Flexible service for people with dementia delivers results

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A new specialised service introduced in Suffolk earlier this year and run in the county by Care UK is proving successful in helping older people with dementia to keep their independence and remain living at home when it’s in their best interest to do so.

The flexible dementia service aims to prevent unnecessary change for the person with dementia by providing a full assessment of their situation as soon as a problem is identified. The Care UK team responds within a few hours of receiving urgent requests which can come from GPs, adult social services teams or even local hospitals.

Paul Fletcher, one of Care UK’s team managers for the service, says: “By responding quickly and spending time to fully assess the situation and understand the patterns of behaviour in the person with dementia we are preventing unnecessary and unwanted moves out of familiar surroundings.”

Carers from Care UK conduct a 24 hour continuous assessment to understand the behaviour and other factors which are causing concern. This will include gaining an insight into what is triggering the person with dementia, for example, to wander off at a particular time of day, or what’s causing the safety issues affecting themselves or others such as leaving gas cookers alight. 

After gaining a comprehensive understanding of the situation the Care UK team continues with their additional care and support for four to six weeks whilst it develops the right longer term plan with all the agencies involved such as the local social work team. The priority is to ensure that any new care plan meets the identified needs of the person with dementia and once this is agreed Care UK hands over responsibility to the regular care provider.

Helen Gray is Team Leader at the West Suffolk Mental Health Intermediate Care Team – part of Norfolk and Suffolk NHS Foundation Trust - and she has been involved with quite a few of the cases managed by Care UK. Her role is to work with people with dementia, assess their mental state and work with them and other agencies to meet their needs.

She says: “The service has definitely made a difference because it has brought an alternative solution and better outcome for people who would otherwise end up in hospital or residential care which isn’t necessarily the long term need. Equally where people are temporarily unwell then having to move makes it a whole lot worse. Care UK is very much focused on the care aspects of what the person with dementia needs and we all work closely together as a team.”

‘Care UK managed to tease out the issues which needed to be addressed’

Douglas New, whose mother Edna, aged 86, lives in sheltered housing in Sudbury, came into contact with the flexible dementia service when his mother’s dementia led to her becoming agitated and wandering at night into other residents’ apartments and sometimes even into their beds. She is deaf and a stroke has left her partially blind.

He says: “I feared the issues with mum wandering would lead to her having to go into residential care but Care UK were called in to have a fresh look at the situation and did a good job observing how her current care was being delivered. They could have said she needed to be somewhere else with a higher level of care but that wasn’t the outcome.”

The flexible dementia service meant that the Care UK carers, who are trained for the specialist care required for people with dementia, could provide additional help to Mrs New on top of the regular care visits she was already getting, whilst they gained a full understanding of what would be the best plan for care going forward. They liaised with her son and facilitated the relationship between all the parties involved whilst a new care plan was drawn up.

In addition, over the period of assessment, Care UK provided more activity including walks in the garden or to a local café and more stimulus in the home.

Douglas adds: “Care UK managed to tease out the issues which needed to be addressed and have continued to work closely with the staff at the sheltered housing, social services and myself on the new care plan, which they will also help review in six weeks’ time.”

Under the on-going care plan carers attend Mrs New at every meal time, in the evening to get her into bed and at midnight to check all is well. Added supervision is included so that she finishes her meals, drinks enough fluids, washes properly and goes to the loo regularly; all of which helps avoid urinary infections and/or agitation which can be a cause of her wandering.

Edna’s son concludes: “With their specialist dementia expertise the Care UK carers can look and see what can be done to keep people in their own home. In our case it’s led to mum’s situation being properly understood and it is now much improved, including less wandering because her eating, fluid intake and loo visits are all more closely supervised. It’s really perked her up.”

Photo: Mrs New as a young woman

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