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Homeward bound

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VOL: 97, ISSUE: 34, PAGE NO: 38

Susan Woodcock, RGN, is nurse manager, Beechwood Place Nursing Home, Malton, North Yorkshire

Beechwood Place is a privately owned nursing home in the Yorkshire town of Malton. It caters for 25 residents with various degrees of dependency. This year we were invited by North Yorkshire social services to join its step-down scheme, an initiative that aims to ease the pressure on beds at the local Malton, Norton and District Hospital.

Beechwood Place is a privately owned nursing home in the Yorkshire town of Malton. It caters for 25 residents with various degrees of dependency. This year we were invited by North Yorkshire social services to join its step-down scheme, an initiative that aims to ease the pressure on beds at the local Malton, Norton and District Hospital.

Step-down was designed for hospital patients who no longer require acute nursing intervention but are not ready to be discharged home. It aims to transfer them to a nursing bed in the community, providing a more homely atmosphere than a hospital ward and greater mental stimulation and social interaction.

Beechwood Place Nursing Home had been involved in a similar scheme during the winter bed crisis a few years ago. That project proved beneficial, not only for the hospital, clients and their families but also for the home.

We were asked to admit a 78-year-old retired farmer who had spent more than a year in hospital after a carotid endarterectomy. Les Dennis had two cerebral vascular accidents after the surgery that left him with a right-sided hemiparesis.

His medical history included aortic aneurysm repair and carcinoma of the prostate. He was depressed and there was concern that, given his long stay in hospital, he was at risk of becoming institutionalised. A move was expected to benefit him in a variety of ways.

A package of care was arranged around a six-week stay at Beechwood Place Nursing Home, with the option of extending this if necessary.

Discharge information from the hospital stated that Mr Dennis required close supervision and the assistance of at least one person, possibly two, to enable him to get around. He also needed help attending to his personal hygiene.

Mr Dennis had been having physiotherapy in hospital but had not responded as well as expected, despite encouragement from the nurses and physiotherapists. This was attributed mainly to a lack of motivation and his depression, and the consensus was that this pattern had to be broken. The team caring for him hoped that a change of environment would help to turn things around.

Before his admission to hospital, Mr Dennis and his wife had been enjoying their retirement from farming in a fairly isolated farmhouse. Their home was some distance from the nearest road and was approached by a wide farm track that had numerous potholes. This had caused problems when attempts had been made to arrange a domiciliary care package to allow Mr Dennis to return home. Agency staff were reluctant to risk damaging their vehicles by taking them down the track.

The multidisciplinary team and the local social services department decided that a short-term package of care in a nursing home would allow a full assessment of Mr Dennis' needs to be made. The package included extensive physiotherapy from the community physiotherapist, who organised a series of in-house training sessions for care staff in the nursing home.

This ensured that the care staff were fully aware of the exercise regime and moving techniques that were essential to improve Mr Dennis' mobility and capabilities. They were also encouraged to use these skills with other residents at the home.

Three days after Mr Dennis was transferred to the nursing home, his wife came to visit and was impressed by the marked improvement in his mobility and mood. She was waiting for a knee-replacement operation, which was delaying arrangements for his return home.

The couple were also waiting to be rehoused by a local housing authority to a bungalow in a nearby village. Had the bungalow been available, and had Mr Dennis' wife had her knee operation, there would have been few obstacles to sending him home with a care package in place. However, alternative plans had to be made.

Within a week of his admission to Beechwood Place Nursing Home, the physiotherapist had managed to get Mr Dennis to perform his exercise regime regularly. He was moving around well, using a walking frame and the help of just one carer. Through socialising and interacting with the other residents at mealtimes his mood progressively improved, as did his appetite.

The fact that he had a single room at the end of a quiet corridor meant he was able to establish a regular sleep pattern, which boosted his energy levels and enabled him to continue with the exercise programme. After the third week he was able to manoeuvre himself in and out of bed unaided, although there was always someone at hand to ensure his safety.

He was immensely proud of this achievement and was keen for the day staff not to pass this information on to the night staff - he wanted to surprise them.

A month after Mr Dennis arrived at the nursing home, a multidisciplinary team meeting was held. It included Mr Dennis and his wife, their son, the home's nurse manager, his care manager, and the community and hospital physiotherapists.

A home visit was arranged to identify any necessary alterations to the house. The visit resulted in a decision to move a single bed downstairs and fit bed grips for convenience and safety.

After discussions between the nurse manager, the care manager, Mr Dennis and his family, a decision was made to discharge him a week later. As a result of assessment under the NHS and Community Care Act 1990, a care package was devised and Mr Dennis' priority status was judged to be high.

A community-based care group was approached to arrange morning and evening visits to help with Mr Dennis' personal hygiene requirements and in getting up and going to bed.

The occupational therapist assessed the family home and recommended fitting an extra grab rail for use with the commode, enabling Mr Dennis to be as independent as possible. The occupational therapist arranged to meet care agency staff to offer professional support, while the community physiotherapist agreed to continue to work on improving Mr Dennis' mobility. The local wheelchair centre was contacted to assess whether he needed an electric wheelchair, even though one had been provided before discharge from the nursing home.

The district nurse at the local medical centre was informed of Mr Dennis' transfer home and agreed to be available if required. The care manager agreed to maintain contact and liaise via the telephone with service providers, professionals and carers.

A date for the review of the patient's care was set for six weeks later. Two homes in the area run by social services agreed to hold Mr Dennis' details and provide respite care if necessary.

As the day of discharge drew nearer Mr Dennis became excited and emotional at the prospect of returning home after such a long time. On the day of discharge the physiotherapist and two occupational therapists from the hospital arrived at the nursing home to work through the programme of exercises and show him how to manoeuvre the wheelchair. The occupational therapists went on ahead to raise the height of the bed and armchair.

There was a tearful and emotional farewell before Mr Dennis left and a care assistant who had often looked after him went along to ensure his safe return home.

Mr Dennis had been institutionalised for more than a year, yet he was able to return home with support services in place within the projected six-week period. Thanks to the cooperation of all parties involved, the step-down scheme proved to be an excellent framework for his return to the community.

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