Crisis and Discrimination

We had a meeting with our crisis team a couple of weeks ago. There is a general perception that they don’t like taking referrals for over 65s. It has increasingly developed into something of an ‘us and them’ situation so an attempt at some kind of reconciliary face to face meeting was planned.

Personally, I’ve had a few problems in referring. Firstly, they don’t accept any referrals for anyone with any kind of organic mental illness namely dementia. The explanation (although I never actually knew this until last week) is that no-one in the teams have any experience or knowledge of working with ‘these kinds’ of mental disorder.

Even with functional disorders, the input has been more than patchy. Certainly, I’ve had less than helpful responses to requests to refer – even within the ‘just passed 65 with no sign of dementia’ type of situations.

What was actually explained at the meeting (which in some ways helped but in other ways didn’t) is that they receive no funding for catering to the needs of over 65s so any referrals that they do take from us are just as ‘favours’.

I was interested that the explanations were not about ‘providing better services to the population’ or managing more appropriately crisis situations in the community to avoid hospital admissions but rather in terms of ‘doing your team a favour’. I mentioned this in the meeting. One of the psychologists later told me that he thought I might have been a little too ‘emphatic’ in my approach. I love our team psychologists!

Nothing actually irritates me more than this type of attitude though as it seems to have removed the actual purpose of the work that is being done and reduces the entire service the Trust provides  to a professional-led structure rather than a patient-led need.

Of course, this raises so many problems with the an institutional discrimination with the service that it shouldn’t be allowed to pass – but it does and it has.

Why somebody should have greater access to a service before their 65th birthday when the need can be exactly equivalent one day after seems to be a particularly short-sighted way of dealing with issues but it is also one of the reasons I am so eager to remain in this specialist team – so that these discrepancies are consistently challenged at an organisational level.

I know I am being a little one-sided and perhaps unfair but it feels sometimes that we are as much fighting within our trust for services as fighting together for the common good.

Such is the way in specialist services sometimes. And so I am free to argue on as long as I am respectfully argumentative and am able to retain an awareness of how far to push and when to stop.

This report then, published in the last week of the existence of the Healthcare Commission (which is consumed tomorrow, into the Care Quality Commission) which states that older people are often excluded from some of the mental  health services which are available to working age adults hit close to home.

the study showed older people were often unable to access the full range of services, including: out of hours services; crisis services; psychological therapies; drug and alcohol misuse services.

This reflects my own experiences so strongly that I had to check to see which trusts were surveyed for the research. In fact, these points ally closely with our experiences

  • out of hours and crisis services were often not open to older people and only took referrals for people under 65 or for conditions other than dementia. There appeared to be a reluctance to refer and a reluctance to accept referrals, due to workload and the age-appropriateness of the service offered. There was no clear justification for this.
  • Staff at several trusts said some older people had difficulties in gaining access to services for alcohol and substance misuse. Even when services were available they were either not offered in an age-appropriate way or were not available when staff attempted to refer to them. Many were geared towards younger people, usually males, and were felt not to be appropriate for older people who may feel vulnerable in the atmosphere.
  • In general the report makes for interesting reading but interesting reading is only useful if it leads to changes and effecting of change across the board.

    I was glad to see the study published, not least because it expresses similar experiences that hopefully can be challenged even more effectively in the future to provide a more equitable and cohesive service for all the members of the community that we serve.

    Avoiding Alzheimer’s

    A couple of related articles I came over at the weekend which are linked in a way that they both refer to delaying the development of Alzheimer’s Disease.

    The BBC reports on a study which shows that longer schooling ‘cuts dementia’. The link is made between the extension of the school leaving age and the prevalence of dementia so that those who left school at 15 fare better than those who left at 14 etc.

    Writing in the journal Aging, Neuropsychology and Cognition, the researchers say “The increase in educational levels that we observed is consistent with changes in the mandatory school leaving age in England.”

    Other factors including fewer heart attacks, increased prescription of drugs to reduce high blood pressure, fewer people smoking and improvements in early life nutrition are also likely to have had an effect on the cognitive abilities of the 2002 group.

    image Sciu3asteveo at Flickr

    I am no scientist but I’d figure the latter comments are as relevant if not more than an extra year of schooling.

    It is apparent from a lay view anyway, that generally those who have longer experiences of the educational system tend to be able to mask some of the symptoms of dementia for longer perhaps, after all, one of the key questions we ask in conjunction with the MMSE (Mini-Mental State Examination) refers to what age the particular individual left school.

    I wonder if it is more about the generally greater awareness of what is and isn’t good for us (i.e. smoking) that leads to, at least a reduction in vascular dementia.

    In fact

    Neil Hunt, chief executive of the Alzheimer’s Society said: “Whilst we have a lot of really good evidence on healthy lifestyles and the fact that they can decrease risk of dementia, there isn’t enough evidence on education and dementia to draw any conclusions.

    “We know conditions such as diabetes and obesity are on the rise and that they increase people’s risk of dementia – unfortunately this may have the opposite effect. “

    Meanwhile, the Healthcare Republic reports that a people should be encouraged to eat more oily fish and omega 3 as a study carried out on mice has shown that this supplement has increased their cognitive functioning. I’m trying not to imagine how cognitive functioning in mice is measured because this is a serious research project..

    Professor John Harwood, from the University of Cardiff, said research had shown that increasing dietary intake of omega-3 could halve the risk of developing Alzheimer’s.

    ‘We are currently carrying out studies in mice that have been fed a diet enriched with docosahexaenoic acid (DHA), the active ingredient found in omega-3,’ he said.

    ‘The mice on the DHA diet did better in cognitive tests compared with mice that were not on the enriched diet. We are working on the hypothesis that this is down to the anti-inflammatory properties of DHA.’

    Professor Harwood told GP that patients should be encouraged to consume omega-3, in the form of oily fish, from early age.

    ‘This is something that patients can do relatively easily and cheaply and should help to lower the risk of Alzheimer’s.

    Omega-3 has clear benefits in reducing the risks of cardiovascular disease (CVD) and arthritis, so it cannot do any harm to increase your intake.’

    I’m happy to go with that as a conclusion – basically it can’t do any harm and might possibly do some good.

    image jem at Flickr

    Fish for dinner, I think.

    Assessing Capacity

    We have, over the last 18 months or so, carried out a lot of capacity assessments in our team. Actually, truth be known, we were and have been carrying out capacity assessments for far longer but as far as codified assessments go, the paperwork has been in place since the introduction of the Mental Capacity Act (2005).

    We receive a lot of referrals from the local social services offices and sometimes from GPs (although more usually from local social services via the GP!) asking for us to assess someone’s capacity. Of course, the law states now that unless we are looking at a particular applications to the Court of Protection (COP3 for reference) , it is the decision-maker – be that doctor or social worker – who makes the assessment, it doesn’t stop us being asked.

    I mention this as I carried out a capacity assessment last week. We have a document which we use in the Trust to record these assessments and they are pretty good at holding your hand through the process – asking about what actions you have taken to ensure that the best conditions are met for the assessment in terms of time of day, place and attendees. We are asked about the ability of the person being assessed to retain and recap information and are prompted through the forms – the need to specify the exact decision which is being assessed as well as noting who has been informed.

    It really does take you through the guidelines established in the Mental Capacity Act’s Code of Practice and Section One of the Act itself and although some may be tempted to scrawl yes/no responses in the rather large open spaces of the form which invite free text, it is a more coherent form that includes  more details.

    The assessment yesterday involves a woman with dementia who had been finding it difficult to manage at home and was admitted to hospital following a fall. Her family are suggesting residential care. I was asked to assess her capacity to make that decision in hospital. It is not something that is particular unique. Except perhaps for the fact that her family are extremely keen for her to move into care. Even then it is a situation that has presented itself many times over the years.

    Coming as it did on the eve of the introduction of the ‘Deprivation of Liberty Safeguards’ being implemented , I had in mind that were she to move –  there is a possibility that this would  fall within the bounds of that law next week.  She wants to go home. She is in hospital currently and although not quite ready for discharge, she will be soonish.


    I’ll tell someone before I start a capacity assessment although often that draws pretty blank gazes, it is placed within some familiar terms of reference when possible.

    I might explain the reasons I am asking the questions – that it is in order to make a decision relating to them. I asked about home, what the understanding of home is (often in simplified terms), what help she thinks she might need and switch the questions around a little or ask the same questions in different ways to ensure that I am not leading the way for her to answer.

    She repeated to me over and over that she wanted to be at home. I expected no different. Sometimes the easier decision to take is to make a move. There were enough grounds to determine a lack of capacity. She spoke about wanting to be near her parents, of visiting them (she is in her mid-80s) – they were reasons for wanting to stay at home. She said that she could manage without any help and that she misses her pets.

    Familiar surroundings are incredibly important and I hate making placements directly from hospital for the reason that, even when necessary, there has been no ‘goodbye’ to a home where someone might have lived for many decades. It is another loss, another process of mourning and to admit someone straight into care can be making a difficult situation worse.

    When she was presented with the choice of moving to a different flat, she remained ambivalent – as long as it isn’t a ‘home’.

    It is also important to consider past wishes if expressed and she had repeatedly explained that she never wanted to go into ‘a home’. She disliked community day centres and the communal environment they garner and encourage.

    Then there is thought to the less restrictive outcome. She doesn’t want carers but would she refuse the help if proffered. It is less restrictive to ‘force’ care in the home than to remove to a different setting. However, if all her family and social networks are so opposed to her being at home, how does that link to her overall well-being?

    Her family to whom I had already spoken, explained in detail why she needed 24 hour care – their worries, concerns and her need to be supervised.

    It isn’t a question of her family’s needs superceding her own but rather how we maintain the networks without alienating a supportive family.

    One of the positives about having an IMCA involved is that they can take away some of the individual pressure on the ‘decision-maker’ but in this situation, she is clearly not ‘unbefriended’ and has a family around her.

    As for the capacity assessment, I was clear that she would not have capacity to make this particular decision relating to her long-term care. Her understanding of home, of safety, of her own needs were far from realistic.

    The final decision about moving? My gut instinct tells me to respect her wish not to move into residential care per se but to move back to her home environment does carry substantial risks. My manager tells me to write a more thorough risk assessment.

    The outcome though may well be pointing to, at least, a move to what we call ‘extra-care sheltered housing’. Sheltered housing ‘with a bit more care’ which provides the 24 hour support and would allow her to keep her cat with her as well as have the necessary privacy as well as the available support.

    I’m not saying we get things right, it’s impossible, but it is about looking at available options and trying to tread a path between risk-taking and personal responsibility – especially when lack of capacity has been clearly established.


    An Assessment

    I mentioned in passing that I was out at an early morning assessment earlier in the week. I wanted to reflect on some of the issues that arose without mentioning too much of the detail. It was the second attempt to assess as the first visit, Mr A had not been in. That was why we went earlier this time. We knew he was more likely to be in.

    This assessment had been troubling me enormously but actually had a fairly satisfactory outcome. I think.  Actually, the real difference made in that assessment was that the GP was present. Although he was reluctant to come to assess because (understandably) he did not want to ruin his therapeutic relationship – it was in fact, exactly that therapeutic relationship which enabled us to try to engage Mr A at home a little longer and see if we couldn’t  avoid a hospital admission.

    There was an interesting conversation beforehand though between psychiatrist and GP when GP claimed his therapeutic relationship was crucial and psychiatrist replied snarkily ‘so is mine – psychiatrists also have to build relationships you know’. It was a gem. It was also, for me, a massive lesson in making assumptions before attending but a good one.

    But, if there’s one thing my almost-one-year of being an ASW/AMHP has taught me is that assumptions are there to be broken. You plan ahead and outline how you think assessments might go and can never fail to be surprised.


    What didn’t help was returning to the office and having a couple of people tell me I’d clearly made the ‘wrong’ decision because I couldn’t possibly not have brought Mr A into hospital – along with a long list of risks which we had previously identified relating to the reasons we had gone ahead with the assessment in the first place.

    Sigh.  Honestly, I generally love my team but they do like to comment on all the ‘bad’ decisions I make – and even if I had felt Mr A should be in admitted forcibly to hospital (which I didn’t – or at least, I felt we needed to try other things before going down that route) – neither of the doctors would have signed recommendations anyway because we all agreed.

    The more stressful decisions come about when you have two signed medical recommendations in hand and then make the decision not to admit. That has almost happened to me – what actually happened is that I had one recommendation and another doctor assessing with me who asked me if I wanted him to write a recommendation or not because it could have gone either way. I told him not to and we didn’t admit.

    I get paid more now than most of the people on the same ‘level’ as me at work – namely, all the people who aren’t in senior or management positions. The reason I get paid most is solely because I get additional increments for the AMHP work. I’m also one of the younger members of the team.  These two combined factors don’t always make me the most popular of people.

    It can feel very isolating at times. I wanted to come back and discuss the assessment and mull it over. The other AMHP I work with has management responsibilities and also has much much more experience than me, of social work, of work in mental health settings and of ASW/AMHP work. But she was on leave. Anyway, I had three other visits arranged for that day.  Actually, I had four but I cancelled the one which I felt could be postponed.

    I probably would have taken today off if I didn’t need to complete the paperwork for a Guardianship renewal. Oh, and apparently I will find out if I’ve been approved as a Best Interests Assessor although it’s likely that I won’t actually find out until Monday as I’m out and about most of the afternoon.  A weekend of two days sometimes just isn’t long enough. I made it to April with my two ‘emergency’ days of annual leave intact! I also realised (and I’m sure all this is related to my general current mental state!) that I haven’t had more than a few long weekends off work for over a year.

    At least I have my holiday in July to look forward to! But actually, I’m very very tempted to book myself a week off – even if it is just a ‘stay at home’ week.

    Sometimes I think I’m not very good at looking after my own mental health.

    Learning Disabilities and Health Care

    It’s amazing how easy it is to become accustomed to writing on a regular basis. I miss one day and it feels distinctly odd! Habit or obsession, well, you can make that judgement! The reason I didn’t update yesterday is that I had an early morning (meaning before ‘normal’ working hours) assessment.  I invariably write up my posts first thing in the morning and apart from always feeling a little bit anxious before Mental Health Act assessments – this one in particular had been on my mind so I wanted a reasonably clear head.

    There was though, one story I wanted to comment on, however briefly.

    Namely, the scathing report published on Tuesday by the Health Ombudsman about institutional discrimination within the NHS relating to treatment of people with learning disabilities. Apart from being horrified by the events outlined in the report, I was also shocked.

    I worked for about seven years in total in a residential care home for adults with learning disabilities. It was my first ever job (discounting holiday jobs!) and my first taste of the social care sector. When I started my social work training (during which I continued to work at the same home on a part time contract) I was absolutely sure I wanted to work in that area after qualifying. Of course, things happen and I am happy in my job (generally) now but unsurprisingly, the more I read of this report, the angrier I become.

    Other sources have unsurprisingly picked up on it.

    Mental Nurse asks how many of the problems related may come down to inexperience of medical staff at relating to and working with people who have learning disabilities as well as poor communication being a key to poor service delivery.

    Campaigning for Health examines the particular case of Martin Ryan, one of those named in the report and the role of the Mental Capacity Act (2005) in defining a drip feeding as medical treatment which can be withdrawn

    The Guardian publishes a picture gallery of the six people whom the report discusses. It is chilling to see the faces of those whom the service has so horrendously disregarded.

    Mencap publish a response to the deaths of each of the six people named in the report.

    To me, the story shows how far we need to go to understand and care for those who need additional support.

    I was thinking about my own experiences in the time I worked in residential care. Generally we had very good relationships the local GP surgery. The GP would visit the home (which fortunately was about a 2 minute walk from the surgery) from time to time and knew each of the residents reasonably well.

    On one occasion, one of the residents fell and broke her arm. She was admitted to the local hospital overnight – I don’t remember too many of the details but I seem to remember it involved some minor surgery. She was terrified. Hospital is where her father went to die. She was sure if she went to hospital she would die. I went to hospital with her – and I was allowed to sit with her through the night, on a chair, next to her bed. So there would be a familiar face. This was going back more than a few years, well over 10 years come to think of it.

    I don’t know how ‘standard’ that would be, nor how many residential homes would be able to release staff like that (although, come to think of it, I think I wasn’t rota’ed to work at the time) – but I felt much more confident being able to sit with her and reassure her.

    My only rather hollow hope is that these reports will lead to some real change, action and soul-searching to ensure that an excellent quality of care is delivered across the board.

    Mencap are currently running a ‘Death by Indifference’ Campaign. The charity’s response to these particular cases is just the start of their campaign to ensure equality of service and sensitivity to the needs of those with learning disabilities.

    Direct Payments and Continuing Care

    We are used to ‘Direct Payments’ in the social care sector. They were introduced in the Direct Payments (Community Care) Act 1997.

    While without doubt they are incredibly beneficial and empowering to some service users as they allow the user to receive the money paid for care directly and for that care to then be bought independently – the concerns remain about access to direct payments not being entirely equitable.

    The actual direct payments themselves though, where implemented, in my experience,  have had an incredibly positive effect on a large group of people who are able to choose how their own care needs will be met and in particular by employing their own care staff directly rather than relying on council provided care agencies and staff.

    image otama at Flickr

    There is also a significant government policy shift to broaden and develop the ideas inherent in the ‘direct payment’ system through the introduction of ‘individualised personal budgets’. There is even a proposal to pilot a system of ‘personal budgets for healthcare’ – something I had been a little more detached from without having read too many of the details.

    I was interested then to read this story in the Independent.

    A case brought by a paralysed former soldier and a woman suffering from a progressive muscular disease who wanted the NHS to provide a direct grant allowing them to live independently by employing their own care staff was dismissed after a judge found that legislation prevented any such payments.

    Steven Harrison, 41, who broke his neck in a diving accident in 1998, and Valerie Garnham, 60, who has suffered her condition since birth, were told in October last year that the NHS primary care trusts funding their care at home would no longer be able to do so because of an edict from the Department of Health (DoH).

    Steven Harrison and Valerie Garnham had been receiving ‘direct payments’ however their physical health and social care needs had increased to the degree that they now meet the criteria for receiving ‘Continuing Care’ – namely having their care funding from the NHS rather than the local authorities.

    So once the band shifts from social care to health care, the entitlement or even the ability to receive direct payments shifts and the carers who have been working with the individuals closely, sometimes for years, have to be dismissed so that support can be funded directly from the NHS.

    Mr Harrison, from Wakefield, West Yorkshire, and Mrs Garnham, from Holloway, north London, claimed their human rights were breached by the denial of direct payments and that the legislation governing the health service meant that such funding could already be given legally.

    Mrs Garnham said: “I don’t look at myself as a useless cabbage that sits at home and gets withered and wizened. Is my life worth living if I’m going to stay in bed and wait for a local authority nurse to turn up? We were very proud that we actually employed five people.”

    Islington Primary Care Trust in north London, which pays for Mrs Garnham’s care, is expected to pay up to three times the amount it paid her in the form of a direct grant to cover the cost of employing a nursing agency to do the same work.

    But Mr Justice Silber, ruling in favour of the DoH, said there were no powers under the NHS Act 2006 for direct payments to patients. Lawyers for Mrs Garnham said they planned to appeal.

    It makes no logical sense of course, but the law is the law even when it is an ass. I hope the appeal succeeds and imagine, from the perspective of a layman, there is more than a little merit to it. We seem to be moving towards systems of increased individual budgetary control and to steal the money away when a cohesive and individualised plan of care is in place already, seems like a step back many decades.

    It seems like a ridiculous position to be maintained even if it needs some quick adjustments to primary legislation just to affect these particular cases.

    We know that government policy is aiming to move in this direction in any case and it seems absurd to remove independence forcibly and as well as potentially less costly and better quality care for the individuals receiving it.

    Training, Universities and the CWDC

    Community Care have an article on their website today about CWDC (Children’s Workforce Development Council) and their submission to the Social Work Taskforce which is considering the future of the Social Work profession following an interview published in the magazine, with the Chair of the CWDC, Mike Leadbetter. In the article, Leadbetter called for more rigour in the selection process for degree courses, claiming it was currently “patchy”

    Apart from the fact that I’d be marginally offended if I were a current student, I think there is something in what he says. It is clear that the universities are ploughing their own merry furrows. Self-directed learning has the potential to be useful in conjunction with other types of learning and teaching but packing more students than can realistically be offered quality placements is bad.  As is offering students places who are not expected to last the course or, a few years down the line, make quality practitioners.

    There is, of course, some crystal-ball gazing and of course, past experience is not always an indication of future potential but the fact that some courses do not even interview applicants is a minor worry.

    My own experiences are a little mixed on this. I know I was lucky to get my place on the MA course I attended. I know because after having been accepted and settling down to study, I had this exact conversation with the tutor who had interviewed me – who told me I had secured one of the last available places on the basis of a reasonably good interview when they had been very reluctant to offer me an interview.

    It was easy to for us to know the ‘borderline’ candidates on that course – we were the ones who had been interviewed – the ‘definites’ had been offered places without interviews!


    Back to Leadbetter who

    .. suggested that candidates should be tested for their “emotional intelligence and resilience” by doing compulsory role-plays

    One this is for sure and that is it would probably attract a different type of student for the course. It’s an interesting point though.

    I went to have a look at the Submission that the CWDC made to the Taskforce. It makes some more substantial points – and it actually an interesting read because it not only sets up the problems currently within the system but relays some answers.

    Just looking at the part relating to ‘Training and Qualifications’ there are a number of excellently made points which I hope will be addressed.

    · differential levels of quality in respect of the three year degree;

    · the quality and variability of the teaching on the degree course and the low level of current practice knowledge of many teachers of social work;

    ·· lack of clarity about what should be taught, how it is taught, the balance between self-directed learning and other more formal methods of learning;

    · graduates are leaving social work training courses with an insufficient knowledge of basic principles and experience of e.g. attachment, human growth and development, psychoanalytic and psychological theories of behaviour, self-awareness and emotional intelligence, scenario and role-play enactments which give a greater understanding of real life situations;

    · insufficient quality and quantity of statutory placements.

    I expect one of the matters which will be addressed will be the variety of experiences on the Social Work degree course. It’s one of the reasons I think that someone being registered to practice immediately after finishing university is proving to be a disservice both to the incoming students and the profession as a whole.

    The universities are eager to suck up any funding they can muster and have no incentives to reduce their intake if they do not receive high quality applicants but rather they are encouraged to fill places for funding purposes.

    This is dangerous when the degree course in itself is seen as enough to prepare for practice. It also puts an extraordinary amount of pressure onto Practice Teachers in the workplace who are responsible for deciding then if a particular student is fit to practice or not and is, perhaps, doing some of the teaching which should be taking place in the university.

    I also wonder how more current practice can be built into university courses – I am a little detached now except through some of the post qualification training I have experienced. I know on the ASW course, for example,  that the course leader taught while continuing to practice (part-time, occasional EDT work) and that was enormously helpful but also reassuring as she was aware and interested in current practice as well as having a firm personal pride in training a group of practitioners who were competent.

    ‘Self-directed’ learning is all very good but sometimes it seems like a cop-out for the university and a ‘cheaper’ option. Has this system of training produced a generation of social workers who are over-assessed but under-trained? Judging by the first year students I have come across, the fervour and desire is still there.

    Lastly, another point I picked up from the CDWC submission saddened me enormously.

    ..  in the 1970s and early 1980s there was hope, vision and an intellectual enthusiasm about the task that is largely missing today. Highly publicised tragedies seem to have drawn the profession into a cycle of despair, defensiveness, fear and lack of confidence.

    I’ll have to claim that being born in the 70s, I don’t retain much knowledge of what was happening in the 70s and 80s beyond cheesy pop music and different varieties of penny sweets but we were taught through the history of social policy and the radicalism of the 70s at least, that it may be possible to work in a climate where there is ‘hope, vision and intellectual enthusiasm’.

    How much more exciting the work is when there is a passion to work towards empowerment and a vision of social justice – rather than the tedium of another set of performance indicators to input before 1st April. Of course a working life has to mix between the two but the balance seems to have shifted too far away from the broader aims and visions of social work practice.

    Are we taught too much about procedures in a system that has to pump us out of university ‘ready to practice’? I think so, personally. We are trained to practice as statutory social workers in a very closely defined model. Statutory placements are seen as being superior to all others as they provide ‘experience’ when really it should make no difference and work experience post-qualification should be able to provide that same ‘experience’.

    If Universities are expected to create ‘ready to work’ social workers immediately on graduation, the needs to be a lot more partnership working as there are few incentives for practitioners to take students on.

    The sadness is that it is often the newly qualified social workers that go straight into the child protection teams – that has been the case consistently – certainly since I qualified.  What those teams need perhaps more than any others are the more confident and experienced workers.

    Universities can provide a great inspirational role and are key to providing the quality practitioners of the future as they are the ones with the ability to select the finest students.

    I wonder if the universities need to take more responsibility for training and if they ever will without the funding.

    I wonder if the agencies that employ social workers need to stop hiding behind the universities and demand a better trained workforce and what role the GSCC is taking in this process. I expect we will see when the Taskforce reports back.

    And I’m still more than a little tetchy that Balls had the temerity to place a newspaper agony aunt on the committee that decides the future of the profession.

    Countdown to DoLs

    The Deprivation of Liberties Safeguards (DoLs) go ‘live’ in  just over a week now. These were a part of the amended Mental Capacity Act (2005) which establish a legal framework by which someone who lacks capacity may be ‘deprived of their liberty’ if it is assessed to be in their best interests and according to a stream of conditions and indicators. It means we are preparing to receive referrals to assess those who are in this situation currently or of whom there are plans to do so in the future.

    We are counting down to the 1st April – and while I should be concentrating my efforts on finishing up the coursework, I’m really at the ‘looking for distraction’ stage of studying that necessitated another posting.

    We had a meeting of Best Interests Assessors last week in the borough. Currently there are about 30 and that covers the Primary Care Trust, the Mental Health Trust and the local authority. Most are social workers – including all the dual-trained AMHPs (Approved Mental Health Professionals)  but there are also a some OTs (Occupational Therapists) as well as some Learning Disability Nurses and Mental Health Nurses.  The meeting was an opportunity for the newly-established DoLs Office to distribute their freshly minted policy and for us to meet with some of the directors who will be ‘our’ signatories. We also met our ‘legal advice’ team which was quite comforting. It was also an opportunity to discuss thoughts and concerns in the run up to April 1st (with chocolate biscuits – they really know how to sell these things to us!).

    One of the main organisational concerns seems to revolve around the Mental Health Assessors who are doctors trained specifically to carry out these parts of the Assessments. Apparently, a list is going to be held centrally (and nationally) of all the doctors who have completed this training.  There seems to be a minor rumbling of concern about how many doctors have actually completed this training.

    Each full set of assessments needs to be completed by at least two people, a trained Best Interests Assessor and a Mental Health Assessor at the very least so we can see where potential concerns may be coming from.

    As for expectations, they seem to be relatively low regarding the amount of assessments that will come in. We have quite a lot of (general) hospital beds in the borough and that seems to be causing a fair amount of stress as they (the acute Trust) have developed an extraordinarily robust policy which seems to set a fairly low threshold for ‘Deprivation of Liberty’.

    Of course, developing a robust policy isn’t concerning but there is a thought that perhaps a lot of referrals will come from that source.

    We heard though that there is likely to be at least an element of reliance on neighbouring boroughs regarding possibly sharing out some of the workload – as there is a regional local implementation network that has been making these kinds of plans for months.. but even just over a week away some of the details are less than clear.

    As for us, best interests assessors (although while I still have this deadline for essay hanging over me I’m almost reluctant to tempt fate in this way!), we have completed a ‘profile’ form to match our background and experience with those who we will be assessing – including home addresses and areas of England which we would find it easy to travel to (I indicted for example, where my siblings live – just in case my borough has placed anyone in those areas – one person who is trained, for example, commutes in from Brighton – I expect he will she kept fairly busy on the south coast.. !).

    Being in central London we make quite a lot of out-of-borough placements, so while the council has done a lot of work with the local nursing and residential homes as well as the hospitals, there is an unknown factor relating to how many out-of-borough assessments will come in.

    I forsee a lot of seaside trips in my future.. Bognor in May. Lovely.


    Crown Cleared

    I saw on the BBC that the Crown Nursing Home in Harwell was cleared of the responsibility of the death of eight of the residents in January.

    As I was so quick to condemn, it’s only right that I raise this again. I wrote about it previously here.

    I want to pick up this information with good grace and move on. I really do. But the broken heating issue still niggles a little with me.

    A spokesman for Oxfordshire County Council said the pensioners died of natural causes.

    An inquiry found that a breakdown in the heating system at the home played no part in the deaths as an alternative had been provided.

    While obviously the inquiry is perfectly served to look into exactly these issues and while not responsible, I was hasty to jump to such a conclusion that broken heating would be linked.

    The Oxford Mail provides a few more details.

    A spokesman for Oxford County Council is quoted as saying

    “As a result of the detailed look there was no evidence to suggest a direct link between the breakdown of the central heating at the nursing home and the sad deaths of people living there, who all died of natural causes.

    “Alternative heating was provided by the privately-run home and the quality of care provided by staff during this period was found to be of a good standard.”

    He said a further review of the case would be undertaken by the Oxfordshire Safeguarding Adults Board so that any further learning from the case can be shared with other care providers in Oxfordshire.

    The CSCI, the Government watchdog that oversees adult social care in England, told the home to improve earlier this month after staff failed to inform them of the deaths and heating problem.

    It issued the 16-bed home with a requirement notice, which means it must improve within 48 hours or within a set timescale.

    It is the first of four steps of action the CSCI can take when care providers breach regulations.

    A commission spokesman said: “As part of the commission’s enforcement powers, we issued the Crown Nursing Home with requirement notices for not informing the commission about several deaths in the home and the failure to inform us of the heating system not working.”

    When CSCI is taken into the Care Quality Commission next month – well, I hope it has more teeth than CSCI – I hope it will provide less ‘desk’ inspections – I hope it will return to visiting every home regularly, and by regularly I mean at least annually. I don’t think that is a part of its remit though.

    If there is one lesson that can be learnt over the last few weeks and possibly months and even years, it is that saving time with ‘desk’ inspections of targets met is a hideously false economy across the board.

    Funding Panels

    I’ve worked in the same local authority for a while. Other authorities I’ve  worked in have similar but not equivalent procedures so I’m not sure how much this experience is reflected.

    When we recommend a care plan or a placement – either permanent or temporary (such as respite) – we have to make our case to a panel of seemingly ethereal ‘higher’ managers and fund-holders  – who will ponder and explore the paperwork and reports we provide to basically see if there is any way that the outcomes we wish to achieve can be successfully identified through cheaper means.

    Of course, there is discussion about the purpose being about ‘advice and guidance’ but really it is about budgets. And that’s fair enough – we are using tax-payer’s money and I have  no problem with being held accountable for the ways that we are making these decisions. Fortunately I’m able to happily argue my case.

    image tvol at flickr

    I went to the panel earlier this week for two proposed care plans. There were similarities between them. Both are people who have what is termed as ‘moderate’ dementia although even that term in itself it very blurred. I probably wouldn’t describe the dementia as moderate to the family and friends who care for them as it presents in very significant ways.

    One of the situations is that a woman who has been receiving informal support from a friend requires increased care because the friend is moving to a different city. Fairly straightforward to argue the point – her needs have not changed but rather her need for formal care has.

    The panel clearly agreed (there weren’t any grounds for them not to really) – in some ways I expected them to argue more as I had been generous although not unrealistic with the times allocated for the tasks specified – but that was not questioned.  We discussed the longer term which is highly likely to involve residential care – but for as long as possible, we want to see how far we can stretch care at home as historically, it is without doubt where she wants to be.

    The other decision was a request for residential care. The person involved had been well-supported at home for a  number of years while she had been deteriorating slowly. It had come to a point where the care provided at home would no longer be substantial enough to support her safely.

    It was a slow and sad realisation, along with her family, that we had reached the stage where 24 hour care really was necessary.

    I used to resent these panels or at least resent the time I would spend attending them. I think that was probably when I was less aware of the ways they argue and make those decisions. Sometimes they can drag you over the coals a bit but usually if you can forsee where the questions are coming from it becomes less forboding.

    Ultimately, it is just another part of the process to take on board in a sea of processing and paper shufflings.