Back in 2016 we redesigned the Memory Assessment Service (MAS) following feedback from the people that utilise it. They told us that they believed diagnosis was not as important as support.

Meet David, one of our MAS service users. In this case study we take a look at how David has been supported since his diagnosis and how he has been involved in his own care journey.

David’s Background

When David was referred to the Memory Assessment Service (MAS) he was 68 years old and lived alone, with no family and a history of alcohol abuse and homelessness.

David had been diagnosed with Parkinson’s dementia and has increasing care and support needs but does not want anyone coming into his home. David felt annoyed that his “brain and body don’t work”. He wanted to feel better but did not believe that his medication is working so quite often didn’t take it. David wanted to stay as independent as possible, and wanted to be able to get out of the house. He didn’t have much food at home but usually went to the pub each day for a cheap meal. If David cannot get out of the house he is a risk of self-neglect as he will not be able to eat.

Understanding what’s important to Janet

What the Memory Assessment Service did for David

During the first 18 months

The Memory Support Worker (MSW) arranged a medication review for David, to reduce the number of tablets he takes and how often he has to take them. The MSW set daily alarms on David’s phone to remind him to take his medication and often too old medication away for his safety.

MSW visited David regularly and MAS were the only service he would engage with in terms of support. MSW discussed the benefits of accepting a care package and David gradually started to agree with this. He also felt able to list his MSW as a point of contact for the Department for Work and Pensions (DWP). MSW talked to DWP about David’s abilities which determined what benefits he would be entitled to.

Additionally, MSW helped David re-book missed appointments, reminded him of upcoming ones, and helped arrange transport to them.

When David was in need

David called his MSW in the Christmas period and said he was “not good” and wanted some help. He could not explain why but his MSW knew this was unusual. MSW arrived at David’s house 30 minutes after receiving his call. They discovered that David had no food in the house and could not remember the last time he had eaten, so they bought him a sandwich and chocolate bar and gave him a glass of water.

David was not sure if he had taken his medication today and wanted help in taking them. So the MSW took away old medication and ensured that David had enough medication for the upcoming week. It was at this point the MSW made an urgent referral to adult social care via a safeguarding alert surrounding his self-neglect.

Memory Assessment Principles

• We pay attention to your emotional and psychological needs
• We will hold you until we have found or helped you to find solutions to what matters to you
• You set the pace and you will always know where you are in our service

Without the Memory Assessment Service

• If David had received the basic service of one initial visit and two follow ups across one year, it is unlikely that he would have built a trusting relationship with his MSW. David was not engaged with any other services so he may not have known who else to contact in his time of need.
• David’s time of need was 18 months after his diagnosis – with the basic service David would have been discharged by this time and would not have been able to contact his MSW. This could have resulted in harm if David was not able to eat
• Without the rapport between David and his MSW, it unlikely that he would have felt able to list his MSW as a point of contact for the DWP. In the past David has underreported his symptoms to DWP. David’s MSW was able to advise on David’s abilities so that he could access what he is entitled to.
• Without the regular contact and reminders from his MSW, it is likely that David would have continued to miss medical appointments, potentially leading to further ill health.
• it is likely that following the safeguarding alert, adult social care would have set up a care package to keep David safe and well. Initially David did not want this but through conversations with his MSW over 18 months he started to come around to the idea of carers coming in and did agree for his MSW to make a referral for him to adult social care. Without these regular conversations David may have felt that this was being forced on him, rather than it being his decision.

Outcomes for David

MSW visited David 10 times over the 2 years that he was in the service and were able to respond quickly when he was in need. David is now receiving a 3 x a day package of care for help with personal care, taking medication and meal preparation. With help in taking his Parkinson’s medication, David feels more mobile and ‘clear headed’ meaning that he can continue to go out of the house and do things he enjoys.

David is now receiving all of the benefits that he is entitled to which can help cover his care costs. With the package of care, someone will see David each day so he should not reach crisis point again MSWs will visit David one more time and then he will be discharged from the service.