Why would four staff be needed for personal care in dementia?

[IDontLikeMondays88]

Dad has late stage dementia. We are being told he is so agitated when receiving personal care ie toileting that he is needing 4 members of staff attending to him to do this.

can anyone explain why 4 staff members would be necessary? I just don’t get it unless they are restraining him which I assume they shouldn’t be doing.

from my point of view I just am thinking well no wonder he is agitated with there are 4 of them at him.

restraint is allowed @IDontLikeMondays88 it would be useful for you to clarify with the home, exactly their position with regards to their care of your Dad.

Legal Criteria for Restraint
Restraint can only be used if the carer reasonably believes it is necessary to prevent harm to the person with dementia. The action must meet two crucial tests:

Best Interests: The action must be in the person's best interests.
Necessary & Proportionate: It must be necessary to prevent harm, and the restraint used must be proportional to the likelihood and seriousness of that harm.

Yeah and I haven’t said they should compromise on their own safety. What I am questioning is whether the approach taken is making it worse. As I said at home he was always clean, showered etc. that was only a month ago!

To add to @Arregaithel, the restraint should also be documented (both in a care plan, and in notes when restraint has been carried out), acceptable (there are accepted methods of restraint), should only take place when other planned interventions to reduce escalating behaviour have failed.

sadly some dementia patients can be quite violent its a sad thing i have seen it in my fil that a number of carers are needed. also they may need to roll the patient and change bed linen or kylies (pads) it does look a bit much to us but i am sure they are doing partly to make sure your father is ok and not too much disruption but also for their safety too

Why do you think they would take staff from other duties to help with him, if it wasn't needed?

My dad violently resisted any form of physical care. He was on a minimal hygiene regime whereby they did the absolute minimum for his health. I don't know details but I know that he had multiple staff to change his pads and they would try and do a bit of pits and bits wash at the same time. He went very quickly from toileting and washing independently to this as is often the case with dementia deterioration. A few weeks later he had another deterioration and was much happier about staff doing personal care. But during his bad period he caused one member of staff to have to go to A&E after he bit her.

@BambooLampshade i haven’t said it’s not needed I just don’t get what 4 of them are actually doing unless it is restraining him which they have not told us they are doing.

Op you're absolutely right 4 carers doing personal care needs agreed through discussion with management, the family and social work first and then full guidance of what is deemed appropriate and what isn't documented in a care plan to be followed by front line staff that don't have the authority or qualification to make these decisions themselves.

If 4 are doing it, my guess is 2 are restraining an arm/hand each, 1 is pulling down and up the trousers and one is doing the intimate care of changing the pad or wiping. I have come across this multiple times in the past as someone who worked with organisations who have failed inspection by the regulators because of institutionalised abuse like this that has been normalised by staff that are inadequately trained and management pretending to be unaware.

Even people with dementia retain a significant amount of rights, including whether they want to receive care or not, when it is within their best interest. Your father has the right to refuse to be changed in the regular way with the number of care staff stated in his care plan if he doesn't want to be. Even if it is in his best interest. If the steps above haven't been undertaken and he is refusing through physically objecting or resisting then they can't just keep adding people until he is physically overwhelmed. They pick up the phone to you and social work and agree a way forward.

I would start by asking for a care review with social work and the management and discussing it there. Good luck.

I used to work in community elderly care in the NHS so I speak from professional experience.
Three things OP. The first is that you really need to talk, calmly and objectively. to the person who manages care in the home because we cannot answer your questions with regard to a person we have never met.
Secondly and sadly a month can be a massively long time in dementia care and can be long enough for quite a change. There must have been a reason why he was moved from being at home to going into care. Was he getting harder to manage at home?
Thirdly, sadly and not often discussed is that the move of residence itself can precipitate a worsening of the condition. I know its a dreadful thing to say but it can happen when a move is made late on in the illness, that some people will be incapapable of adapting to new circumstances and will be made very distressed by the fact that they are in a strange setting and can't remember that this is their new home. Of course they may have refused to move earlier, or their family will have refused it.
OP go and talk to the care home.

I'm not going to speculate on the reasons why your dad has been allocated this number of staff to attend his personal care. This is something you need to discuss with the care home manager and raise any concerns that you have.

So if they just point blank refuses case, what should the home do? My grandad got to the point where he couldn't communicate at all, verbally or otherwise, but constantly resisted personal care. If they had never changed him if he was resisting care, he would have never been changed. Obviously it was awful, and they used to go away and come back once he'd calmed down as many times as they could to try and avoid it, but it would have got to the point where he would have got sores. I am really interested to know what the home should have done instead, or if it's just that they should have social services involvement? My grandad had no capacity and a DOLS order and was under CHC funding if that affects anything.

@Endofyear not sure why you replied to my post if you don’t want to speculate?! How strange to reply to my post.

I have never been in this situation before ie having a parent in a care home so I was just asking for other people’s experiences of this, that is all.

Have you actually seen him in the last month? His behaviour at home does not probably reflect his behaviour at home. I’m not actually saying that you’re wrong but what you’ve said seems to indicate that there is a lot you don’t know. How is he actually behaving? What is his care plan? What has been agreed and why? You need to know all these things before you can make a judgement.

No there is no need at all for 4 staff ! No wonder he is agitated , this is down to poor staff training and probably utter shit carers

No none of that makes a difference. Nor does it matter if he's refusing care by being violent. I would be violent too if I said I didn't want changed and 1 person never mind 4 just ignored me and pulled down my pants.

What you have said has been exactly right. They need to go away, give him space and try again. As many times as it takes. Frail, vulnerable people will tire out at some point. Between that and shift changes so different people and gradually getting more uncomfortable from sitting in a wet pad means people will come around.

If after a set care plan has went in documenting a slow approach, what way he likes it done, keeping gentle but assertive, ensuring the staff have bespoke training etc etc and he is still left soaked, smelling of urine or a regular basis then other alternatives need looked at them. These moght be looking at reviewing medication so he feels more settled or nursing care instead of residential.

The answer should never be 4 care workers physically overwhelming someone. The fact that they do resort to this at times is usually the result of poor management within a broken system rather than malicious peoplei

you don't know that they are physically overwhelming someone.

no you weren't asking others for their experiences, you were asking people to speculate, which is not helpful to your getting the information that you need.

Well it's either that or multiple unnecessary people are present. You don't need extra bodies for reassurance. You need them for physical assistance. Sometimes that doesn't mean grabbing them by their wrist but using their bodies to be obstructive so the person receiving care is restricted in interfering with the care.

Thank goodness for a reasonable voice of advocacy.

Choosing times when a person is tired is an EXCELLENT example of alternatives to restraint which should be the first port of call before we even consider laying hands on someone to restrict their freedom. Obviously not everything can be planned or left until someone is tired and not overstimulated but flipping hell, we should be exploring all possible alternatives instead of reaching for justification to retrain. I don't know about anyone on this thread but if I was confused and with limited mobility and means of escape, I'd be traumatised by four people retraining me - bearing in mind I'd have little understanding of the reasons why. Guaranteed that the next time they came at me, I'd have my hackles up from the outset and why not?!

In my experience, there have been many times when someone is 3 x assist due to behaviour. It is usually 2 x to do the cares as quickly as possible, and the 3rd will be the one talking and trying to reassure.

I've never seen 4 x assist, and I do wonder if it may be contributing to further agitation for him.

As far as your concern about restraints, that depends on what you are envisioning when you say "restraint". I would doubt that they are holding him down on a bed or up against the wall type thing (although I'm not naive enough to think it doesn't happen in some awful places)... but yes someone may be holding onto his hand if he is trying to hit, or holding their arm out to block kicks.
If he was being forcibly restrained, he would probably have lots of new bruises and skin tears every day. Is that happening?

And a move into a care home is likely to have caused a decline in his congnitive function, any move does (as we know from experience). So how he was at home a month ago is unlikely to be how he is now.

Are you concerned that the home aren't managing his needs?

I've been on a ward with my mum where there are people with dementia and changing them is very challenging and distressing.

Someone holding someone's hand in one scenario can be comforting and reducing issues but in multiple others it is restraint by the back door and illegal.

And never should personal care be continuing if the person is so distressed they're kicking out. You leave them alone, not start blocking the kicks.

The CQC and Mental Welfare Commission are very clear that restraint is restraint, and that whether it's holding someone's hand or forcing them down on a bed and all restraint should be approached in the same way in terms of risk assessment, protocol, and absolute minimum intervention as a last resort. The MWC goes as far as to describe a "brusque attitude" as a method of restraint.

Taking the approach that there are lesser forms of restrain is what gives rise to people being inappropriately and excessively restrained because staff don't even recognise their practice as restrictive.

Just ask them?

And sorry I'm not meaning to pick on you specifically but your last line about it's not forcible restraint because it's not marking people is totally incorrect. I can hear you speak as a care worker that undertakes care, which is a hard job but you can also tell you don't have appropriate understanding of the law in and around capacity, human rights and restraint.