DM discharged from hospital to care home for '4 week assessment'

[EyesWithAFace]

I'm hoping someone can offer some advice/reassurance about the situation we've found ourselves in with DM.
To cut a long story short, she was living independently (ish) in her flat until November when she fell and broke her arm. She ended up staying in hospital for a month, was discharged and then fell a few days later and was re-admitted to hospital.
She has various other issues including a decline in her mental health (diagnosed by Mental Health team as depression, not dementia) and balance/mobility problems.
After the second hospital stay of a week, the hospital has discharged her into a care home (we had no say in the matter) for a '4 week assessment'. When she arrived she was put into isolation for a week, and also on the day she arrived the care home announced a 28-day lockdown (due to staff members testing positive), so we have been unable to visit.

I am concerned about the 'care/rehab' she is receiving at this place. She had another fall within a few days of arriving, has hardly spoken and they have managed to lose half the clothng she arrived with.

Apparently the 4-week stay is something that's been initiated during the pandemic, to free up hospital beds (and was originally 6 weeks), but I feel completely helpless, with no-one in charge of her stay, no feedback and no idea how Mum is doing. I think it's really affected her state of mind and must be so confusing for her.
Realistically I don't think she'll be able to return home, but where do we go from here?
If anyone else is or has been in this position, I'd be really grateful for any advice or even just a friendly word.

Have you had a chance to speak to the care home manager for a plan of care, you could ring the hospitals discharge team and qnd ask what plans were put in place and who her social worker is.

It's quite common for residents to fall on admission to care.homes unfortunately, due to the disorientation.
Are you able to speak to the manager there, or the social worker involved?
As you say this is now procedure in order to free up much needed hospital beds.
Hugs for you though, the homes closing their doors is heartbreaking for all involved

Hi OP feel free to DM me as been through the process with both grandparents. During the 4 weeks the CCG and LA will conduct care / needs assessment, after which there will be a financial assessment if necessary.

Thank all for your replies, it's helpful to know I'm not alone.
I think the care home manager is new/temporary, as I've sussed out from their facebook page that the previous (well-regarded I think) manager left at the end of December. I've spoken to her and other staff, but am not reassured by what they tell me (they say things like she's in 'good spirits' which I know is not true). They don't seem to have a plan but are waiting for a visit from 'the physio' soon to assess her.
The Social Care person (discharge co-ordinator) is on annual leave and I don't think we've been assigned a social worker as such yet.

Vesper, I will DM you later. Thank you.

This is happening to my mum too.,Your story is mirroring mine with my mum. She was admitted to a care home for an assessment ( from hospital) on 20tg Dec. The care home has since closed to visitors as they have covid there. I hear the same message - she’s settled or such like. Which from her intermittent phone calls I know not to be the case!
What questions Shoukd I be asking the care home manager? A care plan? I’m just abit clueless !!

Feel free to also DM - i can copy the same advice from my experience across...it can be such a lonely situation so happy to share any lessons I can x

Ask where her clothes are too?

@Vesper8

Feel free to also DM - i can copy the same advice from my experience across...it can be such a lonely situation so happy to share any lessons I can x

Thank you so much, I’ve sent you a pm.

Do you have POA for your mum? How is her capacity?

Ask the care home to justify their complete lockdown - NHS England advice is “ during an outbreak, care providers should also continue to offer visits in well-ventilated spaces with substantial screens, visiting pods or from behind windows – rooms should be left to ventilate with external doors and windows open between uses wherever possible, while aiming to maintain a comfortable temperature for residents and visitors”. Do they currently have any Covid-positive patients?

Also ask about becoming your Mum’s Essential Care Giver.

www.gov.uk/government/publications/visiting-care-homes-during-coronavirus/update-on-policies-for-visiting-arrangements-in-care-homes

In the meantime, what do you think is going to happen next for your mum? Do you know when she is next being assessed?

The rehab your mum will get (depending on her needs) will be provided by NHS OTs and Physios. I can give you advice (as best I can) from the other side of the table so to speak, if you need it

My nan’s social worker was useless.
There was a meeting a month after she went into the care home to discuss funding- nhs or local council etc
We were able to arrange video calls whilst she was in isolation but now we get to visit once a week. (Lfts and proof of vaccination)

Try and speak to the manager

They've managed to find most of her clothes and reckon the rest are in the wash. As she was stuck in her room for a week I don't think she got out of her nightie & dressing gown (she hates getting dressed), so no idea why her clothes would be in the wash. I asked to see their inventory of her belongings (that I'd packed & also made a list of) on arrival, and it was missing well over half the items I'd packed. I insisted they found them and asked for photos, which they have now provided. Does not inspire me with confidence, especially as it's quite a small place (about 30 residents).

Yesterday she was allowed out of self-isolation but said she didn't want to meet the other residents. She has become very withdrawn and uncommunicative over the past year or two. I think this is my main concern as I can't bear to think of her sitting alone in her room everyday. I think she is losing the will to live and has lost all her confidence. I'm so upset as we were always so close, went on holiday together etc. I feel I am losing her by the day.

We do have POA (both).

Care home have said a physio has arranged to visit 'soon'. This seems to be the extent of the rehab. She is getting more and more frail and unsteady, especially since breaking her arm. Why can't they do some proper exercise sessions? She's been stuck in bed in hospital since the end of Nov, so obviously needs to get mobile to stop her muscles wasting away.

Szboox - your situation sounds practically identical to mine. Feel free to DM me or expand on here. Vesper, I have DM'd you. Thanks all.

Sorry, I changed username part way through...

ChocolatePotCafe - any further advice from your side would be much appreciated. Any rehab she's had so far (in hospital) has consisted of walking her to the toilet or getting her to sit in a chair. It's not what i was envisaging. I know they're short-staffed but why call it rehab, when it is just providing the basics?

In my experience not much rehab goes on in carehomes, even less if residents do not want to mix socially or use the communal areas. The most they offer are a visit from a physio who will assess them, supply walking aids suggest exercises and encourage residents to get up and walk around but the staff cannot make them do it. The activity staff do try and get residents to do exercises while they are sitting in chairs or in bed to keep their muscles active. The staff will be encouraging her to get up, get washes and dressed, walk around but she may feel anxious as she has fallen before and has a broken arm. At some point she will need a care needs assessment to see how she will manage in thenduture and where she would be most safe.

Could you arrange a private physio to visit? Dms rehab care home had private chiropodists, and she had physio visits from the falls team plus private physio, before pandemic, though.

Thanks all for your advice. I did look into private physios even before she broke her arm, as I was concerned she wasn't getting any sort of exercise or even activity, but it was all geared towards to young people and sports injuries. Someone could really cash in if they decided to set up a physio service aimed at the elderly in their own (or care) homes.

Mum is reluctant to join in with anything these days, I think she's really lost confidence and just the ability/will to interact over the past couple of years. I really wonder how much of it is due to lockdown, or whether it would have happened anyway.

@EyesWithAFace The rehab in hospital is basic as they are only really focusing on the bare minimum to aim for discharge- eg. A stairs assessment/wash-dress/can they get to/from toilet etc. Rehab once your mum is in her placement should be more tailored to her abilities and goals. We usually visit as many times in a week as is needed as we know we only have 4 weeks in which to do all the assessments etc. In extenuating circumstances, placements can sometimes be extended but this depends on the circumstances and funding streams available to your trust. Is there a social worker involved? I’m sure the physios/OTs involved would be happy to meet you to discuss their plan, if that’s something you feel would reassure you?

On a practical note- can you Facetime your mum?

When our mum was sent into a care home from hospital and they too closed their doors because Covid, we sent in an ipad set up to receive Facetime calls from us. A member of staff set it up for her at a pre-arranged time.

Although she'd had a stroke and couldn't talk coherently, we do believe that being able to see us made a difference to her. We were also able to see for ourselves that she was dressed, clean etc etc.

It might help your mum with interaction?

Thanks ChocolatePotCafe - she's now been in the care home almost 2 weeks, and no-one from 'outside' (ie. NHS, social worker etc) has visited yet, which means she's only got 2 weeks left for the assessment to be done. Hopefully the physio will visit this coming week, but I haven't spoken to anyone official and we haven't been assigned a social worker yet. Is this normal? Is it because the care home is in lockdown? Shall I make a fuss - and if so, who to?

Shodan - they have offered to set up some sort of zoom/skype call, but it hasn't happened yet.

On another note, they seem to be putting her to bed about 6pm every night. Is this normal? She was always a night owl in her younger days, but had started going to bed around 9pm whilst still at home. 6pm seems too early for me, although she does seem tired (she's on morphine-type patches for the pain from broken arm, and also an anti-depressant, so maybe these are making her more sleepy).

@EyesWithAFace have you been told that your DM has rehab goals? If so, please do contact your local community OT/Physio team. I know in my area Adult Social Care have long waiting lists (not excusing it at all, just explaining why there may be a delay) so it would be wise to contact them tomorrow and find out where your DM is on their list. I’ll be honest and say that sometimes people slip through the net so if I was you, I’d not be afraid to phone all the relevant teams. I’m so sorry it’s not been a smooth process for you. Ring the home as well and ask them to chase it up from their end too.

eyes with a face I’m sorry to hear about your dm’s situation.
My mum has been in rehab since last August (after 2 hospitals before that).
She will be coming out bedridden. When she arrived in rehab she could sit in chair.
The rehab stopped in October. They want to send her to a 4 week placement in a care home, but I have major concerns also. The plan has always been that she will come home to us with carers.

I feel that the way elderly people are being treated is not acceptable. It is disgusting how nobody communicates with family members. We seem to be left out of the loop completely.

It’s so stressful and draining, isn’t it? I feel for you, as I can imagine how I would feel if I couldn’t see my dm. It’s not fair, and you need answers.

I’m sorry I can’t offer any advice, as I’m in the dark with this whole process also.

All I can offer is reassurance that you are not alone in this, and if you need to chat to someone who understands the worry and frustrations, you can dm me.

ChocolatePotCafe - I've finally made contact with the social worker, who is going to visit Mum to assess her next week (that will be the 4th week of the 4 week assessment). Not sure why she's allowed in the home, as no one else is being allowed in. The promised visit from a physio has not been mentioned, so I assume that's not happening.

Cherrysherbet - thank you for your support and sympathy. Sorry you are also going through this. I will dm you. I totally agree about the loss of control we as a family, and Mum herself, have in this situation. It seems like the state has taken over and we have no say in anything. It's as if she's been sectioned, or is in prison.
I also feel that the hospital stays have been very detrimental to her, both physically and mentally. They stuck her in bed, catheterised and/or put her in incontinence pants, didn't respond when she pressed the call bell and left her half-lying down so she couldn't drink from her cup. No physio to speak of, and then they're telling me she's incontinent! She wasn't before she went into hospital. What do they expect when she can't get out of bed with her broken arm! When she was discharged into the care home, it was delayed by a day because the hospital had only taken the catheter out that morning (despite saying they were going to do it a few days prior to discharge), and they couldn't discharge her until she'd had a wee on her own. She was also massively constipated. I've lost a lot of faith in hospitals as a result of all this. Yes I know they're short-staffed, but it's inhuman to treat the elderly like this.

eyeswithaface
Thank you for sending a dm, hope you saw my reply?
The shocking thing about your dm’s situation is that it seems to be ‘the norm’ in hospitals when it comes to elderly care.

My up until July last year, my 76 yr old dm was walking with her wheelie frame and mostly independent. Now she is bedridden, can’t even stand up, and nobody seems to think it’s cause for concern. No diagnosis at all.
The staff just don’t listen to family at all, I’ve found. If they had listened to me in the first place, I could have give them a much better insight into dm as a person, and she could have had a much better outcome. Much of her problem is panic and anxiety related, but they just don’t engage with me at all. So sad and frustrating.
Please dm me again if you get a chance. It’s seems like we have had very similar experiences 💐

Hi Cherry - thank you for your dm, which I've replied to just now (sorry for the delay).
Maybe you should take the hospital up on the 'discharge to assess' option, as long as you are reasonably happy (as far as you can be) with their suggested care/residential placement? The more I think about it, the more I think the hospital 'care' is unsatisfactory. Patients just get institutionalised and staff don't seem to have any time for them. At least in a (decent) care home setting, the care might be more personal and individual, if you're lucky.
It's supposed to be a 4-week assessment, and in theory we still have rights as to what happens next.
I will keep this thread updated, in case it's any help to anyone else going through this.