Chapter 5 – Residents with a Disability5.0 Residents with a Disability5.1 IntroductionIt is likely that a large proportion of almshouse residents will suffer some form of disability. Disability is often defined as a gap between a person’s abilities and the fulfilment of the basic activities of daily living. Those who arrive fit and able may gradually develop, even with the best of support from almshouse staff, mobility problems and increased weakness as they age. Arthritis, osteoporosis, diabetes and stroke can all lead to increasing disability.Some disabilities may, of course, be temporary after illness and therefore treatable. If a resident develops a sudden and unpredicted onset of disability, it should not be assumed that this is just an age-related inevitability and medical advice should be sought immediately.This chapter deals with the specific issues to consider when residents have some degree of stable disability.5.2 Rights of Disabled PeopleThe Chronically Sick and Disabled Persons Act 1970 (CSDP Act) and The Disabled Persons Act 1986This legislation gives people with disabilities the right to support from social services. The definition of disabled applies irrespective of age and it is not a requirement to be registered as disabled to qualify for these services. Once the Local Authority agrees that, according to its criteria, the resident needs a service under the CSDP Act it cannot use lack of resources as an excuse for not providing it. The local social services department will have information about the services provided and the eligibility criteria.If not satisfied with the service, e.g. there is an unjustified delay in its provision or failure to abide by the agreed procedure, complaints can be made within 12 months of the incident either through the Local Authority or through the Local Government Ombudsman (see Appendix B).Disability Discrimination Act 1995/Equality Act 2010Trustees are reminded that the Disability Discrimination Act 1995 came into force in October 2004 (this Act was consolidated in the Equality Act 2010). ‘Reasonable adjustments’ are required to be made to some communal facilities to overcome physical barriers to access. Since December 1996 it has been unlawful for trustees to treat disabled people less favourably because of their disability. This means that trustees, as service providers, may face a legal challenge if a resident has to leave the almshouse because reasonable modifications have not been made to the communal areas. Trustees should note that the legislation does not apply to almshouse charities or to listed buildings. All new buildings have to comply with the Act and trustees should use their best endeavours to make their present buildings accessible to disabled people.5.3 Adaptations to BuildingsNew almshouses are now designed with disabled people in mind and have wide doorways, turning circles in bathrooms, and hall and living areas to accommodate walking frame use. It is usual to fit a level or low-level access shower with seat, handrails and thermostat instead of a bath, although there is also a wide choice of special baths suitable for individual homes.In some new developments one or two homes are designed for full wheelchair access. In these the kitchen and bathroom worktops are lower, cupboards and windows are within reach of the wheelchair user and other fitments are placed in a more suitable position for the individual resident. Adjustable kitchen and bathroom worktops provide greater flexibility. Some schemes will have a disabled bathroom with a mechanical assisted bath which residents can use independently or with the help of a carer. Trustees should note that equipment provided for a disabled person’s private use (level access showers, stairlifts etc) can be zero rated for VAT (Value Added Tax Act 1994). Charities can take advice from The Almshouse Association Panel member specialising in VAT, or other professional consultant.As the reduction in price of electric mobility scooters has made them more accessible, there is an increased demand for secure storage/re-charging facilities. Where space is limited trustees may need to limit the number of scooters allowed on a site. In addition, consideration may be given to making a small charge for the use of electricity. Although there is no legal requirement, residents should be encouraged to have third party insurance cover for their mobility scooters.Adapting an old almshouse for full disabled person use is more difficult but many improvements can be made in liaison with Occupational Therapists (OTs). OTs will be able to advise on general principles of design and specialise in tailoring accommodation to individual needs. They will assess the resident, recommend the aids and adaptations that will help in day-to-day living and arrange for their installation. Residents can apply for a means tested Disabled Facilities Grant, usually via social services, for the cost of adaptations such as level access showers to enable them to continue to live in their homes.There are some design features which are helpful to both disabled and able-bodied residents:Plenty of accessible electric points and switches placed at a height to avoid the user bendingThermostatic valves fitted to the tops of radiators for easy access and controlLevel, non-slip floors throughout the accommodationLevel access to and from the home, with grab rails as appropriateLevel or low-level access showers with bi-folding doors and hand rails. Shower hose fitted onto grab rail riser for an extra support optionTaps (basin and showers) with lever handlesLarge handles and knobs, where possible in contrasting colours, on doors and fixturesWhere possible, natural lighting. Lighting in common areas (external and internal) fitted with a daylight control option which makes the best use of natural light (and saves money!)Small profile window frames to allow more glass area therefore more natural light. Trickle vents to aid passive air ventilation. Top hung windows to allow low level opening, with opening restrictors to prevent falling. Where windows are the traditional side opening windows, extended openers or winder action openersWalls/passenger lift doors painted in different colours on different floors to aid recognitionStairs/steps with clearly distinguished non-slip nosings and hand rails.A useful contact is the Centre for Accessible Environments (See Appendix B).There are also charities (Remap, Demand – see Appendix B) which can provide bespoke equipment where suitable aids are not available through mainstream sources.5.4 Dementia and ConfusionDementia is a progressive disease for which there is as yet no cure. It is probably the most difficult disability for trustees and wardens/scheme managers to deal with. The term dementia describes a set of symptoms which can include memory loss, mood changes, a lack of awareness of time and problems in communicating and reasoning. The two most common diseases which cause dementia are Alzheimer’s disease and Vascular Dementia and together these account for nearly 90% of cases. Although some symptoms of dementia are common, every experience is different and can vary according to which part of the brain is affected, the personality of the individual, and their differing experience.Dementia is rare in people under 65 but it has been estimated that 1 in 100 are affected between 65 and 69 and this figure rises to 1 in 6 for those over 80. A person with Alzheimer’s disease tends to go downhill at a regular pace though not invariably. A person suffering from other forms, such as some types of vascular dementia, is more likely to deteriorate in steps. Further information on these can be obtained from the Alzheimer’s Society. (See Appendix B).Dementia can cause bizarre and out-of-character behaviour that can be very disturbing to everyone. Family members and significant friends should be kept informed of the situation at all times and their help sought in any intervention to monitor or regulate the resident’s behaviour.Some forms of memory problem are not permanent and can be caused by a range of emotional, physiological and physical ailments which bring on dementia-like symptoms. It is important that a full diagnosis be obtained to eliminate the possibility of other causes of memory problems before a medical prognosis is made.Residents who develop dementia after occupying an almshouse for some time usually do better than those who move in when they are already confused. They are used to their environment and they are often helped and supported by their neighbours who have known them prior to developing dementia. At some point the resident may need to move into a more secure environment but, in the meantime, staff, trustees, family and other residents should give as much support as possible. When a person with dementia finds that their mental abilities are declining, they often feel vulnerable and in great need of reassurance and support. It is essential that all those affected are treated as individuals and with courtesy and respect. Other residents must be reminded that dementia is not contagious and encouraged to have the generosity of spirit to help the afflicted resident, or to show, at the very least, the necessary kindness and patience.Practical measures should be taken where possible to enable a resident suffering from dementia to remain in their own home. For example, if necessary, cookers should be disconnected and front door locks adjusted so that it is not possible for the resident to ‘deadlock’ the door. Notice boards can be used to remind the resident of the day’s events. Pictures on doors indicating the room inside may help residents recognise where to go. Residents with dementia may not be able to use an alarm pendant as they may not be aware that pressing it is a call for help.A major problem with people who have memory lapses is managing their finances. A family member or friend whom the resident trusts should take responsibility for dealing with the resident’s bills, pension and other money matters. The charity should not become involved.Arrangement of direct debit payments may simplify matters for relatives and advocates.Residents with dementia should always have someone accompany them to hospital appointments/admissions. Where family or friends are not available it may be possible to organise for a community volunteer (via, for example, Age UK) to fulfil this function. The accompanying person should be fully briefed on the medical history and symptoms of the resident as referrals from doctors can sometimes contain brief details only. Some hospitals have introduced a system whereby anyone with a care need or disability (including dementia) can apply for a ‘Care Card’. This card will alert the admissions clerk/receptionist at the hospital that the person requires help.The taking of medication can become a problem with confused or forgetful people. Make sure that the doctor is aware of the resident’s mental state and ensures that all medicines are clearly labelled. Alternatively, the pharmacist should be asked to prepare a pre-packed dosette box for each day of the week. Then the presence or absence of a tablet will remind the person or the carer if the medication has been taken. In some areas pharmacies will deliver medication on a daily basis (during the working week). This is particularly helpful if a resident is prone to taking too few or too many tablets during the day. See Chapter 4.7- Medicines Policy.As the symptoms of dementia vary from person to person, so do the reactions of neighbours, capacities of trustees, staff and the facilities of housing. It is difficult for trustees to establish generic policies to cover every eventuality. However, there may come a point when a resident’s behaviour is putting that resident or others at risk. Confidential records must be kept of any unusual behaviour so that if a decision needs to be made that an almshouse is no longer appropriate, these can be used to assist professionals and family to determine future accommodation needs.Trustees need to take into consideration the effect on the safety and wellbeing of the almshouse community when managing a mentally impaired resident. Residents must be allowed as much choice and freedom as possible to live as they wish, however, there may come a point when the resident causes unacceptable disturbance or becomes a danger to him/herself and others.If a good rapport has been maintained with a resident’s family, doctor and social services, then a move to more suitable accommodation may be arranged without contention. There are occasions, however, when opinions differ. If the trustees or almshouse staff, through their daily contact with the resident, consider that the almshouse environment can no longer meet the resident’s needs but the family or the doctor disagrees, it is advisable to ask for an independent gerontologist’s report. The trustees may have to pay for this specialist report out of the charity’s funds. If the report reflects the trustees’ opinion, Social Services will act accordingly, as soon as there is a suitable place available and the funding issues have been agreed.When considering appointment of a resident with dementia, trustees must establish the extent to which it is likely to affect their ability to live independently. A move to a new home can, in some cases, exacerbate the disease. The new environment can increase feelings of disorientation and can lead to dangerous behaviour. Other residents will be less likely to be patient and supportive with someone they do not know. In this situation, it is prudent to appoint a new resident on a temporary basis with an agreement with the next of kin that the appointment will be confirmed once the settling in process has proved successful.A few of the larger almshouse charities have residential accommodation for the Elderly Mentally Infirm (EMI units). EMI units are the exception for almshouse charities.5.5 Learning DisabilitiesWhere the charity’s governing document permits, trustees may house people from the community of any age who have learning disabilities but can still live independently with a degree of support. In a small group of almshouses such residents can be intermingled with the older residents very successfully. On other sites there may be a group of flats purpose-built for those with learning disabilities but sharing communal facilities with older residents.It is important that social services undertake to provide a suitable care package to support a resident with learning disabilities. As trustees and staff do not necessarily have the expertise to deal directly with these vulnerable people, social services should appoint a support worker for each individual. Sometimes trustees may employ a specialist agency for day-to-day management, if not, it is beneficial if any staff have specialist training to understand better the particular problems associated with housing this group of people. Specific advice can be obtained through MENCAP (www.mencap.org.uk).5.6 Hearing ImpairmentHearing loss is one of the most common conditions affecting older adults. There is no cure for age-related hearing loss but advances in technology have led to a large number of devices, gadgets and other methods to improve everyday function.Many people may not want to admit they have trouble hearing. However, failing hearing can lead to social isolation and depression, and also to a greater risk of accidents because warning alarms may not be heard.A telephone hearing check is available through Action on Hearing Loss (tel. 0845 600 5555). Residents who suffer deafness should be encouraged to obtain an audiology assessment, usually via their doctor, to ascertain the most suitable treatment and/or aid. Most hospitals will run hearing loss clinics where residents can go for advice, support and information.Older people are often reluctant to use a hearing aid, either because they are unwilling to accept the physical effects of ageing or simply because the aids are uncomfortable and can take several months to get used to. Residents should be encouraged to persevere and learn to use and adjust hearing aids, firstly with one other person in a quiet environment and then in noisier surroundings with more people. More sophisticated hearing aids amplify only the frequencies no longer naturally heard by the wearer and so adapting to the hearing aid is easier.The two most common causes of hearing aid failure are (1) discharged batteries and (2) inadequate insertion of the aid. The latest NHS hearing aids have the volume set by the audiologist’s computer.There is a wide range of aids and adaptations for people who have hearing difficulties, including flashing lights when the doorbell rings, modified alarm clocks, screen or text telephones, induction loop systems for communal areas and residents’ homes (the latter being particularly useful to reduce unwelcome television noise). Some devices, such as personal loop systems, used to be available on loan through social services departments. Widespread cuts have, in many cases, meant that social services departments are only in a position to supply such devices on loan on trial for a short period of time.Particular consideration should be given to fire safety devices for deaf people. Smoke alarms are available, designed particularly for the profoundly deaf, which use vibrations and flashing strobe lights to raise the alarm. Most Fire Services will offer free home visits for vulnerable people where they will advise on fire safety and install free smoke detectors. Many also have a range of fire safety devices for visually and hearing impaired people.It is common for people who develop age-related deafness to suffer also from tinnitus - constant noises in the ear. A hearing aid can often override the tinnitus noise. Some sufferers find a sound generator helps; it looks like a hearing aid but plays a sound designed to mask the tinnitus noise. If tinnitus is causing sleep disturbance, sufferers are advised to have quiet music playing. There are devices on the market which produce therapy sounds. Some audiology departments have specialist tinnitus clinics which offer counselling, advice on sound therapy, relaxation techniques and other advice on ways to cope with living with the condition.For more information on what can be done to help with all hearing difficulties, contact social services. Other organisations which can help are listed at the end of the Chapter - see Appendix B for contact details.5.7 Visual ImpairmentMost people experience some decline in vision as they age. Many residents expect their glasses to continue to be suitable for many years when their sight is actually deteriorating. Free eye tests are available for people over 60 years and residents should be encouraged to have a comprehensive eye test on an annual basis.More serious vision loss can be as a result of conditions such as age-related macular degeneration, glaucoma, cataracts and diabetic retinopathy. In conjunction with other physical and social problems of old age, vision loss can have profound implications for older people’s well being. Anyone experiencing sight loss is very likely to suffer feelings of loneliness, helplessness, anxiety and depression. There is a range of support services, charities and devices that can help make life easier for those losing their sight.Social services’ sensory loss teams employ specially trained advisors to provide visually impaired people with information as well as practical and emotional support in order to help them remain, or become, as independent as possible.Someone with poor vision that cannot be corrected by glasses may be registered partially sighted or blind by the hospital eye specialist. Registration can make it easier to take advantage of a range of special services, equipment and advice provided by social services and voluntary organisations, and to qualify for certain benefits.If trustees are designing communal areas with vision impaired residents in mind, it is often helpful to have colour and texture contrasts at entrances to different areas. All switches, plugs and controls should be designed with visually impaired people in mind. Every effort should be made to provide contrasting features to help people who cannot see very well maintain independence. Almshouse staff can help by ensuring that any correspondence or notices are printed in large, bold print in a clear font.Details of some organisations which can help are listed in Appendix B.5.8 Dual Sensory LossIncreasing numbers of older people are developing hearing and vision loss. Most often, a person has just one of these disabilities and the second develops gradually. There can be a delay before the second disability is recognised and subsequently diagnosed. The impact of a dual loss is significantly greater than a single loss as the individual’s ability to compensate is greatly reduced. People suffering from dual sensory loss have different needs to those suffering exclusively from blindness or loss of hearing and will require a combination of services.For more information about what can be done to help with dual sensory loss, contact social services, Sense or Deafblind UK (see Appendix B).5.9 Communicating With Disabled ResidentsWhether a trustee/staff member is communicating with a resident with any kind of sensory loss or with dementia, there are a number of practical techniques which can be used to ensure that they are being understood. Communication takes a great many forms, for example, speaking and writing, facial expressions, actions and gestures. Even the way in which a person sits or stands conveys a message.Anyone communicating with a deaf person can help by making sure that they attract the person’s attention before speaking, face him/her in good light, speak clearly and slowly, augment speech with gestures and write down the important issues. Shouting is positively unhelpful because for some individuals it produces more distortion and thus distresses the non-hearer more. Be aware that just because a person is nodding and smiling, it does not necessarily mean that they have heard and agree with what is being said.When talking to a resident with sight loss, remember that they may not be able to discern facial expressions which most of us use to accentuate aspects of speech. It is also good practice to ensure that correspondence to all almshouse residents or notices to be displayed are in a large, bold print using a clear font.When communicating with someone suffering with dementia, it is generally best to communicate with single, short, simple and specific sentences. Break any complex message into parts and ensure that one piece of information is given at a time. Do not change the subject too quickly. Reduce, if possible, any conflicting background noise (TV or radio). The use of a slow, soothing voice can be very effective in reducing agitation. Listen to the intonation being used by the resident – this may be communicating more than the words being used.Attitude also matters. Always be courteous and respectful and assume that the individual has greater intelligence than oneself until proved otherwise!Any person suffering a disability risks depression and isolation. They may increasingly avoid any physical or social challenge which in turn is likely to lead to further isolation.The charity should encourage disabled residents to take part in all communal activities. Sometimes all that is needed is a little extra help and, even if a resident cannot fully participate in a particular activity, the benefit to be gained by taking part and being part of a group can be enormous.5.10 Mobility and WheelchairsA wide range of wheelchairs including simple push chairs, self-propelled chairs and electric powered chairs is readily available for purchase in most major towns and cities. The advice of a doctor, specialist or local mobility or disability advice centre should be sought before making a purchase. Factors such as the weight of the chair and if it is foldable for storage or stowing in a car boot should also be considered.Wheelchairs are also available through NHS Trusts. The way NHS wheelchair services are organised, the assessment criteria, the timescales in which equipment is provided and the way in which wheelchairs are funded all vary from area to area.Depending on location, referrals to a local NHS wheelchair service can be made by a hospital, GP, consultant or occupational therapist. Some services may operate a self referral system.Assessments are normally carried out at NHS wheelchair services centres by a professional qualified in wheelchair assessments. Sadly there is often a long wait for an assessment. Eligibility criteria vary but usually look at the nature and level of disability, lifestyle needs and ability to use the equipment on offer. As a person's needs may change, the wheelchair service may conduct a repeat review to see if different equipment is needed.Many primary health care trusts and health boards operate a voucher scheme for people who are assessed as needing a wheelchair.In most areas there are charities or organisations that will hire out wheelchairs for people who need them for a short period. In many areas this service is offered by the British Red Cross.The not-for-profit Motability Scheme also sells or hires out powered wheelchairs and scooters.Trustees should be cautious about providing wheelchairs for use which have been donated or left by a former resident although these can be useful in an emergency. For Further Information:Action for Blind People - www.actionforblindpeople.org.ukAction on Hearing Loss - www.actiononhearingloss.org.ukBritish Red Cross Society - www.redcross.org.ukBritish Tinnitus Association - www.tinnitus.org.ukCentre of Accessible Environments – www.cae.org.ukDeafblind UK - www.deafblind.org.ukDemand - www.demand.org.ukHearing Link - www.hearinglink.orgLocal Government Ombudsman – www.lgo.org.ukMacular Disease Society - www.maculardisease.org.ukMencap - www.mencap.org.ukNational Association of Deafened People - www.nadp.org.ukRemap - www.remap.org.ukSense - www.sense.org.uk© 2013. This document is copyright of the Almshouse Association and no part of it may be produced or published without the Association's written consent.