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.

Here is Janet’s story, one of our MAS service users. In this case study we take a look at how Janet has been supported and some of the principles we followed along the way. Names have been changed to protected identity.

Janet’s Background

When Janet came to the Memory Assessment Service (MAS) she was 84, and since her husband died, she lived alone with no other family.

Janet’s husband had dementia and she was his carer. Janet had recently been diagnosed with Alzheimer’s disease and had been relying heavily on her friend and Power of Atterney (PoA) Ann however, Ann passed away suddenly and shortly after Janet received her diagnosis.

Ann’s daughter then took over PoA but Janet didn’t know her very well and she is not heavily involved. Without the help of Ann, Janet was struggling to pay bills, arrange appointments and manage her home. Her home and personal care had declined although Janet was not open to talking about this. She had a neighbour who she went to with things like letters but other than him, she didn’t know anyone else. Janet felt she was managing well and wanted to carry on as she was however, she was at risk of self-neglect in a number of ways.

Understanding what’s important to Janet

What the Memory Assessment Service did for Janet

Safety

Janet had a lot of items in her home and out of date fire safety equipment so the Memory Support Worker (MSW) arranged for Janet to have a free, fire home safety visit to ensure that she is safe from fire hazards.

Janet has a kind neighbour who helps her but he often goes away. She wants to feel safe at home. Her MSW made a referral to Carelink and agreed to be present for their initial appointment.

Money and Bills

Janet’s phone was no longer working so with her permission, MSW looked through bills with her and noticed outstanding payments. They contacted Janet’s phone provider and arranged for services to be reconnected and payments to be put on hold.

Understandably, Janet’s neighbour didn’t feel comfortable being involved with her finances, but said that she did some help with this.

The MSW arranged for Money Advice Plus (MAP) to visit Janet to help with managing her finances and was present for the appointment. MAPs service is means tested so Janet needed a financial assessment and the MSW asked Access Point to do this. Twice they called Janet to offer this and Janet declined as she did not understand the purpose of the call.

Because Janet is self funding but needs support, the MSW referred to Department for Work and Pensions (DWP) to assess her for attendance allowance. The DWP did not feel they could do the assessment as they felt Janet lacked capacity. With this in mind, the MSW referred Janet to specialist older adults team who did financial assessments and helped her to access the care she wants.

“The service we have received (from the MSW) was excellent – she should be commended for the fine work she carries out”

Memory Assessment Principles

• We pay attention to your emotional and psychological needs
• We will hold you until we have found or helped you find a solution to what matters to you

Without the Memory Assessment Service

• Janet would have only received one initial visit and two follow ups from her MSW across 12 months. After 12 months, Janet would have been discharged from the service. She was not on medication and not known to any other services. Given her isolation and the risk of self-neglect and wandering, it is very likely that Janet would have reached a crisis situation and possibly come to physical harm.
• The fact that MSW could visit Janet more regularly meant they could pick up on changes in Janet’s ability to manage at home and could act on problems as they arose to prevent a crisis.
• Without the MSW being involved it is likely that all of Janet’s services would have been cut off. Her phone and home insurance had already been suspended and it is likely that her gas and electric would have been to meaning she would have been without warmth, light and cooking equipment.
• Janet’s neighbour was happy to help her but did not want to be too involved with her finances or personal/home care. Without the regular support of the MSW he may have felt obliged to offer more care to Janet leading to carer stress and possibly even complete withdrawal of his support
• Janet declined input from Access Point as she did not understand the reason for their call. MSW was able to follow up on this with Janet, and re-refer Janet who told them a second time “I’m fine”. Without MSWs input and follow up, Janet would have been left without any input. In the end MSW referred to another, more urgent service to get Janet what she needed.

Outcomes for Janet

The MSW visited or called Janet over 10 times during her year in the service. All of Janet’s services were reconnected and they agreed to put payments on hold whilst MSW arranged for Janet’s LPA to pay her bills. Janet was able to stay at home with her cats and be safe during this time, whilst she decided whether or not she wanted to move into a care home.

Janet was able to make this decision for herself and the MSW attended a final handover to help Janet express her wishes to the specialist older adults team about where she wanted to live. Janet was able to maintain her friendship with her neighbour which she valued.