This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the second two descriptors in the Mobility domain, to help you assess your or your relative’s “level of need” in this important domain.
Don’t miss parts one, two, three, four, five, six, seven, eight and nine of this series!
The assessed levels of need in the Mobility domain range from ‘No Needs’ to ‘Severe’. The vast majority of people we assist will fall into the ‘Moderate’ or ‘High’ needs categories, owing to an inability to mobilise independently and/or a risk of falls. The main differentials are the ability to weight bear and the frequency of falls. It is relatively unusual to see a ‘Severe’ need in this domain and these tend to be individuals with a high spinal injury, brain injury or other significant clinical presentation.
The following clinical factors are relevant to the assessment of ‘High’ and ‘Severe’ needs in this domain:
- Is there a history of falls?
- Have there been any recent falls?
- Were any injuries sustained?
- What is the person’s score on the Falls Risk Assessment?
- Can the person bear their own weight?
- If not, do they need a hoist to transfer?
- If so, is this a standing hoist (Stand-Aid) or full hoist (sling)?
- Can the person alter their own position in bed or chair?
- How many members of staff are required to assist with moving & handling?
- Is the person able to assist with moving & handling procedures?
- Does the person cooperate with moving & handling procedures?
- Does the person experience pain on movement?
- Does the person suffer contractures, spasms or tremors?
- Does the person require specialist positioning?
- Is positioning critical (i.e., life threatening if carried out incorrectly)?
- Is there a risk of serious harm on movement and/or transfer?
The DST provides the following advice to those assessing needs in the Mobility domain:
This section considers individuals with impaired mobility. Please take other mobility issues such as wandering into account in the behaviour domain where relevant. Where mobility problems are indicated, an up-to-date Moving and Handling and Falls Risk Assessment should exist or have been undertaken and the impact and likelihood of any risk factors considered. It is important to note that the use of the word ‘high’ in any particular falls risk assessment tool does not necessarily equate to a high level need in this domain.
This underlines the crucial importance of verifiable, written evidence to support the assessment of needs in this domain. For example, in the case of a person who is at risk of falling, the MDT will expect to see a recent Falls Risk Assessment confirming the level of risk and steps taken to mitigate this; in the case of a person who is immobile and unable to weight bear, the MDT will expect to see a Moving & Handling assessment confirming this. A lack of appropriate documentation may result in a lower level of need being applied, regardless of the verbal testimony of family and/or staff.
Now that we’ve outlined the type of things the MDT will be considering in this domain, let’s take a look at the descriptors for ‘High’ and ‘Severe’ needs. For each level of need, we provide a case study to give you a better understanding of how the descriptors of need might be applied at your or your relative’s assessment.
|Completely unable to weight bear and is unable to assist or cooperate with transfers and/or repositioning.
Due to risk of physical harm or loss of muscle tone or pain on movement needs careful positioning and is unable to cooperate.
At a high risk of falls (as evidenced in a falls history and risk assessment).
Involuntary spasms or contractures placing the individual or others at risk.
Unable to weight bear, requires a full hoist to transfer.
Unable to alter own position in bed and/or chair, requires full assistance.
Is non-compliant with moving & handling interventions and/or unable to follow instruction.
Has a significant falls history and remains at risk of further falls.
Spasms, contractures, tremors.
CASE STUDY 1 – ‘HIGH’ NEEDS
Mrs. X is completely immobile and is dependent on two members of staff to assist her with all manual handling. Staff report that they used a standing hoist until recently, but that Mrs. X is increasingly uncooperative with intervention and is therefore now unsafe using the standing hoist. Staff use a full body sling and hoist for all transfers. A wheeled commode is utilised for showering; however, this is also under review by care provider management due the recent increase in challenging behaviour.
Mrs. X is unable to assist or cooperate with transfers due to a severe cognitive impairment. Staff report that Mrs. X becomes aggressive on intervention which poses a risk to self and others. Staff utilise a slide sheet to move her in bed, and a bespoke wheelchair to move between rooms and on outings.
Mrs. X has not sustained any falls, is not noted to suffer with contractures or spasms and there is no evidence of a requirement for careful positioning.
Mrs. X presents with ‘High’ needs as she is completely unable to weight bear and is unable to assist or cooperate with transfers and/or repositioning.
CASE STUDY 2 – ‘HIGH’ NEEDS
Mr. X’s mobility is variable and has remained as such since his admission to the nursing home.
While he was in hospital, Mr. X was able to mobilise at times with the assistance of 1 member of staff but did suffer a number of falls when he attempted to move unaided.
On admission to the nursing home, he was assessed as being at high risk of falls. He has subsequently suffered numerous falls despite staff’s best efforts to minimise the risk. A sensor mat was placed in his room to alert staff when he was moving. Mr. X is prompted and encouraged to call for staff assistance when he wants to move around, but he can be forgetful owing to a cognitive impairment. He requires prompts from staff when getting in and out of bed, and also to get up from his chair safely.
Mr. X continues to be assessed as being at high risk of falls and continues to sustain occasional falls. He requires staff to monitor his whereabouts and assist him when he is tired.
Mr. X presents with ‘High’ needs as he is at a high risk of falls (as evidenced in a falls history and risk assessment).
CASE STUDY 3 – ‘HIGH’ NEEDS
Mr. X has significant deficits with his mobility and, although he can transfer independently from his bed to wheelchair and wheelchair to toilet, he is extremely unsteady and at high risk of falls.
Mr. X has been assessed by the physio and he now has a Rea Azalea self-propelling wheelchair to use as an interim until his own bespoke chair can be ordered. This has given him increased lateral support and stopped him leaning to the right. Care Plans indicate he can transfer safely and can apply the brakes himself.
Mr. X demonstrated how he moved the foot plates of the wheelchair in order to stand, and he used his feet. He also indicated he had little sensation in his feet and graze marks were evident on his right foot. He was unable to apply the wheelchair brake even with assistance due to chorea-like movements and involuntary tremor.
Falls risk Assessment = high risk due to Mr. X being increasingly unsteady, with tremor and ataxia.
Care Plan indicates that Mr. X refuses to use the hoist but can stand and transfer. Mr. X moves independently in bed. He has difficultly self-propelling his wheelchair and so staff assist him. He is waiting for an assessment on whether he can use an electric chair.
Last documented fall- 08/07/2021- sat on floor between bed and wheelchair.
Mr. X presents with ‘High’ needs as he has involuntary spasms or contractures placing the individual or others at risk, AND he is at a high risk of falls (as evidenced in a falls history and risk assessment).
|Completely immobile and/or clinical condition such that, in either case, on movement or transfer there is a high risk of serious physical harm and where the positioning is critical.|
Risk of serious injury on movement.
Risk to life should incorrect positioning occur.
CASE STUDY – ‘SEVERE’ NEEDS
Owing to an acquired brain injury (ABI), Mr. X is unable to move the left side of his body; there are some minimal movements to right lower limb and he will try to move his feet at times. His left arm is severely contracted in flexion, as is his hand. His right arm and hand can be moved freely, and Mr. X will move them at times, but not for any functional purpose.
Whilst lying in bed in a neutral position on his back, Mr. X’s upper body is contorted to the right, as is his head. His head and neck are extended to the right and staff are unable to reposition to the central line. Mr. X experiences excess secretions which place him at risk of suffocation if he is not carefully positioned; he is unable to call for help.
Mr. X is nursed in bed at all times and can only be showered using a specialist platform as he is very rigid and unable to bend his body. Care Plans confirm that three-to-four carers are required to assist with showering due to the rigidity of Mr. X’s body. This procedure is only carried out once a week. Three members of staff are required for personal care and repositioning: one to carry out care, one to support Mr. X’s body and another to support his head.
Mr. X has been resident at the nursing home for over a decade and his needs have not changed substantially during this time, although his contractures have worsened due to immobility. Care and nursing staff must take particular care when repositioning due to contractures, rigidity and pain. Staff are now very familiar with Mr. X’s mobility needs and know how to reposition and transfer him safely.
Mr. X suffered an unexplained fractured neck of femur in 2008, treated conservatively. Although Mr. X has no formal diagnosis of brittle bones, it is likely he has developed osteoporosis. Femurs do not routinely fracture without a force of some kind being applied. Extra care is required to avoid further injury.
Mr. X presents with ‘Severe’ needs as he is completely immobile and/or clinical condition such that, in either case, on movement or transfer there is a high risk of serious physical harm and where the positioning is critical.
We hope this has helped you to understand the second two descriptors in the Mobility domain. Don’t miss the next part of this series, Communication, coming very soon!
If you need help assessing your relative’s level of need in any domain on the DST, don’t hesitate to contact one of our specialist Advice Lines to discuss your case today.
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