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Hi Rhoda.
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Hi Jay, how are you doing?
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Yeah, I'm good, thank you.
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So we’ve got a chance now to have 10 minutes
or so thinking about your specific case,
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and thinking about it
through the heart of the matter.
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what you've discovered
and what you're hoping for.
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Yeah.
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Yeah.
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I'm looking forward to speaking with you
about Mrs Davies,
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and her family, and her desire right now to go home.
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She's in hospital.
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Right, okay.
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Is there a sense of an outcome that
you have with her and her family?
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Yeah. So...
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she came into hospital
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about six weeks ago
having had a stroke.
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She's a kind of carer
for her husband, Mr Davies,
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and he's registered blind.
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He can see partially so he can move around
and things like that.
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But she had a stroke
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and she's been in hospital,
as I said, for about six weeks.
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She's now medically fit to be discharged.
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But there's an issue now around
how do we help her achieve
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the desire to go home?
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Right.
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And she's looking to go home?
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She looking to go home
as soon as possible now.
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She has a close family around her.
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And they're all chipping in.
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So she has three sons who live...
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one lives very close by
and he pops in all the time,
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and she’s got another one
who visits once a week.
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But together as a family, they've been
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they've been contemplating this
part of their life for a long time.
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So she's just turned 80
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and they've just made
a lot of changes to the family home,
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the structure of the home
in order to be able to
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adjust, make adjustments so that
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she can live there as her age and
as her physical health deteriorates.
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This has just come slightly quicker than
they were expecting through the stroke.
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It sounds like they all have
a shared ambition that she stay at home
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with her husband as long as she can.
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Yes, fiercely independent
and very focussed on her family
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and wants to spend time with them and
wants to be back home with her husband.
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So... you know they,
they're coming back and forth.
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We've had some good conversations
with the family,
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and her desire is to be home.
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Her husband, Mr Davies, he really wants
her to be back home.
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He's been looking after himself,
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and he's managed.
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But as I say, he's partially sighted,
he's been doing the cooking
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and he's doing things, but I think she
wants to be back home and to supervise.
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She's in charge.
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She’s in charge. Yeah, definately.
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And that's an important role for her
is to look after him as well.
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Yes, absolutely.
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For her to look after him,
but for her,
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also I think this is a real adjustment
for her now to be starting to think
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about her own physical health
and how she can...
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how she can manage day to day
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with the support around her
that she's got.
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So she's got her granddaughter
who's training to be nurse, actually,
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and she's in the mid twenties, and she
she goes around quite a lot and helps out.
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So she's doing ironing and some cleaning,
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but she's a real positive resource
and she’s got really close relationship
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with Mrs Davies
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Lovely, and I get a real picture
of the family from your description.
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How would you expand on
what you think about their strengths?
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What have you noticed about each of them
and how they function together?
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Yeah,
it's amazing because they've got a real
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mix of skills in there.
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So one of her sons is a builder.
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So he's been doing the physical
changing the fabric of the house
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to make it possible for her to get around.
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So for example
they fitted a walk in shower.
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They now have a ramp
that goes down to the house.
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They've done all that themselves?
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They've done that themselves,
predicting that at some point
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that their health will deteriorate
and they want to be at home.
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So that's...
you know, they've made those changes
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because they're absolutely certain
they want to be at home.
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They’re close to each other
so they see each other,
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like I said,
she sees her granddaughter every day
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and one of her sons every day.
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And they just want to be together.
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Yeah, that's lovely.
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And it's a real solid family anticipating
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the potential
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deterioration in people's physical health.
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But they thought all that through
and done as much as they can.
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So it seems clear that
that's their outcome,
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all of them, they want to be together
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and there's loads of strengths
you've described.
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Yeah, lots of strengths.
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I think
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one of the challenges though is that
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although she's got some strengths,
I think there's still some worries about her...
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you know,
how mobile she's getting around the house.
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Right.
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And so there are some fears
that she could fall.
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But they've done, you know, again,
they put a riser on the toilet seat,
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they've changed the shower.
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She was talking to me
about what will happen if she falls over,
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almost creating her own safety plan.
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Right.
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Thinking about
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duvets on
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the floor is one of the things
that she'd heard from a friend.
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But I don't think they're yet.
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Her husband, obviously, he's
physically quite strong.
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So between them,
I think they've got the skills
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to be able to look after each other.
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And if they need some extra help,
the ability
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to phone and ask that with people
coming in back and forth.
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So in terms of the priority risks,
is that the risk everybody identifies?
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All the other professionals
and the family, that the priority risk is
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that she may fall or be less
physically safe in the house.
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So there are two main things really.
One is the potential to fall,
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and the other is just those transitions
at the beginning and the end of the day.
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So, whether she can get...
getting herself
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out of bed at the beginning of the day,
washing herself, dressing herself.
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And then the same
when it comes to going to bed at night.
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So what are the family saying about
those key moments that could potentially...
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you’re saying that we don't know yet,
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but we might discover that
those are difficult moments for us.
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Yeah, we don't know yet, but that's
the way the family are describing it.
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And she wants to be at home
and really wants to be able to test out,
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the family say want to say “we want her home
and we need to try this”.
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And, luckily,
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like we said, her granddaughter
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will be comfortable, if push comes to shove
and is needed in the short term,
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to be able to come along and help
her grandmother with those things.
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Right, so that's not a permanent solution,
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but temporarily,
if there are issues, morning and evening,
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granddaughter would step up.
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And I suppose that gives you
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the opportunity to see how things unfold
when she goes home.
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Yeah, to test that out for them
and to get a sense of
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how manageable
is this on a daily basis.
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Beacuse sometimes we can worry,
they worry about
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whether it's going to go wrong is greater
than the reality of the situation.
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And I think they feel confident
they can do this.
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Yes, and they've talked to you
openly about that.
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It sounds like there's a lot of trust
between them and you at the moment.
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Yeah, I've just spent time just listening,
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and they’re determined as a family.
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Even the...
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one of the brothers
who lives in South Africa,
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he's still managed
to join in on the calls as well
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just to give his, you know,
to get a sense of perspective about what
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everybody's
hopes and expectations are around this.
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I'm struck by how much
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you know about each person
and a real sense of the family.
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I can almost see them and I can imagine
her in the kitchen with her husband.
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It's been a trauma and a fright
for all of them, but there's a real sense
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that they can pull together
into this next phase now.
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Yeah.
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So is that agreement around? That
that she should go home
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now under those circumstances?
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Absolutley, and I think what you asked about
one of the priority risks,
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is it's not a risk but it’s a fear
that she stays stuck in hospital.
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And that's absolutely
what she doesn't want to be.
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So I think she's medically fit
to be discharged now.
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And so the question for us now
is, are we okay to support her to go back?
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And based on the information that I've
got, the conversations and the visits,
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I think that I want to support
that as soon as possible.
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And who is most confident about that?
That this is the moment for her to go home?
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She is.
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So she's the most confident?
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She's the most confident.
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Who else would be?
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Mr Davies wants her to be back.
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I think the main one then
is the granddaughter,
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she's very confident,
and the sons as well.
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So, you know, between them, I think
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there's not really
any dissenting voices in that.
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And the staff who've been caring for her on the ward,
how are they feeling?
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Yeah I think it’s the staff in the ward
who are a little bit worried.
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But they don't get the opportunity
to see her at home
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and see the family
and the home set up that we do.
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So they can just see her in the,
in the actual hospital environment.
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Yeah, they may be a bit more nervous
about what she could achieve at home.
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Yeah.
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So what are your...
who needs to be involved from here?
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What are your next...
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what needs to happen?
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Yeah, I think,
I think we would like to get some support
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in for some of those transitions
at the beginning, and the end of the day.
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So whether she can
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go there in there, she can go home
with the support of the family,
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with the long term plan to assess
and to see if she can manage,
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then bring in some additional support
if that's needed.
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Can I... sorry to interrupt.
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Just thinking about
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would she be open to that next step
if extra help was needed in the future?
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Yeah, I think so.
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It's a realistic conversation
that we've had.
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We just don't know.
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We know enough to go
people are around and they want her home,
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and they say they can help
her and they feel confident.
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And she feels confident in that.
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But she's open to the possibility that
there may need to be care in the future.
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Absolutely, yeah, that's it.
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And that's a big shift for her.
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I don't think she'd really contemplated
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that until this event being in hospital
and the distress of being there.
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So where does your conversational focus
need to be?
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Is it in the hospital with the staff there,
is it at home with the family?
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Where do you need to be next?
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I think it's with both together,
coming together and just
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facilitating a
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conversation where we can just share
any additional information
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that we might need, making sure
she got the right medications
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and that people know around her
what they need to do
00:11:02:19 - 00:11:07:04
and I suppose reassure the staff in a way,
just because that would be a good...
00:11:07:04 - 00:11:08:21
Because everybody's
naturally fearful, aren't they?
00:11:08:21 - 00:11:12:03
And they built a relationship with her
and they want to make sure she's okay.
00:11:12:05 - 00:11:14:04
Absolutely. Yeah.
00:11:14:04 - 00:11:16:09
So it feels very clear.
00:11:16:09 - 00:11:19:20
When you talk about this,
what would you say
00:11:19:20 - 00:11:24:09
about how far you've come?
You and the family.
00:11:24:11 - 00:11:26:06
Yeah, it's...
00:11:26:06 - 00:11:28:18
it's quite a long way in a short time.
00:11:28:18 - 00:11:32:04
I think the first concern
they had was just about
00:11:32:04 - 00:11:33:05
is she going to be okay?
00:11:33:05 - 00:11:36:15
Is she going to be alive, really,
00:11:36:15 - 00:11:37:13
having had a stroke?
00:11:37:13 - 00:11:42:03
It's been scary for them all.
00:11:42:05 - 00:11:43:15
But obviously, as her health
00:11:43:15 - 00:11:46:20
has progressed,
00:11:46:20 - 00:11:48:20
so too have they.
00:11:48:20 - 00:11:53:08
And as her confidence has improved
and her physical wellbeing has improved,
00:11:53:08 - 00:11:56:01
so too has their energy
to make that happen.
00:11:56:01 - 00:12:00:04
So it’s not come out of nowhere,
00:12:00:06 - 00:12:01:22
it's taken a bit of time.
00:12:01:22 - 00:12:05:23
And you've invested in solid listening,
understanding their fears
00:12:05:23 - 00:12:08:12
and getting to this point.
00:12:08:12 - 00:12:11:01
So where is the outcome?
00:12:11:01 - 00:12:15:01
What does that look like?
00:12:15:20 - 00:12:19:06
Its for her to return home.
00:12:19:14 - 00:12:21:18
For us to be open
00:12:21:18 - 00:12:26:06
minded about the possibility
of some additional support,
00:12:26:06 - 00:12:31:15
if that's required,
and for us to double check that we've
00:12:31:17 - 00:12:35:02
we know confidently what they need to do
00:12:35:03 - 00:12:38:10
they know how to contact
the different family members.
00:12:38:12 - 00:12:41:08
For example, if she were to fall
00:12:41:08 - 00:12:45:16
or if an incident was to happen.
00:12:45:18 - 00:12:47:15
And that really
00:12:47:15 - 00:12:51:06
we just allow that and
support that to happen, but confident
00:12:51:06 - 00:12:55:17
that that family support around them
is there and can step in any point.
00:12:55:22 - 00:12:59:10
So continuing that open
holistic conversation
00:12:59:12 - 00:13:04:08
with all the family at each step
and see that the trust is there,
00:13:04:08 - 00:13:06:06
that they will call on people
if they're worried.
00:13:06:06 - 00:13:06:14
Yeah.
00:13:06:14 - 00:13:10:05
And I think my role there is that
reassurance that I'm there listening.
00:13:10:05 - 00:13:13:16
So touching base at different stages going
00:13:13:16 - 00:13:19:03
“How is this going and do they need
anything more from me at that point?”
00:13:19:03 - 00:13:21:14
But trusting that they've got it
within their gift.
00:13:21:14 - 00:13:26:13
That’s lovely. And where would you say
your energy levels are in this case?
00:13:26:15 - 00:13:27:20
Yeah. Good.
00:13:27:20 - 00:13:31:11
You know, like with everything
a little bit apprehensive, you always are.
00:13:31:16 - 00:13:33:16
And I think that's realistic,
00:13:33:16 - 00:13:35:17
but confident
that we're going in the right direction
00:13:35:17 - 00:13:37:04
and this is the right decision.
00:13:37:04 - 00:13:41:10
Yeah.
And enabling them to take independent
00:13:41:12 - 00:13:43:22
steps, manage their own risk,
00:13:43:22 - 00:13:47:01
being clear about when they
may need to ask for help.
00:13:47:06 - 00:13:50:06
Feels like they're as is in charge
as they could be.
00:13:50:11 - 00:13:52:02
As in charge as they could be.
00:13:52:02 - 00:13:53:00
But with,
00:13:53:00 - 00:13:57:10
you know, the phone number on speed dial,
if they need anything else.
00:13:57:12 - 00:13:58:18
Lovely.
00:13:58:18 - 00:13:59:12
Thanks Jay.
00:13:59:12 - 00:14:01:02
Thank you.