Case Studies

Jane Newton - Nurse Assessor, Continuing Care and Funded Nursing Care, NHS Sheffield

I had a fabulous telephone conversation with Ellen Moore today, she contacted me to say how pleased she is with the care you are providing to her mum, Mrs Atkinson. She told me that every single member of staff involved is wonderful, she felt very reassured and supported by the telephone calls from Tracy and she feels like she is a daughter again. As you can imagine I was almost lost for words and of course would like to congratulate you on providing such a satisfactory service.

Mrs Jones - Complex Condition

Mrs Jones is an 87-year-old lady who suffered a major set-back in her life after she was diagnosed with circulatory problems. Unfortunately, due to infection, she subsequently had to have her leg amputated below her knee.

For Mrs Jones, this had a devastating effect, as prior to the amputation procedure she was a very social person and enjoyed being out in the community with her friends and family. While in hospital, and after her amputation, PULSE was contacted by a family member to request an assessment in order to identify if we could provide a live-in Carer.

After a long discussion about Mrs Jones’ situation and needs, a meeting was arranged to discuss PULSE Community Healthcare and the services that could be provided. This meeting was undertaken with Mrs Jones and her family whilst in hospital to identify the diverse needs and expectations that Mrs Jones hoped to achieve when she returned home.

PULSE Community Healthcare liaised with Mrs Jones and all key stakeholders (including the hospital) to detail the discharge from hospital and to ensure that all aspects of her discharge needs were met.

Once discharged from hospital, PULSE Community Healthcare was then able to complete a full assessment of care needs in Mrs Jones’ own home. This consisted of the following elements and was undertaken by a Care Consultant, in conjunction with the client and all key stakeholders;

• Care Needs Assessment
• Environmental Assessment of Mrs Jones’ home and surroundings
• Agreement of Outcome-Based Care Plan

As part of this meeting, PULSE Community Healthcare also gained a thorough understanding of Mrs Jones’ criteria to enable us to identify an appropriate carer to provide the required service and realise the key outcomes and objectives of the Care Needs Assessment. In addition, the pricing for the PULSE Community Healthcare support package was also agreed.

Once PULSE Community Healthcare had identified an appropriate Carer, an interview was arranged with Mrs Jones and key stakeholders to ensure that all parties were happy with the selection. A time frame was then agreed for the Carer to start.

On service commencement, PULSE Community Healthcare completed the first assessment after 24 hours. This was a spot check visit to ensure both Mrs Jones and her carer were pleased with how the service had started.

PULSE Community Healthcare continues to maintain constant contact with Mrs Jones and her Carer in order to identify any change in needs and to implement any changes to her support as required. Regular, formal reviews are also being undertaken, in addition to regular carer appraisals.

At the last review with Mrs Jones, it was identified that all her initial goals, objectives and expectations had been achieved. Mrs Jones is now looking forward to arranging her first holiday since her discharge from hospital and continues to live independently in her own home.

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Mrs B - End of Life Care

Mrs B had been diagnosed with a terminal brain tumour and was supported at home by her family. She was admitted into hospital following a marked deterioration in her physical and mental health. However, after a lengthy stay in hospital she was fit enough to leave hospital - choosing to spend the last weeks of her life at home.

A planning meeting was held at Mrs B’s home, organised by PULSE. This included her family, district nurse, MacMillan nurse, lead from the local PCT, social worker and her support staff. During the meeting, relevant information regarding Mrs B’s physical and mental health needs was discussed and guidelines agreed to enable the whole group to support Mrs B in her final days at home - following the wishes of Mrs B and her family.

When her illness progressed and her mental health deteriorated, Mrs B became delusional. However, as a team we were able to put into practise the agreed methods of supporting her - ensuring that she wasn’t admitted into hospital and thus meeting everyone’s wishes.

From the beginning, PULSE managed all the information regarding Mrs B’s health and any episodes of unstable health were reported to the full team so that changes to her medication and support could be made immediately. This resulted in less stress for her family, no admittance to hospital, and ultimately the client having her wish realised - to end her days in her own home, surrounded by family and people she had trust in.

Mrs B’s husband says: ‘PULSE staff member Tracey performed above and beyond the call of duty and looked after my wife and myself. She was always upbeat, caring and sensitive. Tracey took my wife out for rides in the car and to the shops. Tracey was an asset on visits to hospital where her help was invaluable. I would highly recommend Tracey to you.’

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Mrs D – Spinal Injury

Mrs D was involved in a car accident, sustaining a C4/5 spinal break which resulted in limited movement in her hands and arms and no movement below her chest. Mrs D had been in hospital for 11 months when PULSE staff were introduced to her. The Spinal Injury Home Care team met with Mrs D for a long discussion which ascertained her plans and goals for the future, as well as what support she would need once discharged. Following this, Mrs D was introduced to 5 possible support staff while in the hospital, 4 of whom she chose as her support team.

PULSE worked with the hospital to deliver training for the team on Mrs D’s individual needs - arranging for the staff to be with Mrs D for her full daily routine of bowel management, physiotherapy training and exercises. This also helped in building Mrs D’s trust in them.

PULSE staff were on hand after the training to accompany Mrs D to her home and to help settle her back into her family home. They remained with her during each day of her staged discharge and each return to hospital, allowing for an excellent working relationship to be formed with the district nurses while Mrs D was on home visits.

4 months on from Mrs D’s discharge she has worked hard to achieve her goal of returning to work as a Head of Languages at the local college, and is working towards commencement at the start of the new school year. Mrs D has worked relentlessly with her PULSE team in building her strength, following her exercise programs, and maintaining a positive attitude. Supported by a team that she knows and trusts, Mrs D has made the decision to reduce the support hours required and has consequently avoided her readmission to hospital.

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Scot Schofield – Complex condition

Scot is 18 years of age and suffers from Epidermolysis Bullosa (EB) - a very rare genetic condition in which the skin and internal body linings blister at the slightest knock or rub, causing painful, open wounds and skin infections. Pulse Community Healthcare have been working with Scot for18 months following his transfer from the Paediatric Team who looked after Scot within his family home until he was 18 years old. Pulse was commissioned to support Scot and the PULSE team who would be supporting him met Scot and his family at home to assess and plan for his care. Before staff could work with Scot they all had to reach specific competencies to ensure they could support Scot with his medication, skin surveillance and his four hourly dressing changes.

Part of Scot’s plan was to be become more independent and be less reliant on his parents and have his Mum back as a Mum and not his carer.

Scot has a team of 5 PULSE members of staff, who are responsible for supporting him in all his daily and social care activities.

Start of package

When PULSE commenced Scot’s package of care, we planned with Scot what he wanted to do and how he wanted his support delivered. We encouraged him to research via the internet what activities he wanted to take part in and what aspirations he had for his life. The team then provided support to Scot in achieving his goals. Scot also needed a PEG feed 7 days week as his diet was poor. With the full support of his team a plan was developed to encourage his dietary intake which would improve his skin condition.

Present day

Scot now has a good social life, going out with his friends and to the cinema, pub, parties and eating out. Scot is also planning a holiday to Orlando, Florida for two weeks at the end of the year. He feels able to achieve this thanks to the support of the PULSE team workers who will assist him whilst he is on holiday, as well as working with him and his Mum in planning the travel arrangements, medical cover and transport of specialist equipment he will need whilst in Florida. Scot’s dietary intake has improved and he has reduced his use of PEG feed, now having it 2 days week as a top up or when he is unwell. Scot is now eating a well-balanced diet which aids his skin condition and helps him to fight infections better.

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