Case Studies

Case Study 1
Service User (SU) is 48 years old. She lives with her husband and 2 adult children. She lives in a property owned by a housing association. She has multiple sclerosis (MS) and is a full time wheelchair user.

Previous input.
I has been involved with this s/u on and off due to the nature of her condition which fluctuates. This case study is the input I have had over 2 years..

• Transfers are difficult, husband lifting her, including from new indoor power chair.
• Furniture very low.
• Toilet seat breaking due to impact when landing on it.
• Kitchen work tops too high to use from wheelchair.
• Shower leaking.
• Intervention – trialled transfer boards, issued raised toilet seat, mobile shower chair and riser recliner armchair. Contacted repairs re shower.
• Disabled adults resource team (DART) physio said fatigue is a big problem but s/u denies this.
• Referred to MS Nurse.
• S/u pleased with equipment.
• Indoor/Outdoor powered wheelchair applied for through wheelchair services which is NHS funded.
• Transfer practices from bed to chair with sliding board.
• Difficulty pulling herself up bed, trialled trapeze pole - Not successful.
• Joint visit with housing to look at altering kitchen.
• Toilet transfers still difficult. Decided side ways would be easier, but pole of shower doors blocking this. Joint visit with housing surveyor to look at this.
• Bed transfers still difficult.
• Profiling bed approved so she can adjust the height to enable transfers and make it easier for carers to assist. She was independent with transfers when bed delivered.
• Kitchen completed, but she had requested a cupboard was left under it and could not get wheelchair under. Had this removed.
• Problems with shower doors and s/u refusing the new ones. Visit to explain use of them.
• Difficulty with personal care after using toilet – closomat (a toilet that will wash and dry you) requested through Disabled Facilities Grant (DFG).

• Transfers even more difficult.
• Joint visit with neuro physio. Able to stand at times, depends on fatigue.
Agreed to trial a stand aid.
• S/u decided stand aid was too big and not willing to compromise on space used for other things. They decided to look into purchasing a smaller one.
• Carers having difficulty with transfers.
• She declined use of hoist.
• She agreed to stand aid again.

Closed briefly then reopened as problems with carers and transfers.

• Shower chair to go over closomat issued.
• Closomat bypassed to be used without pressure of seat going down.
• Mobile hoist being used, carers struggling with space. Visit done and rearranged furniture.
• Agreed to ceiling track hoist in living room and bedroom, which meant moving more furniture around.
• Remote for intercom system requested as s/u struggling to get to phone before people leave.
June - September
• Problems with single motor chair not meeting her need.
• Dual motor chair trialled, successful and ordered.
• Hoists fitted, furniture not moved to accommodate this. Stressed the importance of this again. This was resolved.

This s/u is quite demanding and always requesteg things from social services and the council they that cannot provide and that should be sorted by herself and family. Most of this is due to her culture. There were a lot of issues around the care agency and the use of hoists and s/u’s inflexibility to compromise at times. The relationship between care staff and s/u and her husband became very fragile at one point. Once I sorted out the mobile hoist they were fine. Things improved further when ceiling track fitted. S/U now managing and just waiting for remote for intercom to be sorted by housing association.

Case Study 2

This service user (s/u) is 55 years old. He has Multiple Sclerosis (MS). Cognitive problems are evident with lack of insight into condition and memory issues.

Social History
He lives with his wife and his adult daughter and teenage son. The relationships between him and his family members are very strained. His wife has been his carer for over 20 years which has impacted on their relationship and she is very stressed and doesn’t feel supported.
Money is a big problem. They have a good income so get penalised for care and adaptations from the council. They feel they have large outgoings so don’t have the money to spare. This causes most of the problems for professionals trying to assist them.

Problems Identified
• Difficulty using stairs.
• Difficulty using shower and toilet.

I went in with the Physio from the Disabled Adults Rehab Team (DART) to discuss the difficulties with the stairs. The s/u was going up and down on his bottom. His mobility was poor; he used a zimmer frame but tended to lurch from sofa to chair etc. Falls were regular and son and wife had to get him up. Mangar Elk (a lifting cushion) was trialled but not very successful.
The s/u felt a stair lift would solve the problem. I had concerns about his safety using a stair lift due to his cognitive problems. He cannot remember what he is able and not able to do. The bathroom and bedroom upstairs were very small and it would not be easy to manage his personal cares. I discussed downstairs accommodation with him. He was against this and couldn’t understand why he couldn’t have a stair lift. I explained this several times over a period of time. His wife was in agreement with downstairs facilities to manage his care in the future. They have a garage that could be converted. A ramp is also needed at the front entrance at there are 2 very steep steps to negotiate.

During this time, his mobility became worse and he became a full time wheelchair user. He was then unable to manage the stairs at all. It was discussed further about downstairs accommodation and we visited another s/u who had similar adaptations to his garage. This gave him a better idea of what it would be like. He finally agreed to it as he did not want to end up in full time care.

His profiling bed was now in the living room and he needed a mobile hoist for transfers. His wife still refused care and she felt they could not afford it. Therefore she is managing all cares on her own.

Disabled Facilities Grant (DFG) applied for and visit done with surveyor to determine the plan for alterations. Garage to be converted into bedroom and bathroom with level access shower. Ramp to be fitted at front entrance. Ceiling track hoist to be fitted in bedroom.
Crossroads (day centre) decided they could no longer take him at this point as unable to use the portable ramps for him. Wife agreed she would have s/u ready in garage for them so they didn’t have to manage the ramps. This is his only outing so this was very important to continue. Also gives the wife a break. If he came off the transport list, it would be a long time until he would have another place on it.

We had a neuro psychologist assessment done to determine whether he had capacity or not. This was inconclusive. He said if he can remember the decision then he has capacity. I was in disagreement with this as I felt he did not have capacity in all areas or at all times.

The DFG assessment came back with a contribution of £10,000. They definitely do not have this kind of money. The s/u was in the Navy so Care and Repair, the agent, approached the British Legion. They agreed to lend them the money on an interest free loan. Wife was not happy with this but felt she had no other choice so agreed. Final application done for DFG and figure then came back at £12,500. I approached social services who agreed they would pay the extra £2500. Care and Repair spoke further to the British Legion who approached someone else in the military and they agreed to give them the whole amount.

This has been a very difficult case to manage due to high emotions in family, capacity issues of the s/u and financial problems. The decision around a stair lift was difficult as I felt he wouldn’t be safe but he was at risk using stairs as he was, and wouldn’t agree to downstairs facilities. In the end, it was a deterioration in his condition that forced him into realisation that he couldn’t use the stairs any more. Once we were over this hurdle, it was the financial problems that were difficult. It took over a year from when I started work with them, to get adaptations it agreed. The final result was a garage converted in a bedroom with ensuite with a level access shower. A ceiling track hoist was fitted over the bed. A ramp was created at the front access. The s/u can now remain downstairs with all his facilities accessible.

Case Study 3

Female aged 51. Her condition is severe rheumatoid arthritis (RA) and obesity (weighs 26 stone), depression.

Previous history
The service user (s/u) used to be able to use a stair lift fitted by social services and a level access shower that is upstairs. She could mobilise enough to get around the house with her kitchen trolley.
I received a referral from an OT with intermediate care stating that she needs a chair but they couldn’t use their budget. The same applied for a ramp at front door.

Social history
Her daughter was initially staying with her and ended up living there with baby and her partner. Her son was there also until recently when he moved out.

My involvement.
Initial visit completed.
• She struggled to get off settee and was sleeping on this as her daughter was staying in her room. She was able to get up with difficulty and use kitchen trolley to mobilise into kitchen and make a cup of tea. I thought a riser recliner chair may make transfers easier for her. Difficulty cleaning herself after using the toilet.
• Liaised with Physio who hadn’t been able to get her motivated or off settee. S/u also cancelled a lot of appointments.
• Chair raisers fitted in the mean time, and referral made to housing renewals for ramp and closomat (toilet that can wash and dry you) as at this stage we thought we would get her to be able to access upstairs again
July – visit with chair company rep.
• Trialled a dual motor riser recliner chair to allow her more freedom of movement as a single motor restricts her positions which are difficult with RA. The riser helped her up but she still needed some assistance.
• She requested a bed pan as having difficulty getting up for bowel movements.
• She then became immobile due to a deterioration in her condition and restricted to her bed in the living room.
• Lack of food and hygiene became a problem. The food seemed to be a problem with money.
October – the new chair arrived.
• She was not using the new chair.
• Disabled adults rehab team (DART) became involved. Not using commode, risk of pressure areas being on bed all the time.
• Closomat put on hold as unsure of her future ability.
• Referral to Mental health team to look at issues with depression and lack of motivation.

• Small goals set with s/u around increasing standing tolerance through use of equipment, use of commode, diet.
• Agreed to trial hoisting with her and DART.
• Hoist in but s/u very anxious about it. Decided to find a stand aid suitable for her.
• Discussed wheelchairs, s/u happy to be referred for indoor power chair. Exercises given by physio to improve strength and tone.
• Rep visited with stand aid. Very successful. Approved by manager.
• Care package increased to 2 carers to handle stand aid.
• OTA went in to practice standing with stand aid but bed was broken so unable to use stand aid as couldn’t get legs of stand aid under bed.
• DART were able to justify a profiling bed for her.
• More joint work with physio around exercises and motivation/goals.
• Wheelchair services visited and decided they could not issue her one due to the environment. There is too much clutter and doorways are too narrow. They are happy to look at it again if these issues are resolved.
• Physio looking in hydrotherapy.
• S/U continuing to use stand aid and get into chair daily.
• letter of support for her DLA application.
September – S/U experiencing a flare up.
• Visit done with new Physio from DART. S/U had joined a radio club and had made enquires about several other things so was obviously more motivated. Going to obesity clinic sometime. Decided to see her again after 2 hospital appointments,
• visit with physio again. Frank discussion about her future ability, as she was unrealistic about walking again. Physio will go back to set some realistic goals for her.

At the end of my time working with this service user, I had concluded that she would benefit from downstairs facilities as it was very unlikely that she would manage to get back upstairs.
I think a powered wheelchair would give her so much independence but it is difficult for her to accept that she may need this. I would need to do more internal alterations and clear the clutter before wheelchair services would agree to provide a powered wheelchair.