Email: PhysiotherapistsCSG@groupspaces.com

References to support training. Jan. 2014

(Three sections prepared by different members of the Physiotherapists Care Skills Group)

Sect 1. Code of conduct for healthcare support workers and adult social care workers in England. (Highly recommended reading to support training)Statement 2:  “Promote and uphold the privacy, dignity, rights, health and

wellbeing of people…at all times.” Always act in the best interests of people who use health and care services.Always treat people with respect and compassion.Put their needs, goals and aspirations first, helping them to be in control and to choose the care and support they receive.Promote people’s independence and ability to self-care, assisting them to make informed choices.Respect a person’s right to refuse to receive care and support if they are capable of doing so.Make sure that your actions or omissions do not harm a person’s health or wellbeing.   

Statement 3: “Work in collaboration with your colleagues to ensure the delivery of high quality, safe and compassionate healthcare, care and support.”Statement 6: “Strive to improve the quality of healthcare, care and support through continuing professional development.”

Ref; Skills for care and skills for health, code of conduct for healthcare support workers and adult social care workers in England 2013

CQC ( Care Quality Commission ) The essential standardsOutcome 1: Respecting and involving people who use servicesPeople should be treated with respect, …..Outcome 2: Consent to care and treatmentBefore people are given any examination, care, treatment or support, they should be asked if they agree to it.Outcome 4: Care and welfare of people who use servicesPeople should get safe and appropriate care that meets their needs and supports their rights.Food and drink should meet people’s individual dietary Outcome 7: Safeguarding people who use services from abusePeople should be protected from abuse and staff should respect their human rights.Outcome 10: Safety and suitability of premisesPeople should be cared for in safe and accessible surroundings that support their health and welfare.Outcome 11: Safety, availability and suitability of equipmentPeople should be safe from harm from unsafe or unsuitable equipment.Outcome 12: Requirements relating to workersPeople should be cared for by staff who are properly qualified and able to do their job.Outcome 13: StaffingThere should be enough members of staff to keep people safe and meet their health and welfare needs.Outcome 14: Supporting workersStaff should be properly trained and supervised, and have the chance to develop and improve their skills.

Ref; http://www.cqc.org.uk/organisations-we-regulate/registering-first-time/essential-standards

British Geriatrics Society -commissioning guidance

“outcomes needed from commissioned services,” –for residents

Improved experience through high quality essential care – reducing distress from depression, disorientation, agitation, pressures sores, contractures, constipation, pain and sleeplessness.

Minimisation of predictable acute events - urinary infections, aspiration and pneumonia.

Avoidance of unnecessary progression of long term conditions.

Reduced risks of falls, fractures and other injuries.

Enhanced autonomy and involvement in decisions about care,

Ref; BGS (British Geriatrics Society) commissioning guidance. High quality healthcare for older care home residents. 2013

References

Ref; Skills for care and skills for health, code of conduct for healthcare support workers and adult social care workers in England 2013

Ref; http://www.cqc.org.uk/organisations-we-regulate/registering-first-time/essential-standards

BGS (British Geriatrics Society) commissioning guidance. High quality healthcare for older care home residents. 2013

Sect 2.

Policies/ research that back up our ideas:

1) Pressure CareCostsRecent cost estimates suggest that the cost of treating a pressure ulcer varies from £1,064 for a grade 1 pressure ulcer to £10,551for a grade 4i pressure ulcer Bennett et al. (2004) estimated that in the UK the annual cost of treating pressure ulcers is between £1.4 and £2.1 billion (price year 2000), that is about 4% of total NHS expenditure

RisksReduced mobility or immobility A key factor in the development of pressure ulcers is reduced mobility or immobility. A number of studies have identified reduced mobility as an independent risk factor in pressure ulcer development. In a prospective inception cohort study of patients fulfilling certain criteria admitted to a US tertiary university teaching hospital, Allman et al, 1995, found that a significant risk factor in patients who went on to develop sores was immobility. Immobility, is reported as a significant risk factor for both the development of pressure ulcers as well as a contributory factor in delayed healing(Guralnik et al., 1988; Berlowitz and Wilking, 1989; Ek et al., 1991; Allman et al.,1995; Bergstrom et al., 1996; Schue and Langemo, 1998; Nixon et al., 2000 and Bergquist, 2003).Sensory impairment For example neurological disease results in reduced sensation and thus insensitivity to pain or discomfort. This results in a reduced (or lacking) stimulus to move to relieve pressure. There are certain groups of individuals that may suffer from sensory neuropathy, for example those with diabetes and spinal injuries. Acute illness

Level of consciousness A reduced level of consciousness may reduce an individual’s awareness of the need to relieve pressure. Likewise an anaesthetised person has no independence to reposition themselves. Extremes of age (up to 65, less than 5 years of age) Advancing age is associated with an increase in cardiovascular and neurological disease, and changes to the resilience and elasticity of the skin. Individuals over 65 years of age are at greater risk than the general population of developing pressure ulcers

Previous history of pressure damageVascular disease Severe chronic or terminal illness places individuals at greater risk because of, for example, multi-organ failure, poor perfusion and immobility. Malnutrition and dehydration

Nice/RCN(2005)

Other contributing factors:Manual handling/ positioning can lead to pressure areas caused by Pressure which causes compression and possible capillary occlusion, which if prolonged can lead to ischaemia. How high the pressure must be and how long it must be exerted to cause damage depends on the individual’s tissue tolerance. The key factors are intensity and duration of pressure. e.g. when a person is too long in one position, particularly on a bony prominence or if two prominences are in contact e.g. kneesShearing occurs when the skeleton and deep fascia slide downwards with gravity, whilst the skin and upper fascia remain in the original position. Deep necrosis can occur when the shearing between two layers of tissue leads to stretching, kinking and tearing of vessels in the subcutaneous tissues. Shearing forces should not be considered separately from pressure: they are an integral part of the effect of pressure. Shearing most often occurs when individuals slide down or are dragged up a bed or chair. Friction occurs when two surfaces move across each other. It often removes superficial layers of skin. Friction damage often occurs as a result of poor lifting techniques (Defloor, 1999). Defloor, T (1999).

Specific points in guidelines/ recommendations relevant to our ideas: Mobilising, positioning and repositioning interventions should be considered for all

individuals with pressure ulcers (including those in beds, chairs and wheelchairs). Individuals who are ‘at risk’ of pressure ulcer development should be repositioned. Repositioning should take into consideration other aspects of an individual’s condition

– for example breathing and medical condition, their comfort, how it fits into their overall plan of care (for example in relation to other activities such as physiotherapy or occupational therapy, meal times, attending to personal hygiene) and the surface they may be lying or sitting on.

Individuals who are considered to be acutely ‘at risk’ of developing pressure ulcers should restrict chair sitting to less than two hours until their general condition improves.

Advice from trained assessors with acquired specific knowledge and expertise should be sought about correct seating positions.

Nice/RCN (2005)

Specific advice given to patients and carers Keeping moving

One of the best ways of preventing a pressure ulcer is to reduce or relieve pressure on areas that are vulnerable to pressure ulcers (for example, bony parts of the body). This is done by moving around andchanging position as much as possible. If you already have a pressure ulcer, lying or sitting on the ulcer should be avoided as it will make the ulcer worse. Your healthcare professional

should advise you and your carer on how pressure is best reduced or relieved on areas of skin that are vulnerable to pressure ulcers. This advice should include:l correct sitting and lying positionsl how to adjust your sitting and lying positionl how often you need to move or be movedl supporting your feetl keeping good posturel which equipment you should use and how to use it.If you have a pressure ulcer you should change your position or be repositioned regularly to allow the ulcer to heal and avoid further damage. This applies whether you are in bed, chair or wheelchair.If you have, or are at risk of developing, a pressure ulcer, your healthcare professional should work with you to find ways to help you move around and change position. The method chosen should bebased on your needs and be acceptable to you. If you are being cared for at home, your carer’s needs should also be taken into account.

Self careIt is important to move and change position yourself as often as you can. Your healthcare professional should offer to teach you and your carer how to redistribute your weight. People with limited movement may need to have their limbs moved by someone else.

Nice (2005)Issue date: September 2005

Relevant CQC Guidelines:Outcome 4: care and welfare of people who use servicesReduce the risk of people receiving unsafe or inappropriate care, treatment and support by:–– assessing the needs of people who use services–– planning and delivering care, treatment and support so that people are safe, their welfare is protected and their needs are met-Identifies risks, and says how these will be managed and reviewed.Outcome 6: cooperating with other providers(providers) Enables them (service users), as far as possible, to access other health and social care services or support relevant to their care, treatment and support needs, provided that their care, treatment and support will not be compromised.

ReferencesAllman RM, Goode P, Patrick M, Burst N and Bartolucci AA (1995) Pressure ulcer risk factors among hospitalised patients with activity limitation. Journal of the American Medical Association,273(11),pp.865-70.Bennett RG, Baran PJ, DeVone LV, Bacetti H, Kristo B, Tayback M and Greenough WB. (1998) Low air loss hydrotherapy versus standard care for incontinent hospitalized patients. J Am Ger Soc,46(5),pp.569-76.Bergstrom N, Braden B, Kemp M et al. (1996) Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnosis and prescriptionBerlowitz DR and Wilkin SVB (1990) Risk factors for pressure sores: a comparison of cross-sectional and cohort derived data. Journal of American Geriatrics Society, 37(11),pp.1043-1050.Defloor, T (1999). The risk of pressure sores: A conceptual scheme. Journal of Clinical Nursing, 8(2), 206-216.Care Quality Commission(2010): Guidance about compliance Essential standards of quality and safety .http://www.cqc.org.ukGuralnik JM, Harris TB , White LR et al. (1988) Occurrence and prediction of pressure sores in the national health and nutrition examination survey follow-up. Journal of the American Geriatrics Society,36(9),pp.807. http://www.nice.org.uk/nicemedia/live/10972/29883/29883.pdfThe management of pressure ulcers in primary and secondary care. Available from www.nice.org.uk/CG029

The use of pressure-relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. Available from: www.nice.org.uk/CG007 National Institute for Clinical Excellence (2001) Pressure ulcer risk assessment and prevention. Inherited Clinical Guideline B. London: National Institute for Clinical Excellence. Available from: http://www.nice.org.uk/page.aspx?o=20052Nice (2005), Pressure ulcers –prevention and treatment Understanding NICE guidance –information for people with pressure ulcers (also known as pressure sores or bed sores) and those at risk of developing pressure ulcers, their families and carers, and the publicNixon J, Brown J and McElvenny D et al. (2000) Prognostic factors associated with pressure sore development in the immediate post-operative period. International Journal of Nursing Studies,37(4),pp.279-289. Royal College of Nursing(2005)_ The management of pressure ulcers in primary and secondary care A Clinical Practice Guideline.Schue RM and Langemo DK (1998) Pressure ulcer prevalence and incidence and modifications of the Braden scale for rehabilitation unit. Journal of Wound Ostomy and Continence NURSE,25(1),pp.36-43.

2) Falls prevention

Costs

Falls among elderly people cost the NHS more than £4.6 million a day, new analysis from the charity Age UK has found. Nursing Times (2010)

Risks

Almost half of all falls are among the over-80s, half of whom fall again in the following year.

Falls are a major cause of injury and death among the over-70s and account for more than half of hospital admissions for accidental injury.

Specific points in guidelines/ recommendations relevant to our ideas:

Balance and strength training, adaptations to the home and practice in getting up quickly could cut the rate of falls by 55%, (Nursing Times (2010)

Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance.Multifactorial falls risk assessment• Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by healthcare professionals with appropriate skills and experience.• Multifactorial assessment may include the following:– identification of falls history– assessment of gait, balance and mobility, and muscle weakness– assessment of osteoporosis risk– assessment of the older person’s perceived functional ability and fear relating to falling– assessment of visual impairment– assessment of cognitive impairment and neurological examination– assessment of urinary incontinence– assessment of home hazards– cardiovascular examination and medication review.Multifactorial interventions

• All older people with recurrent falls or assessed as being at increased risk of falling should be considered for anindividualised multifactorial intervention.• In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors):– strength and balance training– home hazard assessment and intervention– vision assessment and referral– medication review with modification/withdrawal.• Following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identifyand address future risk, and individualised intervention aimed at promoting independence and improving physical and psychological function. Nice (2004)Older adults at risk of falls, such as people with weak legs, poor balance and some medical conditions, should do exercises to improve balance and co-ordination on at least two days a week. NHS 2012Relevant CQC Guidelines:Outcome 4: care and welfare of people who use servicesReduce the risk of people receiving unsafe or inappropriate care, treatment and support by:–– assessing the needs of people who use services–– planning and delivering care, treatment and support so that people are safe, their welfare is protected and their needs are met-Identifies risks, and says how these will be managed and reviewed.Enables people to maintain, return to, or manage changes to their health or social circumstances.(assessment) Is undertaken to reduce the risk of deterioration in their health status.

References: Care Quality Commission(2010): Guidance about compliance Essential standards of quality and safety .http://www.cqc.org.ukNICE (2004) Falls: the assessment and prevention of falls in older people (quick reference guide)Nursing times.net 21 June, 2010 Elderly falls cost NHS £4.6m a dayhttp://www.nhs.uk/Livewell/fitness/Pages/Whybeactive.aspx (accessed 10/07/12)

3) Immobility/ Exercise

It's medically proven that people who do regular physical activity have:

up to a 35% lower risk of coronary heart disease and stroke up to a 50% lower risk of type 2 diabetes up to a 50% lower risk of colon cancer

up to a 20% lower risk of breast cancer a 30% lower risk of early death up to an 83% lower risk of osteoarthritis up to a 68% lower risk of hip fracture a 30% lower risk of falls (among older adults) up to a 30% lower risk of depression up to a 30% lower risk of dementia

NHS2012

Risks

What Health Risks are caused by Immobility?

Light-headedness. With the blood staying predominantly in the legs and feet, when the person goes to sit up or stand, they feel light-headed and may faint or fall over.

Infections. Breathing becomes more shallow when lying down and fluid can pool in the lungs. Bacteria can grow easily in the pockets of liquid which may lead to chronic and severe infections.

Weak muscles and stiff or painful joint movement. Constipation. Brittle bones due to loss of calcium which are prone to fractures. Reduced blood circulation resulting in pressure sores and inflamed veins.

Cameron 2010

Bedridden patients are prone to dehydration, progressive cardiac de-conditioning and postural hypotension.

They show reduced lung function and increased susceptibility to respiratory tract infections.

Prolonged bedrest often leads to venous stasis and blood vessel damage which, together with increased blood coagulability, predisposes bedridden patients to deep vein thrombosis and associated embolisation.

Several studies have reported that long periods of bedrest have negative psychological effects on individuals and their family members (Moffitt et al, 2008; Ishizaki et al, 2002; Maloni et al, 2001). These include symptoms of depression, anxiety, forgetfulness and confusion.

These symptoms could be partly due to the lack of personal control imposed by bedrest, as events usually taken for granted such as walking to the toilet or merely stretching the legs are taken away.

A person’s lack of control over their environment has long been linked to increased levels of stress and the release of stress hormones such as corticosteroids (Ogden, 2007). It has been suggested that control, or the lack of it, directly influences health through physiological changes.

Postural hypotension often becomes apparent when the patient first starts to move about. Fainting or uncomfortable dizziness when first moving about after bedrest can easily cause anxiety and fear in patients. In an extreme form, it can even lead to a panic attack and patients may be fearful when confronted with the same situation in the future (Walker et al, 2007).

Lung volume changes

Tidal volume: This is the volume of air exchanged during normal breathing and is typically around 500ml (Montague, 2005). In a supine person, the weight of the body restricts the free movement of the rib cage, reducing tidal volume.

It has been estimated that, when a person is upright, 78% of tidal exchange is due to the motion of the rib cage but, in the supine position, restriction of rib cage movement reduces this to around 32%.

During prolonged bedrest, patients may develop fixed contractures of the costovertebral joints, further reducing tidal exchange and potentially leading to permanent restrictive pulmonary disease (Halar, 1994).

The residual volume of the lungs drops in bedridden patients, potentially increasing the risk of portions of the lung collapsing.

FVC and FEV1: Forced vital capacity (FVC) is the amount of air that can be forced out of the lungs after a maximum intake of breath, and is typically around 4.5L (Montague, 2005).

The supine position reduces both FVC and another measure called forced expiratory volume in one second (FEV1). It is thought these effects are due to a combination of:

Airway obstruction, potentially due to pooled mucus; Increased resistance in the airways and a loss of elastic recoil as a result of structural

changes within the lungs (Manning et al, 1999).

This reduction in airway size, together with pooled mucus and the extra weight the recumbent body places on the rib cage, combine to make breathing more laboured, and patients tend to take fewer deep breaths.The results can include the collapse of airways and small areas of lung tissue (atelectasis), which reduces the area available for gaseous exchange (Corcoran, 1981).

In bedridden patients, reductions in lung function, plasma volume and erythrocyte number also lead to a drop in arterial oxygen saturation. At the same time, blood carbon dioxide concentrations increase (Trappe et al, 2006; Manning et al, 1999).

Hypoxia - defined by Saddick and Elliott (2002) as low oxygen concentration at the cellular level - is apparent in many older people who maintain a recumbent position for an extended period, even as short as a night’s rest (Heath and Schofield, 1999).

Hypoxia has been proposed as a cause of acute confusion in patients, with some showing decreased memory, and changes in concentration and judgement. Acute confusion can develop quickly over a number of hours. Symptoms can fluctuate during the day and worsen at night.

Because blood is pooling in the veins of the lower limbs, clotting factors are not cleared as quickly

by the liver. This, together with reduced plasma volume and the increased haematocrit seen in

bedridden patients, increases the viscosity of the blood and further increases the likelihood of

clot formation (thrombosis).

Knight et al 2009

Specific points in guidelines/ recommendations relevant to our ideas:

How can the Risks be Reduced?

When caring for someone with limited mobility, there are a number of things that you can due to help reduce the risk of these added health problems. Primarily, you need to help your loved one move as much as possible and prevent them from falling and injuring themselves. Where possible, you need to encourage them to do as much as possible for themselves with the aim at making them independent again.

Prevention is better than Treatment

Light-headedness on sitting or standing can be prevented by doing leg exercises before attempting to sit up, and hanging the legs over the side of the bed before standing.

Encourage your loved one to practise deep breathing exercises and to regularly cough up any fluid in their lungs to help prevent infection. If they cannot move their bodies easily, ensure that their position in bed is changed frequently.

Cameron 2010

It may be possible to reduce the effects of cardiac deconditioning by encouraging bedridden patients (if appropriate) to undertake light bed exercises to help maintain venous return and increase stroke volume.

Frequently turning and repositioning patients can help to prevent abnormal distribution and pooling of mucus in the respiratory tract. Bedridden patients can also be encouraged to try cough exercises to help shift pooled mucus and reduce the chance of an infection.

Most of the adverse effects of immobility will resolve by 3-60 days after patients start moving again and carry out normal activities. In general, the longer patients have been confined to bed, the longer the recovery period (Greenleaf and Quach, 2003).

There is much evidence that active interventions by teams of nurses, physiotherapists and occupational therapists can limit many of the physiological and psychological problems experienced by those going through long periods of bedrest (Markey and Brown, 2002).

Knight et al 2009

Relevant CQC Guidelines:

Outcome 1: respecting and involving people who use services:(g) provide appropriate opportunities, encouragement and support toservice users in relation to promoting their autonomy, independenceand community involvementEnable people who use services to care for themselves where this ispossible.●● Encourage and enable people who use services to be an active part oftheir community in appropriate settings.

Outcome 4: care and welfare of people who use servicesReduce the risk of people receiving unsafe or inappropriate care, treatment and support by:–– assessing the needs of people who use services

–– planning and delivering care, treatment and support so that peopleare safe, their welfare is protected and their needs are met-Identifies risks, and says how these will be managed and reviewed.Enables people to maintain, return to, or manage changes to their health or social circumstances.(assessment) Is undertaken to reduce the risk of deterioration in their health status.(providers) Enables them(service user) to make healthy living choices concerning exercise, diet andlifestyle.

Outcome 5: meeting nutritional needsThey have supportive equipment available to them that allows them to eat and drink independently, wherever needed. They are helped into an appropriate position that allows them to eat and drink safely, wherever needed (to reduce the risk of aspiration).

References:

Cameron, J - 2010 Limited Mobility and Common Health Problems. The Carer

Care Quality Commission(2010): Guidance about compliance Essential standards of quality and safety http://www.cqc.org.uk

John Knight, PhD, BSc; Yamni Nigam, PhD, MSc, BSc; Aled Jones, PhD, BN, RN (Adult), RMN (2009) Effects of bedrest 1: cardiovascular, respiratory and haematological systems. Nursing Times.net http://www.nursingtimes.net/nursing-practice/clinical-specialisms/cardiology/effects-of-bedrest-1-cardiovascular-respiratory-and-haematological-systems/5002005.article

NHS http://www.nhs.uk/Livewell/fitness/Pages/Whybeactive.aspx accessed 10/07/2010

Corcoran, P.J. (1981) Disability consequences of bed rest. In: Stolov, W.C., Clowers, M.R. (eds) Handbook of Severe Disability: A Text for Rehabilitation Counselors, Other Vocational Practitioners, and Allied Health Professionals. Washington, DC: United States Government Printing.

Greenleaf, J.E., Quach, D.T. (2003) Recovery after prolonged bed-rest de-conditioning. NASA TechnicalMemorandum. NASA/T~-2002-211860

Halar, E.M. (1994) Disuse syndrome: recognition and prevention. In: Hayes, R.M. et al (eds) Chronic Disease and Disability: A Contemporary Rehabilitation Approach to the Practice of Medicine. New York: Demos Medical Publishing.

Heath, H., Schofield, I. (1999) Healthy Ageing: Nursing Older People. London: Mosby.

Ishizaki, Y. et al(2002) Changes in mood status and neurotic levels during a 20–day bed rest. Acta Astronaut; 50: 7, 453–459.

Maloni, J. et al (2001) Antepartum bed rest: effect upon the family. Journal of Obstetric, Gynecologic and Neonatal Nursing;30: 2, 165–173.

Manning, F. et al (1999) Effects of side lying on lung function in older individuals. Physical Therapy; 79: 5, 456–466.

Markey, D., Brown, R. (2002) An interdisciplinary approach to addressing patient activity and mobility in the medical-surgical patient. Journal of Nursing Care and Quality; 16: 4, 1–12.

Moffitt, J. et al (2008) Hindlimb unloading elicits anhedonia and sympathovagal imbalance. Journal of Applied Physiology; 105: 1049–1059.

Montague, S.E. et al(2005)Physiology for Nursing Practice. Amsterdam: Elsevier.

Ogden, J. (2007) Health Psychology: A Textbook. Buckingham: Open University Press.

Saddick, R., Elliott, D. (2002) Respiration and Circulation. In: Hogston, R., Simpson, P. (eds.) Foundations of Nursing Practice. Basingstoke: Palgrave Macmillan.

Trappe, T. et al (2006) Cardiorespiratory responses to physical work during and following 17 days of bed rest and spaceflight. Journal of Applied Physiology; 100: 951–957.

Walker, J. et al (2007) Psychology for Nurses and the Caring Professions. Maidenhead: McGraw Hill/Open University Press.

Sect 3

Accompanying information and references care skills training.A stroke is a result of sudden ischaemic or haemorrhagic changes to the brain resulting in damage lasting over 24 hours (The Stroke Association, 2011a), and is the largest cause of severe disability and the third biggest cause of death in the UK (Department of Health (DH) 2010). It is estimated approximately 150,000 people suffer with a stroke each year in the UK, with a quarter of a million people living with chronic/severe stroke disability (The Stroke Association, 2011b), yet the number of nursing home residents with a stroke is unknown (Sackley et al., 2004). Bowman et al. (2004) suggest 25% of people residing in nursing homes in the UK were admitted following a diagnosis of stroke.

It is documented that people living in UK nursing homes receive little access to physiotherapy or rehabilitation (Barodawala et al., 2001; Sackley et al., 2001) despite the evidence that some potential gains for this client group are achievable from physiotherapy intervention (Diamond et al., 1996; Heyn et al., 2004). Only 10% of residents were in current receipt of physiotherapy, mostly through private physiotherapists employed by the nursing homes. Older people in nursing homes in the UK currently receive little physiotherapy and occupational therapy input and are particularly isolated from National Health Service (NHS) services. (Barodawala et al. 2001).This may be due to consequences of previous conceptions of the plateau effect on recovery (Demain et al., 2006), despite evidence for ongoing neuroplastic changes, and potential for functional gains (Ploughman, 2002). Leemrijse et al. (2007) recommend physiotherapists consider quality of life and well-being when selecting which patients may benefit from physiotherapy intervention. Furthermore stroke survivors residing in nursing homes are more likely to be functionally dependent and experience a greater number of immobility related complications; which may benefit in terms of maintaining ability with therapeutic intervention (Sackley et al., 2008).

However several studies have been conducted within nursing home settings to determine if functional status improves following exercise (Heyn et al., 2004 and Sackley et al., 2004: Brittle et al., 2009), many have used the Barthel Index (Collin et al., 1988) or the Rivermead Mobility Index (Collen et al., 1991) to determine functional ability.The Care Quality Commission (CQC) (2011a) has called for improved long-term rehabilitation for stroke survivors in the UK to meet their changing needs, which is added to numerous suggestions for further research into the physiotherapy management of stroke survivors in long-term care establishments (Murray et al., 2005; Leemrijse et al., 2007; Sackley et al., 2008; Wolfe et al., 2008).Depression is reported to affect approximately 30% of stroke survivors (Burvill et al., 1995) and is especially evident in long-term care settings (Sutcliffe et al., 2007). Although this may be underestimated due to poor symptom recognition by staff (Bagley et al., 2000; Sutcliffe et al., 2007), furthermore a study found nursing home residents spent a large proportion of time alone, passive and unable to interact with others (Huijben-Schoenmakers et al., 2009). It has been recommended that increased access to services including physiotherapy could reduce depression and increase social interaction (Sutcliffe et al., 2007).

When a person is admitted to hospital the care component of the disability living allowance and attendance allowance is suspended after 28 days (NIdriect, 2013), if the local authority are paying or contributing to the fees (Medway Council, 2013). If a person is admitted to hospital, the Clinical Commissioning Group (CCG) does not pay nursing care costs to the care home during your hospital stay. The NHS-funded nursing care guidance says CCGs may want to consider paying a retainer to help safeguard care home places of residents while in hospital. It also says any arrangements the CCG makes should not disadvantage residents who fund their own care home place (Age UK, 2013).

A report by the King’s Fund, found that up to 7,000 beds could be freed up in emergency wards by prioritizing key areas, leading to a saving of over £450 million for the NHS, stating that the number of elderly people needing to receive overnight emergency care could be cut by over two million if there was better organization of the care services and home care across England (Imison et al., 2012)

The total cost in the UK to treat pressure ulcers is estimated to be £1.4-£2.1 billion annually, comprising 4% of the total NHS expenditure (Posnett and Franks, 2007). The cost of treating a grade 1 ulcer is from £1064 to treating a grade 4 ulcer £24214 (Touche, 1993). There is a 8% risk of dying as a direct consequence of a pressure ulcer (Byrne and Salzberg, 1996). If a sacral sore develops, the recovery skin is only 70-80% as strong as before (RCN, 2005); therefore implications for limited time sitting and a higher risk of further pressure problems. Pressure ulcers represent a major burden of sickness and

reduced quality of life for patients and create significant difficulties for patients, their carers and families. Even a grade one pressure ulcer is very painful. New pressure ulcers are estimated to occur in 4–10% of patients admitted to acute hospitals in the UK, with one study putting this as high as 20% (Clark M, Bours G, Defloor T; 2004). New pressure ulcers affect an unknown proportion of people in the community, as reliable data is not available, but it is estimated that up to 30% of patients may suffer and 20% of patients in nursing and residential homes may be affected (NHS Institute for Innovation and Improvement, 2013).

References

Age UK (2013) NHS continuing healthcare and NHS-funded nursing care. Factsheet 20: London: Age UK

Bagley, H.; Cordingley, L.; Burns, A.; Mozley, C. G.; Sutcliffe, C.; Challis, D. and Huxley, P. (2000) Recognition of Depression by Staff in Nursing and Residential Homes Journal of Clinical Nursing 9(3) pp. 445-450

Barodawala, S.; Kesavan, S. & Young, J. (2001) A Survey of Physiotherapy and Occupational Therapy Provision in UK Nursing Homes Clinical Rehabilitation 15(6) pp. 607-610

Brittle, N.; Patel, S.; Wright, C.; Baral, S.; Versfeld, P. and Sackley, C. (2009) An Exploratory Cluster Randomised Controlled Trial of Group Exercise on Mobility and Depression in Care Home Residents Clinical Rehabilitation 23 (2) pp. 146-154

Bowman, C.; Whistler, J. and Ellerby, M. (2004) A National Census of Care Home Residents Age and Aging 33(6) pp.561-566

Burvill, P. W.; Johnson, G. A.; Jamrozik, K. D.; Anderson, C. S.; Stewart-Wynne, E.G. and Chakera, T. M. (1995) Prevalence of Depression after Stroke: The Perth Community Stroke Study British Journal of Psychiatry 166(3) pp. 320-27

Byrne DW, Salzberg CA. Major risk factors for pressure ulcers in the spinal cord disabled: a literature review. Spinal Cord 1996:43:255-263.

Care Quality Commission (2011a) Supporting Life after Stroke: A Review of Services for People who have had a Stoke and Their Carers. London: Care Quality Commission

Clark, M., Bours, G. & Defloor T. (2004) The prevalence of pressure ulcers in Europe. In Recent Advances in Tissue Viability. Quay Books, Salisbury

Collen,F.; Wade, D.; Robb, G. and Bradshaw, C. (1991)The Rivermead Mobility Index: a further development of the Rivermead Motor Assessment. International Disability Studies 13(2) pp.50-54

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