Practice Panel: When an 85-year-old woman changed care homes to stay close to her daughter her health and memory began deteriorating. Leeds PCT examines the case

CASE STUDY
The names of the service user and her daughter have been changed

Situation: Maisy Morrison is 85 and lived in a residential care home for four years, which she funded herself from the sale of her own property. She was very happy and was a popular person about the home. However, last year her only daughter, Ellen, 54, who lived nearby and visited daily, moved when her husband’s company relocated from the North to Greater London. Ellen was convinced to join them and a care home, which was both residential and nursing, was found nearby. The home had very good Commission for Social Care Inspection reports.

Problem: Maisy hasn’t taken to the move. She has been ill and withdrawn. The situation wasn’t helped by Ellen – needing to settle down herself – visiting only sporadically. Maisy became forgetful and the owner, a local GP, considered she was developing Alzheimer’s and so “transferred” her to the nursing care part of the home (which costs substantially more). Ellen has become not only concerned about the hike in fees but also about the care her mother is receiving – she isn’t always washed or dressed or, once when she called in around lunch-time, out of bed. However, she feels intimidated by the owner – who she feels is abrupt and condescending. Ellen feels there is an “atmosphere” at the home – it’s formal and not much fun – but nobody else seems to mind. Maisy continues to deteriorate and Ellen doesn’t know what to do for the best.

PANEL RESPONSES

Mick Ryan
This case highlights the difficulties which can arise when someone changes placement within the care system. The reasons for the move were positive but the outcome appears less so. Maisy’s daughter is also struggling with the move and so the prime reason for the move – more family contact – is not happening. This situation may improve as the daughter becomes more settled in the new area.

The fact that Maisy is a self-funder could mean that no advice had been sought regarding the move although clearly the family had acted in good faith and had chosen a home with a good inspection report. Nevertheless the outcome has been unsatisfactory for Maisy. The anxieties about the care delivered at the home, the move into nursing care and Maisy’s ­deteriorating mental health indicate a need for care management.

A full assessment of Maisy’s health and social care needs should be undertaken. This should include a mental health assessment. Does she have a form of dementia or is her mental decline connected to the move and her current unhappiness? Maisy should, as far as her cognitive ability allows, be at the centre of this process and this may give her some reassurance that her distress is being heard.

There is a lack of clarity as to whether Maisy does have nursing needs and a nursing determination should be requested.

There may be adult protection issues regarding Maisy’s care at the home. There are possible issues of neglect about the level of personal care she is receiving and also a reported atmosphere of intimidation.

Because Maisy is self-funding there are no contractual obligations as there would be to someone who is funded by the local authority. The involvement of the Commission for Social Care Inspection is crucial in order to look at standards in the home. It has the statutory powers to intervene if standards of care are deficient.

At the end of the day, Maisy and her family could opt for a move to another care home if the problems remain protracted. One would hope this could be done in a planned way, informed by a clear definition of Maisy’s needs.

Christine Rawson

Clearly, Maisy’s ability to adapt to the new care home was hindered by the fact that her daughter, herself undergoing a major change in circumstances, has not provided regular support.

The emotional upheaval of the move and trying to adapt to new circumstances without support may have caused Maisy to show symptoms which were interpreted as the early signs of dementia. The GP involved may not have made an objective assessment of her cognitive ability, and her transfer to the nursing care section of the home should have happened only as a result of a nursing determination carried out by an independent continuing care assessor.

In view of the short time she had been in the home, the move to ­nursing care seems premature. The circumstances and results of any previous assessment need investigating, and a review of Maisy’s needs requested by the community matron. It may be possible to return her to the residential care section where she could mix with less dependent residents.

Evidently, Maisy has become unwell, but whether or not this has been thoroughly investigated is not altogether clear. As part of a detailed holistic assessment process, Maisy’s insight into her situation and problems needs to be established. Forgetfulness and a decline in communication skills and functional ability can point to dementia, but other conditions which can cause similar symptoms need to be identified or eliminated, such as depression or chest and urinary tract infections.

Screening blood and urine tests would need to be taken, and treatment given if necessary. Validated tools such as the 6CIT and Geriatric Depression Score are used routinely: if Maisy is indeed showing signs of early dementia, referral to the memory clinic would be made.

The daughter is unhappy with the poor communication and the standard of care provided for Maisy: the community matron would ­support her in addressing these concerns, informally in the first instance. If a resolution is not found, then a formal complaint should be made to the home. However, as she is self-funding, Maisy and her daughter may wish to consider another care home which may better meet her needs.

User view

This seems to be a sad case of a vibrant older lady, who had an active life and a sense of purpose which she has now lost completely, write members of Knowsley Older People’s Voice. Although we feel we have an understanding of the pressures Ellen is facing, we also think that older people are not a parcel to be packaged up and moved.

Ellen thought she knew what was best for her mother, but Maisy has the right to choose her own future and should not have been convinced to move to fit in with her daughter’s plans. It is little wonder that Maisy has become withdrawn when you consider the upheaval Maisy has experienced: moving to the opposite end of the country leaving her friends behind and adapting to a new residential care home setting with people with a completely different background. In addition to this, Ellen doesn’t have the time to visit her mother.

It has been suggested that Maisy is in the early stages of Alzheimer’s without any kind of formal assessment there had been no suggestion of this at Maisy’s previous care home. It is more likely that she is feeling depressed after such major upheaval.

This case raises many points of concern. For example, has a change in medication contributed to her deterioration? The home owner is also her GP. This raises questions concerning a conflict of interest as the home owner seems to have “fingers in many pies”. In our mind this could be considered “legally wrong”. There does not seem to be any evidence to justify Maisy’s transfer to nursing care. Ellen should talk with the care staff who provide Maisy’s care.

It seems Ellen has chosen this home based solely on reports by the Commission for Social Care Inspection. Surely she should have visited several homes in the area with Maisy and given her some choice in the matter or the opportunity to change her mind after visiting the area.

The initial step must be to organise, with Maisy’s consent, a complete set of assessments to rule out any underlying medical condition. This must be explained to Maisy so that she understands at this time her involvement is paramount.

Maisy needs to be asked what future she would like for herself. If she would like to return to her “home roots”, enquiries need to be started as to how this can be achieved and safely so. Maisy must be involved in the decision making because this is Maisy’s future, not Ellen’s.

Knowsley Older People’s Voice is a self-advocacy group in Knowsley, Merseyside.

This article appeared in the 19 April issue under the headline “Unhappy change of scene”