Social workers and a service user offer advice on a case involving a stroke sufferer whose stay in a care home raised questions about his ability to live independently
Ernest* is a 62-year-old man. Until recently he had been very active, valuing his independence. Three months ago, friends became concerned when there was a marked deterioration in his physical and mental capacity. It is suspected that Ernest had a stroke. Ernest has received some support from neighbours. However, these neighbours were increasingly finding it a struggle to support him. The case was brought to the attention of social services, and when Ernest’s neighbours went on holiday, a month after the suspected stroke, the social worker arranged for Ernest to go into a care home, initially as an interim arrangement while they were away.
Ernest is keen to return to live in his own home. However, during his stay in residential care, staff have expressed concerns about the suitability of Ernest returning home. His mental capacity seems to fluctuate greatly throughout the day. For example, at certain times he is incapable of finding the toilet by himself. Ernest has been a heavy smoker all his adult life. There is concern that, if he were to return home, he would not be able to care for himself and, perhaps more worryingly, his absent-mindedness and smoking might present a significant fire risk.
*Name has been changed
The social worker’s view
Carl O’Riordan, social worker, Derbyshire Council adult care
I hope that Ernest would return home and regain much of his independence, with risks reduced to reasonable levels. Care home staff often mistakenly believe that people cannot manage without them. Although Ernest may struggle to find their toilet, it does not follow that he will not easily find his own.
A co-ordinated multi-disciplinary team should strive to assist Ernest back home. Urgent medical tests should confirm the cause of his confusion.
If Ernest did have a stroke, medication may reduce the risk of further damage and a rehabilitation programme should increase his independence.
His social worker and a clinical psychologist could help Ernest to adapt to memory difficulties. This may include simple strategies, such as keeping a diary or wall-planner, and technological devices, such as a telecare medication dispenser, programmed to alert and dispense medication as prescribed.
Because Ernest is unlikely to give up smoking, his local fire brigade may be willing to assess and help reduce fire risks. A telecare smoke alarm could automatically telephone for help if fire breaks out. Ernest may be willing to use a smoking aid, a simple device that safely holds cigarettes above an integral ash tray, with the smoke drawn up through a flexible pipe.
Ernest’s closest neighbours may be entitled to carers’ assessments, and their support supplemented by re-enablement home care and services from voluntary organisations such as The Stroke Association. It may be appropriate for Ernest to pay his neighbours for increased support using a personal budget. If Ernest is offered timely, tailored choices, he will have the best chance of regaining his independent and active life.
The manager’s view
Julie Heath, area manager, Derbyshire Council adult care
I would be surprised if Ernest could not return home, with risks mitigated. However, we might consider what could happen if Ernest did not understand the perilous risks of returning home and refused all support.
Today is the first anniversary of the deprivation of liberty safeguards, enacted under the Mental Capacity Act 2005. These safeguard people lacking mental capacity who, for their own safety and in their own best interests, need to be accommodated under care and treatment regimes that deprive them of their liberty.
Thus, if the care home managers sincerely believe Ernest could not understand the risks of returning home, they could issue an urgent authorisation to deprive him of his liberty for up to seven days while a best interests assessor and a mental health assessor would appraise him.
If Ernest is found to have capacity he is free to return home, responsible for his own risks.
Even if Ernest does not have capacity, continued deprivation of liberty in a care home would remain an unlikely last resort. Risks can never be eliminated and should be balanced with rights. Any decision taken on behalf of someone who lacks capacity must always be in their best interests, and restrictions on their freedom minimised.
The service user’s view
Simon Heng, disability writer and activist
What concerns me most about Ernest’s situation is that there is no mention of medical investigation or intervention. Ernest may well have had a stroke, but a thorough medical examination would determine exactly what has happened and whether there is any treatment that could improve his physical and mental condition. It would also indicate what assistance he would need now and in the future. The best social worker in the world doesn’t have the knowledge or skills to determine this.
If this hasn’t been done, Ernest’s interests have been poorly served. Research shows that speedy intervention, from the minutes immediately after the stroke through to swift rehabilitation, reduces the consequences and the level of impairment caused by the neurological damage.
If adults’ services haven’t taken it on themselves to seek medical attention for Ernest, there might be a good case for an investigation on the grounds of negligence.
Assuming that he has had suitable medical attention, and that his condition is stable, intensive physiotherapy and occupational therapy could still help Ernest achieve as much independence as possible. My local authority, in a joint project with the NHS, has set up a rehabilitation unit for exactly this purpose, to get as many older people as possible back to independence. Does Ernest’s locality have a similar unit?
This article is published in the 1 April 2010 edition of Community Care under the headline “Can man, 62, live safely at home after stroke?”