Run by Cornwallis Care Services, staff at Karenza, which is based in St Agnes, talk to the patients to understand their needs, and plan and provide up to 6 weeks of goal-focused and intensive reablement to help them to rebuild their confidence and retain their independence and avoid being readmitted to hospital.
Care home manager Vicki Franklin said: “We have 10 beds at Karenza that support the national discharge to assess (D2A) framework.
“Our role is self-sufficiency, and people who come here know it is a stopover after a hospital stay, while they practise living life. They will have daily supervision from therapists who are on site helping the to get used to daily tasks such as washing, dressing and preparing food.”
Alex Dickinson is physiotherapist team lead for D2A. He said: “When a person stays in hospital, evidence shows that staying in bed for just 24 hours can reduce muscle power by 2.5%. If someone needs to be admitted to hospital following a fall, they may arrive here not being physically capable of moving around much.
“We work hard from day 1 to mimic the home environment, establishing a routine to increase mobility and as much independence as possible. If a person does need support when they get home, we organise that, such as a piece of equipment to get out of bed easier. We practise using the equipment here, so they get used to it and feel confident when they go home.”
Vicki added: “A person may be going home with carers visiting, but there will be periods of time when they could be alone, especially at night. We support them with important lifestyle basics which helps them feel more confident.”
Maggie, 81, has been at Karenza since leaving hospital where she was treated after breaking her leg from a fall. She missed her independence, and family, and was unhappy her leg wasn’t healing as quickly as she’d hoped.
Alex worked with Maggie to encourage her to move around, and although she can’t place any weight on her leg, they are working out a way she can establish some mobility.
Alex said: “Maggie has a good family support network and carers who will visit when she gets back home. We have worked around mimicking what she will need to be able to do when the carers aren’t there. Night-time is an issue for her when she may need to get out of bed. We have ordered a standing hoist that we are getting Maggie used to here before she goes home with it.”
Maggie said: “The care I received at the hospital was good, but I was so pleased to get here, because I knew it was one step closer to getting home. Here they encourage me to do things for myself, and I have regular exercises. Alex has been full of encouragement and made me feel much more reassured about what I can do for myself. I have made friends with other residents here and we have a good rapport and lift each other’s spirits.
“I haven’t seen home for 3 months and I can’t wait to be back to my own bed.”
Speaking on behalf of Cornwall and the Isles of Scilly’s health and care system, Helen Childs, system director of integrated care, said: “We are committed to providing high quality and safe care for older people in Cornwall and the Isles of Scilly.
“We believe your own bed is the best bed, and our Embrace programme brings together health, social care and voluntary organisations to support people like Maggie to get back home to do the things they love as soon as they’re clinically fit and ready, and with the help they need in place.
“We are creating a truly joined-up health and care system with doctors, therapists nurses working alongside social care and voluntary sector colleagues to provide tailored care that meets people’s needs. Our Home First service, which provides short-term reablement to help people recover at home, is helping to reduce people’s dependency on long-term care.”
D2A is the national hospital discharge policy, which requires people to be discharged from hospital within 24-hours of a decision that they are medically fit. This means they no longer need hospital care. The policy states that people should be discharged ideally home (pathway 1), or into temporary bedded care (pathway 2 and 3). The pathway reflects a person’s support needs. The care homes detailed above are commissioned as part of the discharge to assess temporary bedded care pathway.
Embrace delivers targeted and effective support to ensure people aged 65 and older have access to the right care, in the right place, at the right time. It brings partners across the health and care system, and voluntary sector together to improve the way we care for and support older people.
It delivers personalised and individual community-based packages of care to help people retain their independence and stay in their own homes for as long as possible. In future these temporary beds in care homes will be phased out, as Embrace delivers its long-term goal to increase reablement support for people in their own homes after a hospital admission.