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Vanguard - before and after

A care home resident is encouraged to eat by staff member

This case study is fictional but draws on the real-life issues that face frail care home residents. 

When Marie moved to her care home a year ago, she had type 2 diabetes as well as breathing difficulties. During her stay, Marie became increasingly confused.  She was increasingly dependent on staff who were not always informed or confident about caring for her long-term conditions. Marie’s frustration at losing responsibility for her own care led to depression and, without a comprehensive care plan in place, there was little improvement in her weight and mobility. When Marie experienced complications from her breathing problems, care home staff were unsure what to do and called an ambulance to take her to hospital, which Marie found distressing and disorientating.

The same story after the improvements are made
When Marie moved to her care home a year ago, she had type 2 diabetes as well as breathing difficulties. 

  • Training means care home staff feel more confident helping Marie manage her diabetes through nutrition with input from a dietician.  Long term condition training covers respiratory problems.
  • Clinical pharmacists review medication for individual patients, to ensure that medicines provide therapeutic benefit and minimise side-effects.

During her stay, Marie became increasingly confused. She became more dependent on staff who were not always informed or confident about caring for her long-term conditions. 

  • Confusion recognised by staff with dementia awareness training and are generally more confident about looking after Marie as a whole person.

Marie’s frustration at losing responsibility for her own care led to depression and, without a comprehensive care plan in place, there was little improvement in her weight and mobility. 

  • Input from Community Psychiatric Nurse and multi-disciplinary team (MDT) of therapists, district and community nurses and social care staff, Marie is encouraged to join exercise and social/craft sessions.

When Marie experienced complications from her breathing problems, care home staff were unsure what to do and called an ambulance to take her to hospital, which Marie found distressing and disorientating.

  • Care planning becomes a joint responsibility of Marie, her family, MDT and carers in her care home. Breathing complications prompt care home staff to call frailty team. Rapid Response team carries out assessment on Marie, and supports staff to keep her in her care home bed.

HOSPITAL ADMISSION AVERTED