent.

Arguments for risk

– It is considered good practice to exhaust
all possibilities in trying to keep people in their own home. With
a comprehensive package, including night service to turn McGurk
every two hours, it might be possible for her to return home.
Unfortunately, it would prove too expensive to set up.

– McGurk’s husband was very keen for her to
return home and was prepared to continue caring for her. Her
daughter and son-in-law, her only other family, were similarly keen
for her to return home and, indeed, lived locally and could have
provided additional support.

– The social services department had drawn up
a care plan – based on the care McGurk was receiving at hospital –
and had, therefore, considered a move home to be possible and
workable.

– Consideration also needed to be given to
McGurk’s husband’s emotional needs. He had never been away from his
wife in over 60 years of marriage – and he had promised to care for
her at home.

Arguments against risk

– Despite the family’s best intentions in
wanting to keep McGurk at home, her physical condition had
deteriorated to such an extent that she needed extensive care – an
amount that her husband, given his own mobility problems and age,
simply could not provide effectively. He had unrealistic
expectations of his own caring abilities and did not understand
fully McGurk’s needs.

– Even if the potential care package to keep
McGurk at home was funded by the family, there was a real risk that
the family would sabotage the plan by reducing or cancelling
aspects of care.

– A home carer had witnessed McGurk’s husband
physically abusing her – slapping her across the face, after she
spat her medicine out. This may well have been provoked by his
feelings of inadequacy, tiredness and frustration caused by the
relentless requirements of caring. It could happen again. It also
poses the question of what else happens when carers are not
present.

Independent comment

Communicating with those in the later stages
of dementia is certainly difficult, and people like McGurk often
suffer terrible frustration because of the impossibility of getting
their message across, writes Jef Smith. By the time of this
incident her “squeaks and noises” had become clear signs of acute
distress, and the workers used great skill and patience in ensuring
that they understood her needs and wishes.

Social workers often rely too readily on the
views of the relatives of older people, but it is what McGurk
wanted, not what the family felt would be right, that was decisive.
The family undoubtedly had good intentions. But Patrick McGurk’s
loyalty to a well-meant but sadly out-of-date promise and the
commitment of his daughter and son-in-law to trying to support the
couple remaining together were not in Marie McGurk’s best
interests. By exploring all aspects of the situation with the
family, including the financial implications and Patrick McGurk’s
possibly declining ability to contain his own frustration, they too
were persuaded that greater expertise would be available through a
move to a home.

Domiciliary care is not always the best
option. Needing 73 hours of personal assistance a week, McGurk
would have had to be helped by several different staff, with
probably less continuity of care than a nursing home could provide.
Good homes can offer security, ready access to help in emergencies
and an atmosphere that fosters continued family and marital
contact.

Jef Smith is a writer, trainer and
consultant specialising in the care of older people.