Chapter 9 – Prolonging Occupation and Moving On |

9.0 Prolonging Occupation and Moving On

9.1 Introduction

It is a cause for celebration that so many older people now live longer and healthier lives compared with the not too distant past. However, increased longevity has brought with it challenges for everyone involved in the commissioning or provision of services for older people. While some older people will enjoy the benefit of good health well into their latter years, sadly, many will live with increased frailty, reduced mobility and other problems associated with physical and mental ill-health.

It is an essential part of the almshouse philosophy that it aims to maintain an environment that supports residents for as long as possible, even until their death. This chapter seeks to highlight some of the issues involved for residents requiring nursing or residential care.

As a general principle it can be helpful if links are developed with local organisations providing extra care, residential or nursing care so that contact can be made more readily on behalf of a resident when the need arises.

It is important to remember that the deterioration in health or ability to remain independent is usually a gradual process. Residents often reach a ‘grey area’ of growing need that will be variable. It is during this period that options for the future need to be explored sensitively with both the resident and family.

9.2 Planning for Frailty

Strategic questions that trustees will need to consider, ideally in consultation with residents, are:

Does the charity know how to help residents access services for older people? If not, how can it ensure that the necessary knowledge is acquired and maintained by the appropriate people? How can the charity ensure that this knowledge is communicated to residents who need to know and that residents are supported in obtaining appropriate access to services?
Are the almshouse dwellings and facilities suitable for older people with mobility needs? If not, what can be done to make them so? Is there appropriate expertise within the charity, or is professional advice required? If this involves financial resources which the charity does not have, how can financial resources be increased?

If an almshouse charity is unable to provide funding to improve access and facilities for their residents, some funding can be obtained through Disabled Facilities Grants. Chapter 8 of Standards of Almshouse Management (SAM) provides detailed advice on funding projects.

9.3 Hospital Admissions and Discharge

The charity should have an established policy and procedure for hospital admission and discharge. There should always be communication between the hospital and the charity and discharges should be planned whenever possible.

9.3.1 The Admissions Process

Short Pre-planned Hospitalisation Periods

Careful communications with, and the confidence of residents, will very often result in the clerk or one of the trustees being made aware of a proposed period of hospitalisation for a resident. In most instances such scheduled small operations and hospitalisation periods will pass without any real consequence.

Delays in or Re-scheduling of Hospitalisation Periods

The trustee body may well have minor refurbishment plans in place for the period when a resident is knowingly planning to be absent from their dwelling. It is essential to remain flexible in the circumstances of a planned hospitalisation since many elective operations will be postponed at very short notice by the NHS. Any planned work to the premises under agreement or contract must therefore be flexible and realistic for the timeframe of planned absence. Careful discussions should also have been conducted to ensure that any minor refurbishments do not create additional worry or anxiety over and above that which the resident is already experiencing.

Emergency Admissions

Such admissions will cause the greatest difficulty. Whether admission follows a slip, trip or fall, a sudden debilitating illness, or the rapid onset of physical or mental frailty, it may take both family and the trustee body by surprise. There is a real need to be prepared for this eventuality.

Admissions Letter

Irrespective of the nature of the admission, there should always be communication between the hospital and the almshouse charity, thereby ensuring that both the Ward Clerk and the Hospital Discharge Coordinator understand the ethos of an almshouse charity and that it is not able to provide any form of personal care, administer medicines or provide meals. This is especially important if the name of the almshouse charity includes the word ‘hospital’ which can be misleading.

The purpose of an admissions letter is twofold. First of all it will advise the hospital that their patient is an almshouse resident and that the charity will have to give approval for the discharge to take place back to the almshouse dwelling - if this is suitable and appropriate.

Please see Appendix D for a model Admissions Letter

The Period in Hospital

One of the trustees, the clerk or, if appointed, the scheme manager or warden, should maintain communication both with the hospital and the resident throughout the period of hospitalisation.

Suitable arrangements need to be made to safeguard the almshouse while a resident is away for a short period. Potential hazards include plumbing and heating issues, security of doors and windows and any sign that the property may be unoccupied. If the almshouse charity does not have on-site staff, other residents or local neighbours might be willing to keep an eye on the property for the charity.

9.3.2 The Discharge Process

The framework for a discharge from hospital is established under the NHS & Community Care Act 1990, the Community Care (Delayed Discharge) Act 2003 and the Hospital Discharge Policy. If the hospital authority believes that an individual is ready for discharge, it is entitled to do so provided that discharge is safe and that the agreed support is in place, services are ready to start, adaptations have been made to the premises and equipment has been delivered. Finally (which will have been made clear in the admissions letter) the charity has been advised of the discharge proposals and has agreed them.

Discharge Planning

This process should start as soon as possible after admission or when health conditions are stabilising. The charity’s representative should talk to their resident (patient), family members and/or carers. Was the patient receiving care from community nursing or social services prior to admission? Is it possible that either this ‘Care Plan’ will need enhancing or a new ‘Care Plan’ will have to be developed in preparation for the discharge? Will the resident now suffer a significant disability? Has the resident now had multiple hospital admissions?

9.3.3 The Multi-Disciplinary Team (MDT)

The Hospital Multi-Disciplinary Team (MDT) is an intrinsic element in all hospitals and will have an input to the discharge process. Formed by personnel from both the PCT and the Local Authority it consists of:-

Doctors
Nurses
Occupational Therapists
Physiotherapists
Dietician
Community Worker
Specialist Nurses
Social Workers
Speech Therapist.

9.3.4 Patient Assessment

During the hospitalisation period an assessment of the patient’s future needs should be undertaken by the MDT. This should include:-

Personal Care
Kitchen ability (or lack of)
Cognitive ability
Manual handling
A home visit
An access visit
A financial appreciation.

It follows that the needs identified during the resident’s (patient’s) period in hospital will be compared against the Local Authority’s eligibility criteria. A ‘Care Plan’ should then be agreed that will show to the resident and the trustee body how those needs will be met.

In devising a ‘Care Plan’ hospital authorities should be made aware of the support that the charity can or cannot provide. A home assessment by an OT is recommended.

The assessment might also show that the almshouse dwelling may need adapting, or that a move to a more manageable property, extra-care sheltered housing, a residential home, a care home or a hospice is necessary.

9.3.5 Case Conference

As the potential for discharge is approaching, social services should call a Case Conference. This should include representatives from the charity, GP and ward staff. The resident (patient) is unlikely to be directly involved though their point of view and opinions should be clearly expressed at such a conference and represented by next of kin, or family member.

These are delicate issues and charities should work closely with residents, their families and with health & social services to ensure the best outcome. Whilst every effort should be made to keep residents in their own homes, on those rare occasions where trustees feel unable to discharge their duty of care adequately, due to the limited support that the charity can provide, it may be necessary to set aside the appointment. See SAM Chapter 6.23.

Please see Appendix E for a check-list regarding Discharge from Hospital.

9.3.6 Post Discharge

A large percentage of admissions and discharges to and from hospital will be conducted to everyone’s satisfaction. The clerk or the chair of trustees should not hesitate to write to thank the hospital authorities appropriately.

Similarly, if positive criticism is warranted from the charity’s point of view, and the process can be improved, the hospital authorities would wish to be informed. Such a submission should be made without prejudice to the resident’s right to contact the Patient Advisory Liaison Service (PALS) or other patient complaint process individual to that health authority.

9.4 Temporary Moves

It may not be necessary for the resident to move out permanently. Relatives may be able and willing to nurse a resident back to health, or the resident may benefit from a spell in hospital or respite care. Many care homes provide respite care and the Local Authority may be required to fund the cost, depending on the income and assets of the resident. Third party top-ups, when a friend or relative has to make a contribution towards the costs of care in a care home, are becoming increasingly common.

Re-ablement services are those which provide recuperative care either at home or in a care home for a temporary period. These are usually funded by the health or social services.

9.5 Alternative Accommodation

If the dwelling in which the resident currently lives is unsuitable and cannot be improved within an acceptable timescale, one option is to move to more suitable housing. For this reason, trustees or their staff should maintain knowledge of suitable local accommodation, including that provided by the Local Authority and local Housing Associations. This option may be more relevant to almshouses that are historic buildings and not conveniently adapted to improve access. Local Authorities should have lists of housing providers and accommodation.

9.6 Recognising Frailty

In the majority of cases the decision that a resident can no longer live independently will be recognised by all concerned, including the resident, and their move to more suitable accommodation can be arranged with everyone’s agreement. Some examples of when independent living is no longer possible are:-

There is a risk that the resident may harm her/himself or others if s/he continues to live alone, for example by operating gas appliances incorrectly. The risk may be greater in almshouses with no staff permanently on site
the dwelling is no longer suited to the needs of the resident and cannot be made suitable within a reasonable timescale or without unacceptable disruption for the resident.

In the first circumstance, it can be difficult to judge when forgetful or irrational behaviour crosses the line to become dangerous, but regular sympathetic liaison with the resident and friends or relatives, observing appropriate confidentiality, may help. Professional help can be sought from social services or it may be possible to obtain help from one of the organisations dedicated to helping people with a particular condition, for example the Alzheimer’s Society. Contact details can be found at Appendix B.

9.6.1 Risk Assessment

A specific risk assessment would be helpful in clarifying actions to ensure the resident’s safety and in determining when the risk becomes too great. It may be necessary to request an assessment from social services Occupational therapists (OTs) can provide professional input and obtain helpful equipment but demand for their services can be substantial, resulting in long delays. The charity should agree to all reasonable suggestions and take action accordingly.

Risk assessments should be regularly reviewed to ensure that necessary action is taken and changing circumstances are addressed.

A sample risk assessment is attached at Appendix F.

9.7 Residential Care and Continuing Healthcare

There are two types of care home: those with nursing and those without. Under the Health and Social Care Act 2008, both types must be registered with the Care Quality Commission (CQC), which is responsible for inspecting homes to confirm they continue to meet registration criteria and to take appropriate action against those who do not.

People living in residential care will usually occupy their own bedroom, although shared bedrooms have not entirely disappeared. Bedrooms may be en-suite, otherwise toilets and bathing facilities will be shared. All food and drink will be provided by the home, although some may have small kitchenettes for residents to prepare snacks. Lounges will be communal and laundry will be done by the home. Trial periods of up to 28 days are common, during which time the resident can decide whether to stay long term and the home can determine whether or not they can meet the person’s needs.

People may opt to fund themselves in residential care but almshouse residents are unlikely to have the necessary level of income or capital to do so and will need to access state funding.

Social services authorities are the ‘gatekeepers’ to state funding for residential care (except for those assessed as meeting continuing healthcare criteria, see below). Eligibility depends on a needs assessment by a social worker and the criteria have progressively tightened over the years, partly due to a philosophical move away from residential care to care at home, but also to save money. In particular, Local Authorities have withdrawn from direct provision of residential care, instead referring people to the generally much cheaper independent sector, a mixture of private profit making homes and those run by the voluntary sector.

The social services assessment will take into account the person’s ability to perform activities of daily living, e.g. can the person prepare meals and eat unaided, get into and out of bed, etc. If the person is assessed as needing residential or nursing care, s/he can choose which home s/he moves to under the National Assistance Act 1948 (Choice Of Accommodation) Directions 1992. When choosing a home, there is no substitute for visiting and talking to the staff. The home should be willing to let enquirers have a copy of the latest CQC inspection report, This will also be available on the CQC website.

People needing state funding to help with the costs of residential care will have to go through a financial assessment. There are two thresholds: anyone with money in excess of the higher threshold will have to pay the full cost of care until their funds are reduced to the higher threshold. Anyone with money in excess of the lower threshold will have to make a contribution towards costs until their funds are reduced to the lower threshold, after which social services should pay the full cost of care except any third party top up and any amount in excess of the amount usually paid by the particular authority. More information on state funding of residential care and up to date financial thresholds can be found by following the appropriate links at www.ageuk.org.uk.

Even with state funding, the cost of residential care may not be affordable if a third party top-up is chargeable or they choose a home that charges more than social services are willing to pay. If the home is a charity, it should have a policy on helping those who cannot afford to pay. If the home is not a charity, or is unwilling or unable to help with costs, there may be another charity willing to help. Social services will undoubtedly have a directory of care homes.

In cases where a person has nursing needs that are substantial, the NHS would be required to meet the cost. People meeting the criteria are usually already in hospital or a nursing home, so it is unlikely, although not impossible, for an almshouse resident to be assessed as having continuing healthcare needs.

9.8 Residents Refusing Help

Some residents will, inevitably, not recognise their inability to live independently and will resist any suggestion of a move. These situations need to be handled with tact and understanding.

In the majority of cases the consensual approach is the best, and can generally be achieved through the involvement of as many interested parties as possible. It is a good idea for the charity to be represented at a case conference that may also include family, carers and hospital team to ensure that those involved understand that the charity does not provide personal care.

9.9 Mental Capacity

There will be occasions when the charity suspects that the resident lacks the mental capacity to make rational decisions. In such cases the charity should discuss the situation with the next of kin and GP in order to obtain a social services report that clarifies the position. It is unlikely that someone would be able to stay as an almshouse resident if they lacked mental capacity, except where the almshouse charity has a care home, in which case the charity will no doubt have provided appropriate detailed training on the Mental Capacity Act (MCA) and deprivation of liberty safeguards. Most trustees and staff will not need in-depth training on these issues but it is possible that they will be involved in procedures to establish whether or not someone does have capacity.

The underlying philosophy of the MCA is to ensure that those who lack capacity are empowered to make as many decisions for themselves as possible and that any decision made, or action taken, on their behalf is made in their best interests.

When appointing residents to an almshouse charity it is recommended that the resident is requested to authorise the charity to discuss their ability to live independently with their GP, as this would enable the charity to take action if such an issue were to arise.

The Mental Capacity Act Code of Practice is recommended reading and can be found by following the appropriate links at www.justice.gov.uk.

Social services have powers of intervention in extreme circumstances under the National Assistance Acts 1947 and 1951, where someone is a threat to themselves or others. It may be that an application can be made to section someone for treatment under the Mental Health Act 1983. This will only be possible if the resident’s GP feels that the resident’s psychiatric condition is such as to warrant the intervention of a psychiatrist prepared to sanction sectioning on medical grounds of psychiatric illness.

For more information on Lasting Power of Attorney – please see Chapter 7.4

For more information on managing residents with dementia – please see Chapter 4.11

9.10 Setting Aside An Appointment

With a professional but sympathetic approach, the charity can help almshouse residents whose needs can no longer be met in the almshouses to move to more appropriate accommodation. For those who refuse to move despite the best efforts of the charity, the ultimate sanction is to set aside a resident's appointment

This can be difficult and costly in terms of time and legal fees. If trustees feel they have exhausted every available strategy and seek a Possession Order that is granted by a court, the resident still needs accommodation appropriate to his or her situation. It is unlikely that almshouse trustees would be willing to turn an individual out onto the street, so the resident may remain until the Local Authority is persuaded or coerced into finding accommodation. A strategy to safeguard all concerned will be needed until alternative accommodation is found.

When a resident can no longer live independently even with the assistance of care packages and other forms of support, then the charity can no longer exercise its duty of care. In these circumstances it would be necessary to set aside the appointment, albeit reluctantly.

For further details see SAM Chapter 6.23.

9.11 Technology

Telecare is a general term relating to aids and appliances used to assist someone to live independently. They are often put in place as part of a care package and usually rely on a telephone link to a 24-hour response centre. Telecare can be obtained privately or, if the resident is eligible, through social services. Motion sensors can make accidents and falls less likely by automatically switching on bathroom or hallway lights at night when people get out of bed. Other sensors can raise the alarm that something is wrong, such as a pressure mat on a mattress that can tell if a person has made it back into bed, or a sensor on a door that can tell if it is open or closed, raising an alarm if too much time passes between doors being opened or closed, or if an outside door is left open. Telecare is discussed in detail in Chapter 3.

For Further Information:

Age UK: www.ageuk.org.uk

Alzheimer’s Society: www.alzheimers.org.uk

Care Quality Commission: www.CQC.org.uk

Dementia UK: www.dementiauk.org

Elderly Accommodation Counsel (EAC): www.housingcare.org

First Stop: www.firststopcareadvice.org.uk

Justice: www.justice.gov.uk

Social Care Institute for Excellence: www.scie.org.uk