Care Environment: Professional Care
John and Mary have been married since 1968. After more than a decade in the Royal Navy, John joined the MoD Police, before retiring early due to ill-health.
John suffers from severe depression and anxiety, as well as type 2 diabetes and peripheral neuropathy, which severely restricts his mobility. John is now completely confined to the bedroom.
For many years, Mary had handled John’s care single-handedly. However, as John suffered a two-week bout of diarrhoea, Mary found herself unable to manage. John had suffered from faecal burns, and his skin integrity had deteriorated. The District Nurses put together a care regime of one carer visiting John three times a day, for two hours at a time.
Eventually, the Vendlet was proposed to resolve the manual handling issues and resulting cost implications (see below).
|Outgoings (per year)||Before Vendlet V5||After Vendlet V5|
|One-off cost of the Vendlet and sundries||£0||£5,375|
Full case study
John was born in Kent on 21 June 1946. He entered the Royal Navy in 1962, aged 15. He met Mary in Portsmouth and they married in 1968. In 1973 he left the Navy in order to settle down and be a father to their only daughter and joined the MOD police. In the mid eighties he was pensioned out due to ill health.
In the mid eighties John developed depression and was diagnosed with Bi-polar disorder (Timms 2012). Following a psychotic episode in 1996 he was admitted to an acute psychiatric hospital in Oxfordshire. He now has ongoing severe depression and anxiety, and has medication which his GP controls as he declines to engage with the mental health team. He is a very large gentleman, currently 22.5 stone, although previously was 28 stone. He has a very large abdomen and legs. He has type 2 Diabetes and developed peripheral neuropathy (NINDS 2012) in 2004, which severely restricted his mobility. During 2006-7 he had repeated falls. He was unable to feel the damage to his legs due to the neuropathy and started to spend increasing amounts of time in bed. By July 2008 he had stopped getting out of bed altogether, having given in to the effects of his depression, and has not left his bedroom for 3 years. John and Mary were unwilling to engage with any authorities or health providers apart from his own GP, and John continues to have fear and anxiety related to hospital admission.
In January this year John was referred by the Community Rehab Team (CRT) to Social Services for ongoing care following crisis intervention. He had developed severe diarrhoea over a two week period and Mary had not been able to manage this. He had faecal burns and his skin integrity had deteriorated considerably. The District Nurses had intervened and started a care regime which involved four carers rolling him onto his side three times a day to attend to his personal care and to treat his skin. The care was carried out by the District Nurses themselves and a care agency were also commissioned. The District Nurses had also expressed concerns over the overall situation and safeguarding was discussed. After a few weeks his skin integrity had showed significant improvement and Social Services were approached to take over the case. Prior to this episode Mary had attended to all his care needs herself and had done so for many years. However, she was now reporting that she was unable to carry out that level of support on her own. John already had some equipment in place: bariatric hospital profiling bed, bariatric riser/recliner chair, ceiling track hoist, bariatric slings and slide sheets.
Identification of specialist equipment
The VENDLET positioning system was demonstrated at the Disabled Living Foundation (DLF) Moving and Handling People Conference in January 2013, where it won ‘Most interesting product award’ (Assistdata 2013). The system was developed in Denmark by Christian Buus (VENDLET Aps. 2011) to assist turning his disabled daughter in bed, as he and his wife were finding they could no longer manage the physical strain. The first version was invented approximately thirty years ago. A demonstration of the system was arranged at West Berkshire Council’s Turnham’s Green office for all West Berkshire Occupational Therapists, with the UK supplier Felgains UK and as a result of this, an application was made to resource panel for funding. The system is expensive at approximately £5,000, but, in conjunction with a ceiling track hoist, can be operated by a single carer and therefore has the potential to reduce larger care packages.
Potential savings and benefits of equipment
Aside from the financial saving related to the provision of this piece of equipment, there are also personal benefits to both the client and carers which meet the required outcomes for the Putting People First, Adult Social care Strategy (WBC 2013). Although this strategy has been updated, the seven basic outcomes are still relevant.
(Services promote and facilitate the health and emotional well-being of people who use the services.)
The client is handled less, with fewer carers resulting in reduction of pain on manoeuvring. There may also be mental health issue to take into account. The client may feel that the number of carers involved in their care is a direct statement about his physique, and contribute to feelings of depression and reduced self-worth. The carer also benefits from the improved health of the client and therefore is likely to have reduced levels of stress.
Improved quality of life
(Services promote independence, and support people to live a fulfilled life making the most of their capacity and potential.)
It can sometimes be the case that when two carers are working together, the client can be ignored for a great deal of the time as the carers will chat to each other and not involve the client. With a single carer working with the client, the carer is fully focussed on the client, and the client will be more involved in what is happening to them. Having multiple carers through the house several times a day can have a big impact on quality of family life. A frequent comment is ‘it’s like Piccadilly Circus here’. In this case, John was, at one time having an equivalent of 9 people a day walking through the house. This adds up to 3,285 people a year. As well as the disruption, there is also wear and tear on carpets to consider.
Making a positive contribution
(Councils ensure that people who use their services are encouraged to participate fully in their community and that their contribution is valued equally with other people.)
The improved client care, and reduced stress levels of the informal carer allow for more opportunity for contribution to activities outside the home.
Exercise of choice and control
(People who use services, and their carers, have access to choice and control of good quality services, which are responsive to individual needs and preferences.)
The informal carer has more control of the care and there is more opportunity to have a care package that meets the client’s needs as timings of visits can be more flexible with a single carer.
Freedom from discrimination or harassment
(Those who need social care have equal access to services without hindrance from discrimination or prejudice; people feel safe and are safeguarded from harm.)
The provision of specialist equipment can reduce the need for a large care package and can prevent the need for residential placement which maybe a cheaper option, both of which could be considered to be a statement about the client and therefore could be considered as prejudiced. The equipment can allow the client to have a similar care package to any other client requiring personal care in bed and, allows for easier and safer care and reduces the risk of harm to both the client and the care-givers.
(People are not disadvantaged financially and have access to economic opportunity and appropriate resources to achieve this.)
The provision of specialist equipment can reduce the amount of money required for the care package making large savings, which allows the council to support more people, and supports the personcentred ethos of the personal budget.
Personal dignity and respect
(Adult Social Care provides confidential and secure services, which respects the individual and preserves people’s dignity.)
It is extremely undignified having multiple carers completing personal care tasks. The provision of the equipment allows for a better, calmer and more efficient service and an improvement in quality of life.
Issues around provision of equipment
Specialist equipment can be very expensive initially. In this instance the equipment was funded through a personal budget. During the crisis intervention, the Health providers ordered a specialist bed for John, at a cost to them of approx £10,000. The bed addressed pressure care, but not care package costs which was an important issue for Social Services. Earlier involvement and joint working with health colleagues would have prevented the unnecessary provision of two pieces of expensive specialist equipment and improved the outcome for all parties.
Installation of equipment and issues arising
Arrangements were made for the installation of the VENDLET system, at the beginning of April. The evening before, John’s bed failed and was stuck in the lowest position. However, it was decided to go ahead and fit the system, and then arrange for the bed to be repaired. In the event, the system did not fit and required an extra 20mm on the clamps that held it in place on the bed rails. It was also found that the bed could not be easily repaired. It would cost in the region of £1,000 and take a minimum of two weeks. This meant that carers were having to manage personal care on the bed, with the bed at the lowest height, causing risk of injury to the carers. The decision was taken to have the new bed delivered and for the VENDLET system to be fitted to it. A joint Health and Social Services review would be held once the equipment was in place. The care agency reported that they liked the equipment, but that carers needed training as if Mary was unwell and unable to operate the controls, the carers would need to be able to do this. They reported that their insurance does not allow for family members to train carers in the use of equipment.
Review of specialist equipment
The joint review was carried out with John, Mary and the Occupational Therapist one week after installation. Mary reported that the system was working well and that after two days of getting used to it, she was able to reduce the care package from three carers three times a day to one carer twice a day. John initially said that he did not like lying on his side, but that the system meant that he only had to be turned onto one side now for all care to be completed, and did not need to be rolled onto one side and then the other, which he found much better. John reported that the bed was very comfortable and that it suited his needs.
The joint Health and Social Services decision was that both pieces of equipment should remain in place. Carers reported that they found the equipment very good and it was much easier to complete personal care. A training session was arranged for appropriate staff from the care agency, who would cascade this training to their staff.
Within 4 weeks, John was reporting that he was very happy with the system and his mood has lifted considerably. Mary reported that she is also much happier and feels more in control of their lives which has resulted in reduced stress levels.
Proposed further intervention
John is having his care completed with increased dignity, which has improved his quality of life and state of mind. There is also improved rapport and trust between John and Mary, and Social Services. This may lead to a willingness to accept that spending a period of time out of bed on a daily basis would further improve his condition. A more upright posture would allow for improved breathing, eating, drinking and communication (The Brookside Associates Medical Education Division 2007). Therefore further assessment for a specialist chair and in-chair sling may be appropriate in the future. This is an assessment that may be carried out be the Long Term Physical Disability Team. Health providers are continuing to provide support with physiotherapy and dietician referrals, and the district nurses visit regularly.
The previous concerns which may have led to safeguarding have now been resolved, as have the carer breakdown issues. John’s general mental and physical health has shown marked improvements and his dignity, respect and well-being have been restored. John and Mary are now happy to engage with the authorities.
The care package, which originally consisted of three carers, three times a day, has now been reduced to one carer twice a day and is sustainable for the foreseeable future, with strong contingency plans in place. The equipment was expensive to purchase, but is a single outlay, and if, at any point, it is no longer required, can be easily recycled and used for another client. The financial benefits over time, of providing specialist equipment are considerable (Mickel 2010). However, without the ceiling track hoist John would still need a substantial care package.
Mickel A (2010) A ticking timebomb. Occupational Therapy News. 18(5) 38-39
National Board of Social Services (Assistdata) Denmark (2013) VENDLET V5 wins a prize in London
Available from: www.hmi-basen.dk/en/news.asp?newsid=1106&x_newstype=3
[Accessed 13th April 2013]
NINDS (2012) Peripheral Neuropathy Fact Sheet.
Available from: www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.htm
Richmond W (2013) Manual Handling Risk Assessment and Care Plan Intermediate Care Service, NHS Foundation Trust Berkshire.
The Brookside Associates Medical Education Division (2007) Body mechanics
Available from: www.brooksidepress.org/Products/Nursing_Fundamentals_1/lesson_4_Section_2B.htm
[Accessed 29th April 2013]
Timms P (2012) Improving the Lives of People with Mental Illness – Bipolar Disorder
Available from: www.rcpsych.ac.uk/mentalhealthinfo/problems/bipolardisorder/bipolardisorder.aspx
[Accessed 23rd April 2013]
VENDLET Aps (2011) About VENDLET Aps
Available from: www.vendlet.dk/en/content/about-vendlet-aps
[Accessed 13th April 2013]
West Berkshire Council Community Services (2008) Putting people first in West Berkshire 2008 – 2011 Adult Social Strategy
Available from: www.westberks.gov.uk/CHttpHandler.ashx?id=14582&p=0
[Accessed 29th April 2013]
Intermediate care services care plan
Rapid Response Initial visit was done on the 6.1.13. Patient was referred to Rapid team as he was suffering from diahorrea and his wife was not coping with his care and his skin on his lower back, bottom and the top of his legs was at risk of breakdown.
On initial visit: Patient was assessed by OTto required 4 carers to ensure carer and patient safety in manual handling when rolling. The use of the slings was unsuitable as patient’s skin was raw and sore.
Subsequent visits were done by a manual handling advisor and (bariatric specialist) who supported that 4 carers were required to move patient safely. Patient was lifted using the hoist but on observation it as evident that patient could not be adequately be washed in the sling or on the commode, discussed the option of a smaller bed as carers were struggling as they had to stretch over to reach the patient. Larger slide sheets were discussed and ordered. A sling system (system romedic top sheet) was considered to roll the patient but patient’s wife and the carers said that patient would roll over onto his stomach and they did not feel it would be beneficial.
On a follow up visit, it was agreed with patient’s wife that she should become involved in patient’s care so that she could engage and feel part of the patient’s care. She agreed to this.
Social services OTs are now involved and would like to trial the VENDLET system to aid patient’s movement and reduce care involvement.
Patient’s skin was in a very poor condition on the rapid visit, patient and his wife had declined the DN’s seeing his skin on his legs up until the crisis period. There are concerns that patient’s wife requires support to ensure that patient receives the right level of care, to ensure skin integrity and hygiene to help avoid infections. Patient is vulnerable as he is confined to his bed. His wife answers questions for him and he appears to have limited choices. He has a mental health condition which makes him anxious regarding any changes in his circumstances and he always looks to his wife to help him make decisions.