Worried! Mum to be discharged home after stroke

Ask the ward to carry out a chc assessment, you can also find it online to read to give yourself an idea of what it involves. He shouldn't need to sell the flat, how old is he, are they married, who owns the flat. You can also ask about reablement which is up to 6 weeks funded care if she does need to contribute. There is also funded nursing care and attendance allowance available for self funding residents if she would benefit from time in a carehome. If everyone agrees she can go home then the ot can make arrangements for any equipment which they order and provide and the discharge worker and nurse will co ordinate everything else. It's important that she doesn't go home until everything is in place, that she and sd are happy and she is safe. Does anyone have power of attorney for her.

Sounds like there are some strong arguments for CHC eg strong skin care needs, mood after stroke, risk of TIA etc

Learn the domains of CHC as you might need to know this going forwards. CHC at home is not that good u less in terminal decline and a care home might be better. I would refuse to move her until a full CHC assessment made.

Partner over 65. So if he’s over 65 and has some stake in the flat he should be OK

In a very similar medical situation (10 yrs ago) we applied for CHC for DM and got it. It certainly helped with nursing home fees.

Why would your step-dad have to sell the flat? The value of housing can't be taken into consideration for paying for care if the person's partner is living there.

www.ageuk.org.uk/information-advice/care/paying-for-care/paying-for-a-care-home/do-i-have-to-sell-my-home-to-pay-for-care/

Not sure the sale of the flat can be forced when there’s another adult living in it?

Your mum would need someone with her 24 hours a day with those care needs. If she isn't fully mobile and doubly incontinent then she will be at high risk for bed sores and skin breakdown and will need turning during the night and changing promptly if she soils herself.
I wouldn't be in a rush to discharge her unless you have a good care package in place or you will be on your knees with exhaustion within a few weeks.

You might want to involve the discharge team and hospital social workers and discuss a nursing home as it sounds as though it would be very difficult to meet her needs at home.

Your mum sounds like she is doing really well, all things considering if she can use a Sara stedy with one person. It's also lovely that you want her home. Yes be clear about what you can and cannot help with, occupational therapy may be able to recommend some major adaptions but this takes time (or private funding). People can make gains years after a stroke but they tend to be slow and it's a bumpy road. Take any care you can get, you can always reduce it if needed.

It's the sort of stuff that's doable for a weekend. Manageable for a week or two. Because you've thrown everything at it.

And 3-4 weeks in you're dropping with exhaustion, totally overwhelmed and it's far far harder to get any more support because the person is at home.

By 'throwing everything at it' I meant to take the long view and consider what's sustainable for you long term and what you can physically and practically manage.

I made the mistake of focussing entirely on getting the person home, had absolutely no idea what caring for a bed-bound doubly incontinent adult who wasn't aware of much and needed hoisting involved. And naively thought 4x care visits a day (2 carers each time) would cover everything. I had no idea someone would need to be with him all the time, that that meant even getting shopping and meal prep done (and turning everything into puree) would become a major logistical operation. The same with washing, feeding, moving. Them needing to go the toilet never coincided with a carer visit. It was impossible to do anything else, barely time to eat a meal or make sure I'd got clean clothes myself, let alone do something like exercise or work!

Fatigue is a very real part of life after stroke. I work in a therapy team for stroke survivors and I don't know anyone we work with who doesn't deal with significant fatigue. That can mean in the early days that they don't tolerate long therapy sessions, and when just getting up, washed and fed are major operations it can be a huge barrier to lots of therapy. I agree that a realistic view of the future is important.

Sometimes rehab is rejected if they feel the person doesn't have rehab potential and won't benefit from it, there should be a stroke team who can advise you about the realistic future so she gets the care she needs.

This doesn’t sound like they don’t want her, rather that they cannot meet her needs as they re so severe. That doesn’t mean they will send her home though.
You need to wait until the MDT meeting to see exactly what they are proposing. It may be that she will end up in a nursing home rather than rehab.

My advice would be to see if you could speak with someone from one of the Stroke charities. There is some information here:

www.stroke.org.uk/stroke/support/caring-for-a-stroke-survivor

Age uk may also be able to talk about what support and any benefits can be claimed

you have to be honest with yourself about what you can manage. Caring for someone who has even four lots of care calls a day is emotionally and physically draining. Will you father be able to look after her overnight. Could you get her to medical appointments. Can you drop everything at a minutes notice to go round to deal with emergencies.

make sure you attend the discharge planning meeting OP…l.if you have concerns about anything at all, tell them you want it recorded on the notes that you think it’s an unsafe discharge….. why is she not entitled to the free nhs 6 weeks in a rehab unit?

Maybe she doesn’t….but no way will she be eligible for CHC

Maybe she doesn't want to be confined to bed and the family don't want to deal with feeding tube