Nursing home - who organises ongoing medical care?

[miimblemomble]

MIL just moved into a nursing home. She has a range of conditions - osteoporosis, Parkinson’s, dementia, and a vaginale prolapse.

Now that she’s in a nursing home, who takes care of her ongoing medical needs? Her pessary is meant to be checked every 6 months at a gynaecology clinic. She needs physio for her osteoporosis and Parkinson’s. She’s on medication for both the osteoporosis and the Parkinson’s, and also omeprazole for gastric upsets. Obviously she can’t go to her GP or to the Gynae clinic any more. FIL has received a letter saying she’s not going back to the memory clinic - the consultant there is the one that prescribed her Parkinson meds.

Who takes over? Is it all done by the nursing home now?

Thanks for any advice.

She has a GP just the same as anyone else - most homes have a contract with a local practice, but people with capacity can choose their own still. GPs should usually visit the home weekly to review people who need reviews. Sometimes an ANP does the visits.

If appropriate they still go to appointments but sometimes it is not deemed in their best interest to take them to a busy outpatient department. The home is required to plan their care and treatment and if your MIL lacks capacity, the family should be involved in agreeing this. Does anyone have LPA to enable them to make decisions?

She may not get her physio if she is unable to consent and the appointments become distressing. Ask the home manager.

The nursing home will have nurses who will do the nursing care (e.g look after catheter, wound care, medication administration, routine observations as needed) but they should have a GP surgery that provides GP service to the home. There is often a "choice" but normally 1 main GP surgery who should do e.g medication reviews, see your MIL when needed and refer to hospital consultants as required. If the surgery your MIL is registered at covers the nursing home (or the nursing home is in the catchment area, she should be able to
stay registered with the same one). Alternatively, the nursing home staff should be able to complete the forms to ensure she is registered with a GP.

I think the home should be able to arrange hospital transport if your MIL needs to be seen in a clinic (and probably an escort if required).

There are also a lot of specialist services who could see your MIL in a nursing home if needed or provide advice (e.g Parkinson's specialist nurse) - the home should be able to access those services as needed.

If she is still living in her previous GP's catchment, she will remain their patient. If not, ask the nursing home which surgery/surgeries they use and register her there. To be honest, the home would usually register their new resident with their assigned GP within the first few days of their arrival.
Nursing home residents are usually seen at the home but if mobile and family are willing to help, no reason why somebody couldn't be seen in the surgery.

Thank you all! MIL is not mobile - she could be taken in a wheelchair but would not be able to get in or out of a car. She doesn’t have capacity and FIL had POA for her.

They are in Scotland btw.

Due to Covid I don’t think the meetings are happening as they should, and FIL gets quite muddled when discussing things with the nursing home.

The Nursing Home will register her with the local GP. They together with the home will be responsible for any relevant referrals such as pessary changes (she prob can go to clinic via hospital transport for this unless she is really end of life), Parkinsons nurses etc.

I've found it helpful to get access to my father's medical records so I can keep an eye on what meds he's being prescribed, test results and so on.

Nursing home has weekly visit from a Nurse Practitioner and access to GP as needed, they arrange all appointments and arrange transport and an escort.

You say your FiL has Lasting Power of Attorney in Health and Welfare - just as well as failure to do that and no matter what happens, various people have control over her wellbeing and it will never be you or your FIL.

That means she may be placed on covert end-of-life care (aka ending life care, often done by dehydration carried out by the care home in cooperation with the local NHS CCG and local authority) and they wouldn't need to tell you because legally you're not the decision maker once your relative has lost mental capacity (not that they need to tell families anyway, it's better to beg forgiveness than ask permission.)

The care home has a GP. Often they will be in the pay of the care home - on a retainer of up to £20k a year so they won't bite the hand that feeds them. They legally don't have to inform you of this, as it's not accessible under a FOI request. And any GP that whistleblowers malpractice or wrongdoing by the local authority - I'm thinking of Surrey in particular - will sure enough find themselves no longer in general practice.
Sorry I wrote all this before doubling back to learn you did have LPA for her, and she doesn't have capacity.

I'm not sure if your FIL can extend LPA to others in the family for safekeeping.
I get the impression that Scotland isn't as bad as the South East on all this largely because there's less of a population density, that said the Cover situation in care homes there is no better.

She should remain under her usual hospital departments and be able to access appropriate hospital transport for her needs.

@NewspaperTaxis

You say your FiL has Lasting Power of Attorney in Health and Welfare - just as well as failure to do that and no matter what happens, various people have control over her wellbeing and it will never be you or your FIL.

That means she may be placed on covert end-of-life care (aka ending life care, often done by dehydration carried out by the care home in cooperation with the local NHS CCG and local authority) and they wouldn't need to tell you because legally you're not the decision maker once your relative has lost mental capacity (not that they need to tell families anyway, it's better to beg forgiveness than ask permission.)

The care home has a GP. Often they will be in the pay of the care home - on a retainer of up to £20k a year so they won't bite the hand that feeds them. They legally don't have to inform you of this, as it's not accessible under a FOI request. And any GP that whistleblowers malpractice or wrongdoing by the local authority - I'm thinking of Surrey in particular - will sure enough find themselves no longer in general practice.
Sorry I wrote all this before doubling back to learn you did have LPA for her, and she doesn't have capacity.

I'm not sure if your FIL can extend LPA to others in the family for safekeeping.
I get the impression that Scotland isn't as bad as the South East on all this largely because there's less of a population density, that said the Cover situation in care homes there is no better.

I’m afraid this is scaremongering twaddle and shows a deep misunderstanding of current end of life care best practice.

No, your FIL cannot hand over the LPA. It was only your MILs to give. You could apply for a deputyship to the Office of Public Guardian' if your father in law is becoming too muddled to be an appropriate advocate.

In order to understand better the care homes end of life care policy and practice, I would suggests talking to them about the future care plan for your mother in law.

It is entirely likely there will have been a decision about the appropriate ceiling of care and a decision not to resuscitate, should her heart stop beating. That is a clinical decision to avoid the hideous situation where a confused dying person is transferred to hospital and possibly dies alone in an accident and emergency department. It’s not about ending someone’s life but rather about about allowing them a natural death, in safe and familiar surroundings. Nobody would want a very frail person with dementia to suffer the indignity and pain of a failed aggressive resuscitation attempt. If a person is outside of an acute hospital the chances of any resuscitation being successful are minimal. It just moves the place of death if an ambulance is called. Far better to have a familiar person sit and hold their hand in a calm place.

There is no “covert end of life” care. People are not starved or dehydrated to death. There is a form called a ReSPECT form which many services use to record a person’s preferences and clinical plans as they approach life’s end. It is shared between all involved professionals and usually the person or their family representative. Ask if one has been completed, perhaps.

GPs are often contracted to provide primary medical services to care homes but they retain their professional responsibility to act within the guidance of the GMC. It’s not quite the same as the suggestion that they are in some sort of corrupt arrangements to cover up wrongdoings. They aren’t. Most GPs try to do their very best by frail elderly people. As do most care home staff.

You are the one talking nonsense, CherryPalova.

I was not talking about DNR. That is a different issue - what happens when a person's heart stops. Oddly, that is one area where the law really does kick in. If DNR is not in place, legally the paramedics or whoever must resuscitate or they get into big trouble, even if the patient has clear extreme dementia and was on the way out anyway. I've no real issue with DNR, as to resuscitate is a very onerous and traumatic intervention and if someone is slipping away it can simply lead to a horrible demise. I know of one daughter whose mum was on respite in a care home, she was DNR and had a massive heart attack but because the DNR papers were not on site, she had to be resuscitated and the last 24 hours were hell for her. Eventually something had to be administered to put her out of her misery and the hospital chaplain had to strongarm that to happen. Of course, according to CherryPalova, nothing like that could ever happen.

The whole DNR stringency misleads the public into thinking that covert end-of-life care doesn't happen.

Presumably the stories about Gosport are 'twaddle' too - and maybe they are because no charges have been brought. Fact is, that would open a massive can of worms and successive police forces appear to have been warned off pursuing it despite all the evidence and column inches devoted to it.

It is you who are talking twaddle, CherryPalova. Stories are rife about dehydration and malnutrition in care homes. Nobody gets held responsible for it. I wonder why?
Fact is, it is very hard to prove that an elderly person's dehydration or malnutrition was down to poor care and not just a person giving up at the end of their days. Care home malpractice is endorsed by the corrupt CQC which sits on bad care home reports for up to eight months - keeps them secret in other words - as the bodies pile up and families are kept in ignorance. That happened at two care homes my mother was at, and both nearly killed her. Nobody held responsible but relatives who sniff around the issue get harassed by Social Services.
But I'm pushing at an open door, surely? After Covid-19 was ushered into care homes, killing thousands, what outrage did we hear from the CQC, the NMC and local Safeguarding teams? Nothing - not a shot fired in anger. So you decide whether you want to believe me or the the official line on this.

Yeah, talk to your parent/relative about what they want and get it in writing more to the point or it never happened. Of course, if they've lost mental capacity and are not very conversant you can't do that, and Social Services step in. They are, it turns out, a law unto themselves and wholly toxic.
In fact, you'll be in much the same position as those parents who've had their kids placed on end-of-life care and won't be allowed to take them out of the country for potentially life-saving treatment. Once the State has its hooks into you, it will not let go.

In 7 Surrey care homes over six years, I never heard of a Respect form. In the last three years my sister and I had to take it in turns to visit the care home daily to tend to Mum and give her drink as successive care homes refused to do so - never in writing, of course. When we handed in our notice, after paying a grand a week, the care home simply contacted Social Services who put a stop to the move. Did the usual fit-up, pretending to be our new best friends - 'Would you like to get your mother back to the family home?' no intention of allowing that of course, then tasked the care home with acquiring dirt on us to allow them to obtain the Deputyship of my mother and assume total control. Utter bastards, we almost fell for it.

Never presume to tell me what I do or don't know about adult social care in this country, CherryPalova.

@NewspaperTaxis

You are the one talking nonsense, CherryPalova.

I was not talking about DNR. That is a different issue - what happens when a person's heart stops. Oddly, that is one area where the law really does kick in. If DNR is not in place, legally the paramedics or whoever must resuscitate or they get into big trouble, even if the patient has clear extreme dementia and was on the way out anyway. I've no real issue with DNR, as to resuscitate is a very onerous and traumatic intervention and if someone is slipping away it can simply lead to a horrible demise. I know of one daughter whose mum was on respite in a care home, she was DNR and had a massive heart attack but because the DNR papers were not on site, she had to be resuscitated and the last 24 hours were hell for her. Eventually something had to be administered to put her out of her misery and the hospital chaplain had to strongarm that to happen. Of course, according to CherryPalova, nothing like that could ever happen.

The whole DNR stringency misleads the public into thinking that covert end-of-life care doesn't happen.

Presumably the stories about Gosport are 'twaddle' too - and maybe they are because no charges have been brought. Fact is, that would open a massive can of worms and successive police forces appear to have been warned off pursuing it despite all the evidence and column inches devoted to it.

It is you who are talking twaddle, CherryPalova. Stories are rife about dehydration and malnutrition in care homes. Nobody gets held responsible for it. I wonder why?
Fact is, it is very hard to prove that an elderly person's dehydration or malnutrition was down to poor care and not just a person giving up at the end of their days. Care home malpractice is endorsed by the corrupt CQC which sits on bad care home reports for up to eight months - keeps them secret in other words - as the bodies pile up and families are kept in ignorance. That happened at two care homes my mother was at, and both nearly killed her. Nobody held responsible but relatives who sniff around the issue get harassed by Social Services.
But I'm pushing at an open door, surely? After Covid-19 was ushered into care homes, killing thousands, what outrage did we hear from the CQC, the NMC and local Safeguarding teams? Nothing - not a shot fired in anger. So you decide whether you want to believe me or the the official line on this.

Yeah, talk to your parent/relative about what they want and get it in writing more to the point or it never happened. Of course, if they've lost mental capacity and are not very conversant you can't do that, and Social Services step in. They are, it turns out, a law unto themselves and wholly toxic.
In fact, you'll be in much the same position as those parents who've had their kids placed on end-of-life care and won't be allowed to take them out of the country for potentially life-saving treatment. Once the State has its hooks into you, it will not let go.

In 7 Surrey care homes over six years, I never heard of a Respect form. In the last three years my sister and I had to take it in turns to visit the care home daily to tend to Mum and give her drink as successive care homes refused to do so - never in writing, of course. When we handed in our notice, after paying a grand a week, the care home simply contacted Social Services who put a stop to the move. Did the usual fit-up, pretending to be our new best friends - 'Would you like to get your mother back to the family home?' no intention of allowing that of course, then tasked the care home with acquiring dirt on us to allow them to obtain the Deputyship of my mother and assume total control. Utter bastards, we almost fell for it.

Never presume to tell me what I do or don't know about adult social care in this country, CherryPalova.

Indeed your understanding is highly questionable. The language you use in relation to elderly people is unprofessional. You suggest there are non existent laws around DNACPR and don’t even use the correct acronym. Gosport was over twenty years ago and wasn’t a care home. People weren’t starved or dehydrated. The issue there was inappropriate governance of opioid medication and a failure to listen when concerns were raised. You are clearly a conspiracy theorist. Police forces haven’t been warned off. The decision not to prosecute was not theirs to make.

The stories of care homes are just that usually. Stories. There are a few that provide inadequate care but not most. Most do their utmost to provide very good care. You won’t have heard of ReSPECT forms over six years as they are quite recently introduced by the resuscitation council. There is really much improved oversight of end of life care from all agencies.

Your poor experience is not the norm. I’m sorry if you feel your mother didn’t receive adequate care. It is very, very unusual for the court of protection to award deputyship to a local authority where a family have contested it, unless there was sufficient evidence of the family not acting in a person’s best interest.

As death approaches many people do stop eating and eventually drinking. Most care providers continue to offer drinks for as long as possible but many dying people simply don’t want it. It would be cruel to start forcing nasogastric or intravenous fluids onto people in their last few days.

Your personal experience and views are not representative, thank goodness.

Hi. As she's in a Nursing Home I would expect there to be written Care Plans (mostly written by the nurses) to cover all her issues and how they would address these. Maybe FIL can ask to see them?
I hope all goes well.

Just picking up on the rubbish CherryPalova peddles - it is genuinely hard to know where to start here!

Of course my language is 'unprofessional' - I'm not paid to do this. I don't work in the adult social care sector. Again, bearing in mind the complete silence from regulators such as the CQC, NMC not to mention local authority safeguarding heads on the ushering of Covid-19 into care homes, I'd say that is high praise, eh?

The main comment from the NMC is that because of the pandemic they candidly won't bother to investigate a good many referrals ie complaints about their registrants and indeed won't even inform said registrants about any complaint against them so as not to upset them during this difficult time! Bless.

As for your complaining that I don't use the correct terminology regarding DNR that really is pathetic nitpicking! Why don't you write to the Telegraph, seeing as they and all the other press use the term DNR such as here only a fortnight or so ago
www.telegraph.co.uk/news/2020/08/23/care-homes-asked-place-blanket-do-not-resuscitate-orders-residents/
Obviously they don't know what they're talking about.

I guess it's like the LCP - the Liverpool Care Pathway. Just change the name of it and you can outfox the Muggles. Or rather, don't call it that but keep it going - kill folk off by dehydration and you can't late prove anything.

I know Gosport wasn't a care home. Yep, that was done by opiates. It is less likely to happen these days because it shows up on a post-mortem. Dehydration solves that largely, for reasons both you and I have helpfully outlined.

You say: 'Police forces haven’t been warned off. The decision not to prosecute was not theirs to make.' Okay - so who's tipping them off not to bring charges then? The CPS?

You then say: 'You are clearly a conspiracy theorist'. Now, the allegation that anyone who brings these allegations is a conspiracist is straight out of the Social Services playbook. We all get that! Other complainers or whistleblowers will be branded 'vexatious' or 'abusive and intimidating' often with no idea why or no evidence but that is how they are dealt with. 'Best interests' is another term bandied about - it really means 'We are going to do what we want and then say it's in the person's best interests'.
Gosport, Hillsborough, the Contaminated Blood scandal - all the victims get smeared up til the point decades down the line when it emerges they had a point all along.

You write: 'The stories of care homes are just that usually. Stories.' Again, this is a bloody insulting thing to write. I put my mother's case in the local paper, the Daily Mail and Mirror Online. In each 'story' the truth was bad enough but actually they were watered down for publication. In each case, Surrey's Social Services - get this - simply never contacted us in any way shape or form about the concerns we raised. THAT my friends is what we are dealing with.

It's not the care homes who decide who dies, BTW. The relationship is triangular, between the local NHS CCG and local authority Social Services. Often, the families don't even know about it and are kept in the dark. Care homes who don't cooperate can be blacklisted by both NHS CCG and local authority - as we saw when many felt forced to admit suspected Covid patients under pressure from the former. Many know which side their bread is buttered.

BTW yes care homes should have a care plan.