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A balancing act to retain Alice's independence and improve her wellbeing

Alice’s Wellbeing Consultant balances her initial desire to return home with her overall safety and situation, ultimately making sure that Alice is settled and retains some independence.

Alice had recently started living in a residential home in Canterbury when her solicitor asked Plan with Care to become involved. She had required multiple ambulance callouts and a long stay in hospital. She was saying that she wanted to go home again, but she changed her mind frequently.

When I first met with Alice, she impressed upon me her desire to return home. She did not remember any of the details that had led to her admission and was not able to give details of her home situation or any support package. I sought her permission to involve statutory services and, with her agreement, made a referral to social services for an assessment of her needs with a view to her returning home. After this, a social care worker visited and Alice told her that she wanted to stay in the care home; as such, they said they would be closing the case. In addition to this, Alice had suffered a couple of falls and had lost confidence in moving on her own.

The care home management felt that Alice would be quite unsafe if living on her own, even with visiting carers. I went back to see her again and she confirmed her desire to stay at the care home as she felt safe and well cared for. I arranged to meet with her and the social care worker to ensure that we both were hearing the same message. The care home staff told me that she would sometimes ask about going home. It was a dilemma, as I could see that she would be at high risk of falls and readmission, but that she was clearly torn in her attachment to her home and concerned for her loss of independence. I assessed her mental capacity and determined that, due to her dementia and associated memory loss, she lacked the capacity to make the decision as to where she needed to live. I worked closely with her solicitor, who was holding her financial and property lasting power of attorney. With Alice’s consent, I spoke with all parties, including her sister, her attorney and the care home manager, and it was agreed that it was in her best interests to remain in the care home.

By this point, Alice was more consistently saying that she wished to remain in the home and was asking for her possessions to be brought to her. With her permission and the involvement of her solicitor, I visited her property (she did not want to accompany me) and collected her precious items and all her clothing and toiletries. It was sad to know that she was unable to return to her own home. After such a momentous decision, I made sure that I listened to her wishes to have her belongings, and I looked at what could make her life more comfortable, ensuring that she could maximise her independence while enjoying the benefits of communal living.

Plan with Care arranged for Alice to have a Creative Companion, called Sarah, who visits her at the care home and is able to take her out in the car or just sit and chat. It has become clear that Alice really enjoys these visits – she shares her interest in plants, and they have visited a garden centre. Sarah reports that Alice loves going out as it gives her a sense of freedom and independence. Sarah says: “Her whole persona changes and she engages well with conversation. We also have a laugh. She chose a beautiful orchid that has taken pride of place on her windowsill. It brightens up her room and she is so chuffed with it.”

Although occasionally Alice forgets what has been discussed or arranged, she benefits from the security and structure of her living environment. It is a smaller care home where she is known and loved by the staff and where she has made several friends. She also greatly enjoys the ability to go out with Sarah. Her family have not been able to visit due to distance and their own health concerns, so she is very much reliant on these contacts to reduce loneliness and increase her sense of self-worth and independence. The care home manager also offered her a larger bedroom and told me that, when they helped her move into the room for the first time, Alice was in tears. She said: “I love it, I just love it.” I feel so privileged to have been able to play a part in assisting Alice to decide about her choice of residence and in enabling her to have companionship and to maintain her independence for as long as possible.

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