Case Study: Respite Care
K was a gentleman of 53 years of age, he came to the service from hospital where he ended up due to health deterioration at his previous supported living accommodation.
It was noted that during the last few months of him living with others in his supported living accommodation that his health had suffered so much that he would continuously physically challenge staff and himself (self-harming) to a point where his previous placement served notice on him as they were no longer able to support or meet his needs as they struggled to engage with him within his home. The local authority along with CCG were struggling to find a suitable placement for him due to his behaviours (high assault cycle, unsettled) that could meet his needs, and as he was considered fit to be discharged from a hospital environment, they needed a placement that would take him until a new permanent home could be sourced.
The service received a phone call asking if we could meet his needs until a suitable permanent placement could be sourced for him as he had been served notice from his previous placement as they felt they could no longer support his needs, so he was unable to return there.
K had tunnel vision, was none verbal in communication and on the high end of the autistic spectrum which meant he was routine orientated and extreme with his learning disabilities with challenging behaviours. K although was an amputee of his toes, was mobile and able to weight-bare with the use of furniture to hold onto but for distancing he used a wheelchair . When walking, K would walk in a stiff uncoordinated way. K’s balance was not good, and he struggled to walk for longer than a few steps, if he needed to move for more than a couple of steps he would proceed to crawl. Due to sitting for long periods/crawling he was prone to pressure areas on his knees and on toes due to extra mobility.
The clients situation/ circumstances at the start of the support.
Because of his high autism and profound Learning difficulties, K could not tolerate other people in his personal space. For the first few months of the 6 months that K was at the service there was a high number of assaults against staff trying to support him along with many self-harming incidents. Initially and because of the risk to staff through assaults cycles, K was 2-1 staff support at all times through waking hours and 1-1 support through the night as he was unpredictable in his sleep pattern and could remain awake throughout the night at times. In the past people who have supported him have at times tried to introduce others into his space, but this resulted in him becoming upset and distressed. K preferred more firm surfaces and sometimes would bang his head in anger or press his finger into his right eyeball.
K liked to wear clothing that was tight fitting to his skin, though at the start of his placement he refused to wear any clothes on his bottom half of his body, occasionally he would accept a towel, blanket or sheet over his legs at this time. Due to constant urine infections K was fitted with a catheter which he would constantly play with the tubing and often pull the catheter completely out at times, on these occasions this would have to be re inserted by district nurse if he allowed it as he was not keen on medical interventions.
Due to his unpredictability staff and other health professionals would initially greet K from a distance in order to ascertain if K wanted to interact, If he did want to he would initiate this by placing his hand in front of his face and waving my fingers.
What we did to support the client
Staff found that music especially 80’s really helped when supporting K as he appeared to settle more when there was background music playing although at times he struggled with other noises and he would indicate this through his behaviours (aggression, hitting out, nipping, kicking and or self-harming) so staff would support using low arousal techniques. Having high autistic needs meant that he liked to smell foods and drinks before trying them which helped settle him along with giving him predominantly finger foods as this was also a part of his sensory feelings and enabled him to settle far better than when using utensils to eat with.
With K having tunnel vision staff needed to show him things directly in front of him (in his eye level) and close up, explaining to him what they were showing him in order that he was able to understand what was being given to him and whether or not he wanted what was being shown to him
As K had limited tolerance for waiting for things to happen for him and this was proven to be a huge trigger for his behaviours and challenging towards staff when supporting him with his personal care needs ensured that all of his toiletries were gathered prior to support being carried out, this also included giving K the choice of clothing that he chooses to wear for the day if he could be persuaded to wear any at all. K due to his autistic needs would not tolerate having to wait for things to be carried out, (having his shower first thing in the morning was essential and a huge part of his routine which could not be changed and if this was not carried out as soon as he left his room would trigger behaviours) If this was not done then his behaviours would escalate and could last for several hours.
K was always supported by two staff members when having his personal care requirements, this was to ensure not only could the care be carried out quickly (to reduce K’s anxiety and behaviours but also to ensure staff safety should his behaviours escalate. All personal care had to be carried out in an environment that was spacious in order that staff and K were able to move around in should there be behavioural issues and so that staff were able to have a safe exit should they need to.
As K wasn’t able to understand what to do in order of showering himself although he was able to follow verbal direction which if he was calm he would do to limit confusion one staff member would take the lead and only give verbal instructions to lessen confusion and reduce any anxieties should K become anxious. If K did present behavioural issues and refused to have a shower, then and only if he were tolerant to do so then a full strip wash was another alternate option that he was more tolerant of
If K did not engage with having his personal care needs met and would become agitated, then to reduce risk of harm/injury to both K or staff then the process was halted immediately.
How we made a difference
To begin with staff observed him to ensure he didn’t become over distressed owning to the fact that his routine for the past few months had been massively altered and upheaved and that he was now living and in an environment that was strange to him and with the added factor of suspected medical ailments. These factors and indicators were clearly quite emotionally distressing for him and he did present extremely physically challenging behaviours throughout for the first few weeks. by maintaining a routine that was
By giving small choices in easy-to-understand information, i.e. choosing clothes not having a huge variety of foods to pick from etc, staff enabled K to make decisions that didn’t overload him with information maintain as much as possible a calm environment for him.
By Staff not overloading him with too much information at once, (one member of staff to speak at a time) this reduced his anxieties leading eventually after several weeks of him preventing as challenging to become acceptant of his environment and more tolerant of staff who in turn learned to adapt to K’s needs.
When supporting K staff would speak clearly and slowly in order that he had chance to understand what was being said. Staff often had to repeat what they are saying in order that he has understood them, and the information was processed by him. He needed simple easy to follow instructions, limited words and none ‘gobbledy gook’ sentences in order for staff to be able to work with him and visa versa by doing this it appeared that in time K’s confidence was built up in order that when he was communicating his needs with staff, he would sometimes take hold of the staff members hand and lead them to what he wanted or where he wanted to go.
After several months and with strict and robust support without deviation from his support plan and routine K finally settled to a more manageable level where assaults against staff and self-harming incidents became more minimum, support staff levels were able to be reduced to 1-1 through waking hours (1-1 remaining at night).
After 6 months of placement at the service the local authority finally found a permanent home for K where he could live semi-independent in his own flat with 24-hour support. The environment was well chosen to meet his needs and in order to comply with his routine. The new supporting provider came out to firstly observe K and how staff supported/interacted with him to continue that specific care and routine over into his new placement for a smooth transition. Whilst seeking a new placement discussions and meetings were held with the local authority and CCG where we gave as much input as possible in respect of K and his needs and how we had worked with him to reduce his assault levels and give him more stability. We did express that any move my again raise his levels of anxiety as again his routine would potentially be altered and K would once again have to go through the process of settling in with a new provider. We did suggest that initially extra support may be required, and K be 2-1 to begin as he was when he was placed at the service due to experiences that we had. This was agreed that it would be in everyone’s best interest to initially commence this level of support until K had time to settle in.
A month after K had moved on, we did speak with the local authority to ascertain how K was doing and we were informed that the transition had gone far better than expected and K had settled in really well, so much so that the 2-1 support was not actually required and 1-1 staffing levels were sustainable when supporting K.