The Care Inspectorate received a complaint concerning the support of a resident in a care home, Mrs Wright.

A concerned daughter who visited recently from abroad has written to complain that there has been "inappropriate supervision" offered to her mother, a lady of 76 years of age. She describes her mother as being vulnerable and experiencing severe memory loss. The care home where Mrs Wright resides is registered with the Care Inspectorate and provides specialist care for people with dementia. Mrs Wright had been living in the care home for some five months by the time the complaint is received.

Mrs Wright's other daughter, who lives locally, did not participate in the complaint. However, in the past had been concerned for her mother's safety, especially concerning her desire to go outside unaccompanied since she received a diagnosis of dementia.

The care home supporting Mrs Wright

Around four months before the complaint, the care home manager left on long term sickness leave, following many episodes of absence. Another manager, from a different home, has taken over. At the time the new manager takes over, the care home has received, on average, grades of 4 at the most recent inspections.

The new manager quickly started getting to know people, exploring care plans and conversing with staff, families and people living in the home. The manager was concerned by numerous reports from staff that Mrs Wright frequently behaves aggressively towards them, and appears reluctant to accept care and support.

The new manager reviewed the care plan and realised that Mrs Wright was displaying more distressed behaviour. It was clear that "as required" sedatives were being used more often and staff were more regularly reporting on how "challenging" and "aggressive" Mrs Wright was, particularly when she wanted to go out.

From outcomes focused conversations with Mrs Wright and observations it was clear that Mrs Wright enjoyed going out. She described how she loved to window shop, enjoyed walking and the outdoors. She repeatedly mentioned her frustration at not being able to get out and about.

The manager reflected on whether the culture in the home meant that balances between independence and safety for residents were needing reviewed. Staff were genuinely worried about the safety of Mrs Wright and other residents with dementia. However, this concern resulted in a more limited ability to see the importance of their role in promoting and facilitating independence.

The manager wanted to nurture a different culture in the home by leading staff, family and the community through an innovative process of change. For Mrs Wright this involved working with her, the staff, the daughter who lives locally, local shops, the church Mrs Wright used to attend, the involvement of social work and Mrs Wright's mental health nurse. Mrs Wright's care plan was comprehensively reviewed to reflect what she wanted; "to get out and about". The plan for a period of three months was agreed.

The desired outcome of the plan was for Mrs Wright to have more independence - but this involved significant mind set changes for everyone with a role supporting Mrs Wright.

Investigating the complaint

Upon visiting the service and conversing with Mrs Wright, the care home manager and staff, the Care Inspector finds out more about Mrs Wright's recent independence plan. The information below is a summary. Mrs Wright's plan for going out independently

1. At the beginning of the three month period, Mrs Wright had one-to-one support on daily outings to the local shop, post office and park. Mrs Wright found this very frustrating as she knows the area well and did not understand why members of staff were with her. Sometimes she had to wait for staff to be available to go with her. Mrs Wright's daughter living locally supported this and scheduled some visits at convenient times to join her mother on outings. Although Mrs Wright enjoyed her company she still wanted to get out on her own, when she wanted. A considerable amount of work and time was spent explaining this plan to Mrs Wright to help her to understand why this was happening.
2. This support then reduced and the staff member supporting Mrs Wright began to observe her from a distance on outings. At times, Mrs Wright would call out that she was "being followed" and again much investment was made to help her understand the responsibilities she and everyone had in making sure she was safe. Conversations with staff members, some key local shops where Mrs Wright often visited when out, her daughters and the manager are recorded, helping to evaluate Mrs Wright's care plan, in addition to the outcomes of various outings.
3. Eventually a tracking device was introduced (GPS, global positioning system). It became clear that Mrs Wright never left without her handbag, so the device was placed in her bag when she went out. Before this happened, the manager, Mrs Wright and the keyworker sat down with Mrs Wright's daughter in order to explain what this was for and obtain Mrs Wright's permission to monitor her using the device. Mrs Wright's social worker was also informed. Mrs Wright called the device the "gadget". She did at times question what it was for and a discussion was had to go over why it was needed and what it was for. In discussion with Mrs Wright, the Care Inspector was able to ascertain that she did have some awareness of what the device was for.
4. After around ten weeks, which included one week of distanced support when the tracking device was active, Mrs Wright went out by herself. The staff continue to follow a protocol which supports them to monitor her whereabouts via the GPS, but Mrs Wright can go out when she wants to. Initially staff monitoring her whereabouts were concerned that she was returning to the house where she used to live. They had gone out to offer support, in case she was confused and trying to get into the house. However when they saw her she was sitting on a bench near the house watching it. When they sat with her she explained she was reminiscing about old times. After two weeks of monitoring Mrs White it became apparent that she had particular routes and places that she visited and this reassured staff that Mrs Wright was able to get out and about safely.

Outcome of the complaint investigation

The complaint was not upheld. The Inspector found that the supervision offered to Mrs Wright had been carefully planned, evaluated and resulted in the promotion of Mrs Wright's independance. However, the Inspector did recommend that the staff in the home should discuss the purpose and aims of Mrs Wright's care plan in more detail with the daughter who had made the complaint. They suggested that skype might be useful to allow the daughter to discuss with her mother and the staff the support offered and how it allowed Mrs Wright to "get out and about" in an appropriately planned and supportive way.

References

Bartlett, R., and O'Connor, D. (2007) From personhood to citizenship: Broadening the lens for dementia practice and research. Journal of Aging Studies 21(2): pp 107-118.
Accessed via OpenAthens, March 2015, at Sciencedirect.com

Duffy, S. (2013) Imagining the future: Citizenship. Centre for Welfare Reform. (Publisher: IRISS)
Accessed March 2015 at Centreforwelfarereform.org

Sanderson, P. (2011) The Citizen in Regulation. Cambridge Centre for Housing & Planning research. (Publisher: University of Cambridge)
Accessed March 2015 at Gov.uk