Outcomes for residents: supporting a couple living with dementia
Case study
Mr and Mrs P are an older couple, both living with dementia and residing at home together. Prior to Adult Social Care involvement, health professionals were already supporting the family and had identified and diagnosed dementia in both individuals. However, due to the complexity of managing 2 people with progressive cognitive needs within the same household, the health team experienced increasing challenges in sustaining safe and effective support.
A referral for Adult Social Care intervention was made to provide additional coordination, risk management, and holistic assessment. The case required a highly coordinated multi-disciplinary approach involving Social Work, Occupational Therapy, Community Nursing, and medical professionals.
Adult Social Care played a key role in leading on care coordination and risk management, Supporting decision-making in line with the Care Act and Mental Capacity Act and ensuring the voices, wishes, and wellbeing of both individuals remained central.
Initial concerns focused on Mrs P declining care support for her husband, as she felt they could manage independently. This presented risks, particularly given both individuals’ cognitive impairments.
Following Mr P’s hospital admission, he was discharged to a Discharge to Assess (D2A) placement. This provided an opportunity for professionals to assess needs in a supported environment and plan for longer-term arrangements. The couple’s daughters, who hold Lasting Power of Attorney (LPA), were actively involved throughout. Recognising the pressures on the family, both daughters were referred to Carers Trust for independent carers’ assessments, ensuring their needs were also acknowledged and supported alongside the cared-for individuals.
A Best Interests decision was made to support both individuals to remain at home together. While it was acknowledged that some risks could not be fully eliminated, the decision prioritised:
- their strong emotional bond and relationship
- their clearly expressed wish to remain together at home
- the importance of maintaining stability and familiarity for people living with dementia
Adult Social Care worked with partners to put in place a robust care package and monitoring arrangements to mitigate identified risks as far as possible. Mr and Mrs P were successfully reunited at home following discharge; a sustainable home care package was implemented. Risks were managed proportionately, balancing safety with quality of life.
The family felt supported and involved in decision-making, carers were recognised and signposted for support. At the most recent review, care arrangements continue to work effectively, supporting positive outcomes for both individuals.