The client was one hundred and one years old at the time of this case and had been supported by Trinity Homecare for six years through regulated visiting care. Over that time, a strong and trusting relationship developed between the client, her family and her regular carers. Consistency, familiarity and feeling safe at home were central to what mattered most to her.
Despite receiving visiting care, the client did not have night-time support in place. One night, she got up independently and fell down the stairs, resulting in a hospital admission. This incident led to a significant decline in her health and capacity. While in hospital, professionals confirmed that she would require an increased level of support in order to return home safely.
Throughout her hospital stay, the client continued to receive visits from her familiar Trinity carers. This continuity provided reassurance during a period of uncertainty and helped maintain her sense of identity and trust. The family were anxious about the prospect of live-in care, as the client had a strong bond with her visiting carers and valued those relationships deeply.
The care management team worked closely with the family, hospital staff and the wider multidisciplinary team to design a solution that respected the client’s wishes while ensuring her safety. Rather than replacing one model of care with another, the visiting and live-in teams worked together. A carefully planned transition was put in place, with live-in care introduced alongside continued visiting support. This approach reassured the family and allowed the client to experience continuity at a time of major change.
Discharge planning focused on one clear goal. The client wanted to return to her own home and be there in time for her one hundred and second birthday. Through coordinated planning, joint working between care managers and close communication with professionals and the family, this goal was achieved. The client returned home safely and was able to celebrate her birthday in familiar surroundings.
The impact of this approach was significant. The client was able to remain where she felt most comfortable and secure. The family felt supported, listened to and confident in the care arrangements. The combination of live-in and visiting care ensured continuity, familiarity and reassurance while meeting her increased needs.
This case demonstrates Outstanding practice through flexibility, collaboration and a deep respect for what matters to the person. By working together across teams and with the family, the service ensured a safe transition, preserved trusted relationships and enabled the client’s wish to remain at home to be fulfilled.
CQC KLOEs demonstrated:
- Caring
- Safe
- Responsive
- Well-led
