Positive Risk Taking – Trish O’Hara

Most of the choices that people make in life naturally involve some element of risk. Avoiding risks altogether can limit life opportunities, and impact negatively on quality of life.  People want choice and control for themselves and safety for those they care for. This is because risk is a concept that tends to have negative connotations, but people take considered risks all the time and gain many positive benefits.

People perceive risk differently, including people who use services, practitioners, and families. This can be difficult for social care practitioners and confusing for individuals and families. Therefore, adopting a balanced approach at a practice level can be a challenge. Balance and proportionality are vital considerations in encouraging responsible decision making.

In our work streams we have been considering:

  • What skills do staff need to properly develop positive risk taking in their practice?
  • How can learning programmes be developed that inspire and motivate practitioners to take a bold approach to positive risk taking?
  • What systems need to be in place to enable a responsive approach to positive risk taking?

Getting out of bed, and all that it entails – getting washed, dressed having breakfast, and taking the bus to work – carries risk. Though, staying in bed could still involve both psychological and physical risks.

Back in the mid 80’s the social care sector often ignored risk assessments.  There were risk assessments in place for health and safety of the building and staff. However, what was lacking was person centred risk assessments to support  the people using our services to positively live their lives.

I recall us supporting  extremely complex individuals to go to Glastonbury music festival.  We did this without a risk assessment, and this was back in the day when you could speak to Martin Eavis directly to get free tickets.   They were the days of ‘try it and see’.

By the late 80’s risk assessments were firmly and quite rightly in place to ensure staff were confident to support people to try new things, and live as full as life as possible.  Managers who would start a sentence ‘Yeah,  let’s try that,  let’s do a risk assessment’ with a smile.  It was as if doing the risk assessment itself was the incentive to make it happen.   Over time, I noticed that the sentiment of risk assessment changed.  The managers started to say, ‘oh no,  you  had better risk assess that’.   It seemed like the idea that risk assessment had become  a way of limiting people. The intention changed. Risk assessment should be used as a tool to support  empowerment, and innovation. It should also be used to listen to  those that need care and support.

Finding time to embark on meaningful co-production,  ensuring the person is an equal partner in the shaping of their services is likely to mean that people will be faced with more choice. Where people are faced with more choice this is likely to lead to options that introduce more risk.

So what is stopping our services effectively undertaking positive risk assessments, what are the barriers?

People perceive risk differently.   For instance,  it you ask nurses what is the main risk for older people in care homes,  they are most likely to say,  falls.  If you ask social workers,  they are likely to be concerned with risks to adequate housing or benefits.  If you ask their family, it is likely to be that they  are concerned that their loved one is treated badly. If you ask the person themselves,  they may be more concerned with losing their identity and/or purpose.  We come to the table with a bias based on role and relationship.

Getting the balance right requires professional competence,  partnership working and understanding that safeguarding is about improving quality of life as much as safety, and can only really work if we keep it personal.

Because risk assessment is considered a skilled endeavour,  we often see managers or team leaders completing the risk assessment from beginning to end from inside of an office,  rather than inside the life of the person.   Key-workers need to be trained to understand risk assessment and be part of the process, as they are often the people who know the person best.

There is also a real fear of being accused of neglect.   Staff also struggle to understand that what may be important FOR the person may be in direct conflict with what is important TO them.   A disproportionate response that infringes the rights of individuals to make their own,  albeit at times,  unwise decisions.   Often there is a lack of a working knowledge of the Mental Capacity Act and what it means to deprive a person of their liberty. A general lack of knowledge when and where to apply the law.

Ultimately,   risk is part of life and arguably the most successful people take many of them.   It is impossible to self actualise without taking risks.  It’s the only way to face the challenge of Everest.    Many of us would make it to the top if we were given the chance to do it at our own pace (maybe years),  using our own methods,  with the right people and with the adaptations required to help us along the way.     We would find our own peak and reflect on our own troughs knowing where we are,  where we have been and where we are going.

We will continue to challenge practice in our work streams, and get practitioners to really believe that positive risk taking is a fundamental core of practice.

Trish O’Hara

 

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The Use of Technologies in Care Homes

at-and-dementia_web

Introduction

In our work on the Vanguard projects in reducing hospital admissions to care homes we have been considering the role of technology within the care homes setting. Areas that we have been looking at include but are not limited to telehealth, I Pad, and more modern, possibly contentious technologies, such as virtual reality headsets.

When planning this programme we considered:

How might technology increase social engagement in the care homes, without replacing human contact?

How might technology be used to proactively monitor health, to prevent/detect delirium and / or reduce unnecessary hospital admission?

How might technology be used to promote physical exercise in care homes?

The picture in other areas may well be different, but for here, and for now, at least we seem to be lagging as we found a fairly limited take up. This is also representative of the many care homes that we train. However, the potential use of technology in dementia care has been gathering pace, as new technologies emerge onto the market. A recent coping review that was carried out by GIbson et al (2016) identified 171 product types and 331 services. However, many of these are unregulated, and have not been rigorously tested in research conditions. Despite this there is a significant pull for these technologies. One of the driving factors (although not the only factor) is how these technologies increase efficiencies.

Some definitions:

Assistive Technologies: ‘any device or system that allows an individual to perform a task that they would otherwise be unable to do, or increases the ease and safety with which the task can be performed’ (Royal Commission on Long Term Care, 1999)

Telecare: remote social care monitoring

Telehealth: Telehealth is the remote exchange of data between a person at home and their clinician(s) to assist in diagnosis and monitoring typically used to support people with Long Term Conditions. It comprises of fixed or mobile home units to measure and monitor temperatures, blood pressure, glucose levels and other vital signs parameters

The reasons to use technology are vast, and extend far beyond safety but might also include:

Increase engagement, support independence through multiple mechanisms (prompting memory, orientation, supporting motor skills etc), facilitate proactive and preventative health monitoring, improve wellbeing through multiple domains (including encouraging exercise) and relieve carers stress. Then there are the organisational benefits which might include better targeting of human resource, support communication across teams, support compliance and safeguarding through effective monitoring and reporting.

AT are used by different people in different ways. GIbson et al (2016) usefully categorised the AT into 3 camps: ones that are used by people with dementia, ones that are used on people with dementia and ones that are used with people with dementia. For each of these there is a different set of ethical questions, and differing drivers in design. Who is making the decisions about the purchase and use of these technologies? For informal carer’s the quest may be driven by questions like, how can this technology reduce the caring stress levels?  Where these technologies are being used to unobtrusively reduce risks, such as monitoring technologies. How much of this is creating a false sense of security? (Nygard et al 2005).

The context

There has been significant investment in the community to respond to demographic challenges. Policy has stimulated investment in the Assistive Technologies (AT), with the Technology Strategy Board investing £25 million of matched funding between 2008 and 2011. However, whilst these technologies are more widely available in the community, at a practice level, there continues to be real challenges in the uptake, both in the community as well as in care homes. Yet the conversations continue about the evolving possibilities of technology. The Dementia Congress in Brighton this year, as well as the Alzheimer Europe conference in Denmark, featured presentations on ‘robots’. The conversations that ensued included ethics, as well as how these could be used in cashed strapped times.

Greenhalgh et al (2012) suggest that there are several conversations going on around the use of AT, of which ethics is only one. The ‘ethics’ conversation is mainly driven by the professionals working in the sector. Developers and ‘modernists’ are concerned with the benefits and use of AT in saving time, and creating efficiencies.  There is also the ‘political’ conversation stating the economic benefits of the telehealth, and telecare markets and the role of industry in influencing, or managing vested interests.  Then finally there is the ‘change management’ conversation which argues that there is a mismatch between the system, and actual work practices, and work needed to be completed to address this. These conversations create tensions in the development and uptake of AT, and there is boundless interconnectedness between these.

Nauha et al (2016) looked at the use of AT for people at home with a memory disorder. In this study they also explored how the use of these technologies can facilitate, and support the work of the care staff, together with how the technology is effective in supporting the person with dementia. An important consideration, if we are to address the concerns of the ‘change management’ conversations we need to be thinking unilaterally about the benefits of AT. This means looking at the benefits not only to the individual but also for the service.

Barriers

So as stakeholders continue to battle it out in different forum, on a practice level there is more concern about where and how do I source these technologies? Are they affordable? Will they work? How can they enable? How do they support carers both formal and informal? And finally, and possibly most importantly, how can they be used ethically?

Assistive technologies (AT) might include low tech, to high tech. These might include clocks and signage to support orientation. Devices which prompt and remind, such as medication dispenses, recorded devices or iPad technologies. Alerts and alarms, communication aids or technologies that support recreation and engagement.

Local authority social care support has traditionally been the largest supplier of AT, most of which are tele care, services like just checking can monitor movements / or lack of movements, and successfully identify issues, hopefully before they develop. In addition to telecare, telehealth is having an increasing role. In Croyden a pilot project was undertaken, which successful reduced the admissions to hospitals

Therefore, on a strategic level technologies are being introduced to enable us to work more effectively, to reduce impact on an overburdened NHS. However, many of these technologies are being introduced much later on post diagnosis, often where there are already significant challenges to an individual’s health and wellbeing. As local authority eligibility increases, often individuals are at crisis point before accessing these services, and along with that accessing information about suitable AT. To compensate for this many individuals are now looking in other places for up to date information on the range, and suitability of technologies. Sometimes unsuccessfully sourcing the right technology at the right price. Whilst there are some great websites, like www.atdementia.org which was set up some years ago, brilliant and comprehensive these ‘of the shelf’ products are being purchased without any proper assessment. As the major risk factor for dementia is age, many individuals are living with co-morbidity, including, but not limited to sensory problems, impact significantly on the application, and use of these technologies. In addition, individuals are often have cognitive challenges: memory problems, impaired judgement and visual perceptual challenges.

Cahill et al (2007) found for the AT to be utilised effectively, informal and care staff need to be available to support, show and encourage individuals to use the products. Therefore, what training is being provided to front line staff, and informal carer, on how to maximise the use of these technologies, and how many staff are reluctant because of unanswered ethical concerns?

 

Potential barriers to the use of technology:

  • Accessing timely and suitable information
  • Sourcing technology that works with comorbidity
  • Accessing suitable assessment
  • connection problems
  • stigma associated to use
  • costs and relative funding for technology
  • as much of the technology needs to be supported by others, training is needed

 

Another major factor, which is often overlooked and not evident in the research papers I have read is the impact of the cuts on the uptake and use of technologies. On the one hand, you might consider that having technologies in place will create efficiencies, however introducing new technology requires change. As we have seen with the introduction of the Home Spirit Tool home care services are simply too stretched to even entertain the idea of piloting new ways of working.

 

Ethical barriers

In addition to the potential barriers we have the ethical considerations to make. One of the principle concerns is how can technology be used to address loneliness, but without replacing human contact? How might we manage effectively the tensions between surveillance for safety and privacy. As technology evolves it pushes the boundaries around ethical concerns. For example, we have seen the introduction of Virtual Reality, augmented reality for the individual to simulate experiences. Supporters believe that this can support the recall of memories and positive emotion. However, is this a form of treachery (Malignant Social Psychology – Tom Kitwood)?

Conclusion

Despite these ethical challenges, we will continue to explore the benefits and application of AT in our work both in the development of the Home Spirit Tool  www.homespirit.org, and in the development of our training. We aim to give our learners the confidence to explore the ethical dilemmas openly as well as engage the people that they support in these conversations. Particularly, how might AT enable us to positively risk take.

 

References

Gibson, G., Newton, L., Pritchard, G., Finch, T., Brittain, K. and Robinson, L. (2014) ‘The provision of assistive technology products and services for people with dementia in the United Kingdom’, Dementia, .

 

Gibson, G., Dickinson, C., Brittain, K. and Robinson, L. (2015) ‘The everyday use of assistive technology by people with dementia and their family carers: A qualitative study’, BMC Geriatrics, 15(1).

 

Greenhalgh, T., Procter, R., Wherton, J., Sugarhood, P. and Shaw, S. (2012) ‘The organising vision for telehealth and telecare: Discourse analysis’, BMJ Open, 2(4), pp. e001574–e001574.

 

Hagen I; Cahill S; Begley E; Faulkner JP (2007) ‘It gives me a sense of independence’ – findings from Ireland on the use and usefulness of assistive technology for people with dementia. Technology and Disability 19 (2007) 133–142

 

Nauha, L., Kera nen, N.S., Kangas, M., Ja msa , T. and Reponen, J. (2016) ‘Assistive technologies at home for people with a memory disorder’, Dementia,

 

Nygård, L. and Starkhammar, S. (2007) ‘The use of everyday technology by people with dementia living alone: Mapping out the difficulties’, Aging & Mental Health, 11(2), pp. 144–155

 

Rosenberg, L. and Nygard, L. (2013) ‘Learning and using technology in intertwined processes: A study of people with mild cognitive impairment or Alzheimer’s disease’, Dementia, 13(5), pp. 662–677.

 

Sugihara, T., Fujinami, T., Phaal, R. and Ikawa, Y. (2013) ‘A technology roadmap of assistive technologies for dementia care in Japan’, Dementia, 14(1), pp. 80–103.

 

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Home Truths to Home Spirit

Last week the Kings Fund and Nuffield Trust produced a report, ‘Home Truths’, demonstrating the impact of the local authority spending cuts over the last six years on social care. The report highlights the combined pressures on services, such as maintaining Fundamental Standards (CQC), working towards achieving the Living Wage, dealing with contract cuts, as well as coping with significant staffing shortages. Cumulatively these pressures have meant that many services have fallen short of demand and for some there have been serious failings. However, for the majority, the shortcomings are visible in delayed discharges from hospital, which has a negative fiscal impact.

The report highlights some of the strategies adopted by services to compensate for these cuts. For example, some providers are relying more heavily on privately funded clients to subside their local authority contracts. Some are actively identifying options for support in the wider communities and using volunteers to bolster their service.

The report warns that the social care sector will not cope against the continued planned cuts and additional sector pressures, and recommends three possible options to address the dismal outlook:

 

  • achieving more with less
  • a different offer
  • long term reform

 

Whilst the latter two can be debated over the longer term by politicians and senior social care figures alike, providers need to be getting on with the ‘what can we achieve for less’ more imminently. There is an urgent and critical need to think outside the box about how we can do things differently.

As part of the ongoing strategic review many services have been actively reviewing their resource input against their outputs and outcomes in an attempt to get more for less. Good business strategists understand that the skill lies in leveraging resources effectively to create a comfortable operating profit. This isn’t always about cutting back but rather doing things differently. Training is one example of a resource that can be manipulated for different outcomes. There has been a growing reluctance to spend on training, with more services opting instead to develop independent capabilities or deliver E learning in the hope that this widens the profit margin. However, in reality some of these ‘cutting corner’ decisions can impact on quality, leaving services ill prepared to ‘fire fight’ issues such as safeguarding incidences, health and safety concerns, complaints and/or poor service outcomes. Many of these matters often rear their ugly head at a time when services are logistically challenged, forcing the focus on resources toward just covering the job instead of on maintaining and improving outcomes.

On a more strategic level, within our local area some excellent joined up thinking has been going on. Integrated projects have developed, which have been supported by the pooling of NHS funding  (Better Care Fund), aiming  for smarter working through integrated practice. Our organisation has been involved in one of these projects, working with care homes to reduce hospital admissions. Hospitals are very disabling places for people living with dementia, and poor outcomes are typically observed; economic and individual. Clearly there is a lot of work to be done to upskill staff to ensure that there is a timelier reporting of health concerns through better quality observations, and ensuring that preventative measures are put in place to avoid unnecessary admissions.

One of the areas that has seen the largest cut in funding is community based services, such as support at home (homecare). Spending is down a whopping 30% despite policy objectives to support more people in the community. This is a significant cut in comparison to residential and nursing services which were only cut by 4 – 6%. Home care services now are delivering more hours for less money.  So what solutions are there available for our home care services?

This key question has been the driving force behind the development of Home Spirit, a platform developed for home care providers. The platform equips services with the tools to literally think differently, be proactive and add value to their service.

 

The portal consists of a number of tools. The person centred planning tool has several potential domains which are selected by the client, and are based on their specific identified outcomes. It is easy to use and prints and uploads reports, making sharing easy. It avoids duplication, or having to write anything out so saves time. It can be completed on mobile while at the client’s home, and, with an easy to use navigation system, it has sensory appeal. The tool helps agencies to reduce operational costs in assessment and reporting. It can highlight risks easily, both those that are determined by the individual as well as the care agency. The report can be produced in a shorter version (similar to a one page profile) which informs busy workers in a simple snapshot HOW to provide the support. At £19 per month for as many reports as required, it is also excellent value.

The environment audit is intended to be a proactive tool. It may reduce hospital admission and risk of falls through environment assessment. It can be used by families and individuals to identify potential assistive technologies (a requirement of the NICE Home Care guidelines 2015), which include health monitoring options, safety and activity monitors, and leisure and communication technologies. These technologies now have a much wider scope and can promote human connection and tackle loneliness. Loneliness has been linked to poor health outcomes, leading to additional financial burdens on community and NHS services. Tackling loneliness through supported use of assisted technologies is only one of the many benefits that can be introduced by the tool.  The environment audit tool also makes simple recommendations for environmental adaptation to improve independence. The environment tool will also make recommendations around how an environment can be adapted around a specific task for a person with dementia, and therefore informs and educates, offering a tailored support plan.

The ‘still my life’ post diagnostic tool is completely FREE to access and helps families to plan together to take proactive steps to manage the condition; this aims to reduce anxiety. One of the first questions asks the person to consider the difficulties they face and what actions they plan to put in place to mediate these challenges. The design of the tool aims to encourage people to rehearse their own strategies, helping them recall them with more proficiency, as well as have very clear goals on how to compensate for their difficulties. Another question prompts the person to consider aspects of life that they appreciate and value (positive psychology), this can have a direct therapeutic value. One of the questions guides individuals to complete appropriate legal planning. Local authority resources spent making ‘best interest’ decisions could be avoided by documenting decisions in a timelier manner. The planning tool provides accessible guidance on how these measures can be put into place. The tool also asks individuals to consider early interventions for nutrition and sleep. As 72% of people living with dementia are also living with another condition (co-morbidity), early strategies to support sleep and nutrition can have a positive effect, reducing risks of delirium and inappropriate admissions to hospital. The post diagnostic planning tool can be easily downloaded and completed on paper. This additional tool is potentially an asset to home care providers, as providing access to this resource as part of your service shows that you provide added value. Perhaps more importantly a tool like this provides hope, and motivates families and individuals to think proactively.

The circle of support tool helps to identify communities of support to build upon existing community networks and engender a sense of belonging and affiliation to the wider community.

The learning resources (infographics) available through the portal support staff, through bite-size learning, to observe better, develop better relationships, and improve reporting.  The flexible resource reduces the need for staff to be removed for training at critical pressure times. Community services are now working with higher levels of need and the skills sets required are reflective of this. Appropriate investments need to be made in knowledge management. The resources available on this portal are specifically designed to work well in busy environments.

Therefore, while services are scratching their heads considering their next move to survive this hostile environment, we have been actively developing a solution. The benefits of the Home Spirit tool are potentially far reaching and offer a legitimate opportunity to services to do things differently and to achieve more for less.

www.homespirit.org

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Deprivation of Liberty

Are we Getting it Right?
Trish O’Hara February 2016

I continue to have an believe in the necessity of adhering to Article 5 of the ECHR and delighted that Lady Hale pointed out that however golden the cage, it is still a cage.

But,  the new threshold following the Cheshire West ruling :-

Continuous supervision and

Lacking capacity to consent to remaining

And how it falls within the Human Rights legislation:

The objective element: i.e. that the person is confined to a particular restricted place for a non-negligible period of time;

The subjective element, i.e. that the person does not consent (or cannot, because they do not have the capacity to do so) to that confinement;

State imputability: i.e. that the deprivation of liberty can be said to be one for which the State is responsible.

It seems to have created an unprecedented amount of paperwork for those who, perhaps, need to be focussed on emergency situations in hospital.

The Law Commission’s consultation paper published 7 July 2015 (consultation ends Nov 2015) suggests comprehensive replacement scheme.

Renamed protective care: Separate scheme to apply to hospitals & palliative care settings: shorter stay than long term care & aim is for person to return home

Supportive care: To people living in care homes, supported living or shared lives accommodation

Restrictive care and treatment: Provide direct replacement to DOLS: Whether care & treatment arrangements are becoming sufficiently intrusive/restrictive to justify enhanced formal safeguards

To include: continuous supervision and control, person not allowed unaccompanied to leave premises or unable to leave.  To include where barriers are being used, the person’s actions are controlled.  For example significant restrictions placed on diet, clothing or contact

We are yet to see the agreed changes expected in 2017.  Let’s hope those changes will continue to uphold rights but remove some of the cumbersome red-tape involved in realising them.

The Cheshire West ruling works well for those living in residential care homes,  nursing homes and hospices but am not sure this is money well spent on those in Intensive Care Units and in transportation from one hospital to another.    It seems to me that those completing the assessments – such as Section 12 doctors and Best Interest Assessors are in the lucrative situation of charging £250 or so to assess people who are sick in hospital for a week or so.   The nursing staff having to make applications,  to spend time with the assessors – all of which is time away from using their expertise in keeping the person alive.    I am aware that on many occasions,  assessors have gone out to complete an assessment and the person has either gained capacity or indeed died or been discharged.   I expect the assessors are still paid for their time and yet more public money is swallowed by this over-zealous interpretation of the ruling.

Of course,  when a patient is resisting treatment and needing restraint,  there needs to be protocols in place to ensure it is to maintain the life of the person,  but can this not be regulated within ordinary hospital procedures?

Although £25 million has been promised by the Government to help authorities process DOLs – Public monies are a dwindling resource as services face further cuts.   Surely,  there needs to be a common sense approach to deprivation and when it is necessary to authorise it.

Yes,  all patients should be prepared to sign consent for a time when they may not have capacity, following an operation and yes the MCA is a wonderful piece of law that protects the rights of all of us.  But,  the idea that a person who has suffered perhaps a head injury and needs to take an ambulance for numerous hours to a specialist hospital needs a DOLs seems to me to be wasting peoples time and money.

I am not sure there is enough emphasis yet on getting this right where it needs more attention,  time and money spent.

Although I have seen a change in demand for training from Home Care Agencies and Supported Living Providers – I am still sure there are many who are involved in supporting a deprivation in a persons own home,  not registered, still untrained in the subject and perhaps believe it ‘does not apply to them’.  Not realising that they too need to make applications to the local authority who can then make sure it is sent to the Court of Protection for authorisation or refusal.  Indeed,  it is the Court of Protection what give us the case law that challenges and progresses our practice.

Do families understand that deprivation of liberty may be seen as false imprisonment?

Do enough care homes understand the right for people with capacity to make unwise decisions?

Do we warn families of people who are held within DOLs, that if their loved one should die ‘within state detention’,  there may be a long wait before burial is possible due to the legal requirement for there to be a coroners report.

Surely,  these are the areas of real concern. And where assessment and monitoring is most needed.

I await 2017 publication with much anticipation.

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Deprivation of Liberty – Are we spending public monies wisely?

Deprivation of Liberty – Are we spending public monies wisely?    Trish O’Hara April 2015

I for one, am fully aware of the necessity of adhering to Article 5 of the ECHR and delighted that Lady Hale pointed out that however golden the cage, it is still a cage.
But, the new threshold following the Cheshire West ruling :-
Continuous supervision and
Lacking capacity to consent to remaining
And how it falls within the Human Rights legislation:
The objective element: i.e. that the person is confined to a particular restricted place for a non-negligible period of time;

The subjective element, i.e. that the person does not consent (or cannot, because they do not have the capacity to do so) to that confinement;

State imputability: i.e. that the deprivation of liberty can be said to be one for which the State is responsible.

seems to have created an unprecedented amount of paperwork for those who, perhaps, need to be focused on emergency situations in hospital.

I am fully behind the new ruling for those living in residential care homes, nursing homes and hospices but am not sure this is money well spent on those in Intensive Care Units and in transportation from one hospital to another. It seems to me that those completing the assessments – such as Section 12 doctors and Best Interest Assessors are in the lucrative situation of charging £250 or so to assess people who are sick in hospital for a week or so. The nursing staff having to make applications, to spend time with the assessors – all of which is time away from using their expertise in keeping the person alive. I am aware that on many occasions, assessors have gone out to complete an assessment and the person has either gained capacity or indeed died or been discharged. I expect the assessors are still paid for their time and yet more public money is swallowed by this over-zealous interpretation of the ruling.

Of course, when a patient is resisting treatment and needing restraint, there needs to be protocols in place to ensure it is to maintain the life of the person, but can this not be regulated within ordinary hospital procedures?

Public monies are a dwindling resource as services face further cuts. Surely, there needs to be a common sense approach to deprivation and when it is necessary to authorise it.

I understand that new guidance is due to be published in 2017 which I hope recognises the paper driven exercise that often seems both pointless and expensive.

Yes, all patients should be informed and asked to sign consent for a time when they may not have capacity, following an operation and yes the MCA is a wonderful piece of law that protects the rights of all of us. But, the idea that a person who has suffered perhaps a head injury in a road accident  and needs to take an ambulance for numerous hours to a specialist hospital needs a DOLs seems to me to be wasting peoples time and money.

I am not sure there is enough emphasis yet on getting this right where it needs more attention, time and money spent.

Are there enough home care providers who are involved in supporting a deprivation in a persons own home, not registered, trained in understanding liberty?

Do families understand that deprivation of liberty may be seen as false imprisonment?

Do enough care homes understand the right for people with capacity to make unwise decisions?

Do enough supported living services realise that they may need to apply to the court of protection if they are depriving a person of their liberty?

Surely, these are the areas of real concern. And where assessment and monitoring is most needed.

I await 2017 publication with much anticipation.

Trish

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Wellbeing is Outcome by Trish O’Hara

Wellbeing is Outcome – by Trish O’Hara March 2015

So the opening chapter of The Care Act is all about wellbeing. I presume every agency has wellbeing in their mission statement. We talk about wellbeing all the time in services today. It is the main driver of our delivery. It is how we are measured. It is the point. And yet, in my experience, practitioners struggle to define it.
Let’s be honest, care packages are created on the back of need, not want. Budgets mean that only ‘need’ is eligible. Any social worker who thinks their assessment processes are person centred must accept that their assessment processes are purely needs led. Person centred planning is aspirational and dreams led – it’s about want not need. What is important for the person is often in direct conflict to what is important to them. Whilst a person’s care package is based on need – the service providing said package is then measured on outcome. This means the provider must know how to move on from the initial assessment and turn the process on its head – still making sure that the person is in receipt of the service they are paying for.
This is not easy.
In essence, the budget meets the persons needs – but your service will be measured on the persons wellbeing and outcome.
So let us define outcome focused practice;
Input The resources required to provide agreed service
Activity The action plan that delivers said service
Output The service is evidenced as delivered
Outcome How this makes the person feel
An example to help us as follows;
Colin is a man with Down Syndrome and a mild to moderate learning disability. Colin has had a life long dream of meeting Elvis in Vegas. Colin lives with 5 others in a registered care home. Colin has the capacity to make his own decisions in the main and chooses to eat very surgery and fatty foods. Colin has diabetes and is about 5 stone overweight which is putting a great strain on his heart and effecting mobility. Colin often refuses his medication and has uncontrolled epilepsy with several seizures per day. Colin is very gregarious and friendly, often singing Elvis songs and making people around him feel good. The staff at his care service have spent years attempting to support Colin to make ‘better’ decisions about his diet and medication. He ignores them. Colins mum is very involved in his care and is worried about his health.
It is when Colin begins a person centred plan – using PATH that his life changes.
Starting with the dream – Colin is in Vegas meeting ‘an’ Elvis.
Colin has a hotel room and a ticket to an Elvis concert
Colin is on the plane with a ticket, passport and visa
Colin has saved £3500
Colin has permission from his GP and insurance to fly

We can see there are a myriad of barriers to this trip. We can see that there a many risks.
Colin tells the staff his dream – staff work from the dream to support Colin to take control over his life.
Colin is excited about going to Vegas. Colin takes his medication without fail and even agrees to a blood test. Colin actively involves himself in healthy eating and manages to lose 3 stone. Colin chooses to walk from the bus the final mile to the day service every day – this was his idea. Colin no longer drinks fizzy drinks. Colin is offered money from his mum and his uncle toward the trip. Colin saves and budgets toward his trip. Colin goes to see Elvis impersonators in the UK. The GP agrees that Colin is now fit to fly. Colin flies to Manchester to see family who he had lost touch with and to see how flying felt. Colin gets a passport.
Let’s use the language to describe events.
Input:          Staff time – Actions plan creations – Appointments with health professionals
Action:        Nutrition Plan, Exercise Plan, Budget/Savings Plan. Colin begins to shop, cook and eat according to plans – along with medical appointments, taking of his medication – controlling his epilepsy and blood sugars.
Output:       Colin goes on his dream trip to meet an Elvis in Vegas
Outcome:    Colin has outcome long before output – Colin takes control of his health, his diet, his life. Colin loses weight, becomes more active, controls his seizures and enjoysa full active life in his community. Colin makes plans, budgets and makes decisions.
It is often presumed that outcome comes after output, but as you can see by this example, often outcome arrives before output. In fact, Colin may never get to Vegas, (although I jolly well hope he does) – but still the outcome comes pouring in.
Staff have been working on Colins health and diet for years – but never before had Colin engaged in it. Colin needed to be heard. Colin wanted a trip to Vegas to meet Elvis, which was seen as impossible – Evidently, people believing in Colins dream and supporting him to work toward it – meant that he felt in control, empowered and made his own great steps to achieve his dream. The outcome is clearly filled with evidence of wellbeing.
It is this example that helps us think about what we measure. Output is not where we stop and is not what we measure.  Wellbeing is outcome – and it is wellbeing that must be documented as evidence that we are providing the services that the person is paying for – Not need.

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The Mental Capacity Act and Safeguarding

Blog by Trish O’Hara 24 January 2015

The Mental Capacity Act continues to be pivotal in safeguarding
Following The Care Act and The Care and Support Statutory Guidance (Oct 2014), it is clear that if we are to understand safeguarding, we must first fully understand The Mental Capacity 2005.
I was also pleased to see that the Fundamental Standards thread The MCA throughout and The Care Quality Commission have The MCA at the centre of their inspection process.
In 2005, I was thrilled to see the principles of The MCA and truly believed there would be a radical change in practice almost overnight – But it’s 2015 and some services are still failing to uphold the principles fully. Whilst, I understand why it is hard for providers to support an individual in their often ‘unwise’ decision making, and realise it challenges the tradition of care and the instinct for care providers to feel they have the right to stop a person making poor decisions – I find it is a constant revelation in the training room.
When I pose the idea that an individual with diabetes may want to eat 12 doughnuts, it is still considered neglect by the service providers to ‘let’ the person do so. I spend much of my time reminding people that they start with The MCA. Does this person have capacity? In line with the first principles of the Act, we must presume capacity unless we have proved otherwise – and our duty of care is to provide information, education, opportunity and choice to said person with capacity, who may continue to eat doughnuts and it is clear that the law protects their rights to do so. The evidence of our information, education, opportunity and choice is vital and of course the risk assessment. In fact, it would be neglect to deny the person the right to make their decision. Of course, if the person does not have capacity then the decision would be made in their best interests. This of course, is where the final principle of the Act takes main stage. Are we using the least restrictive approach? I am not sure it has been challenged enough. My hope is that the ‘new style’ CQC inspections will find a way of monitoring the 5th principle in action.
It is with all this in mind that I continue with the 6 key principles of safeguarding. The order of which is vital –
Empowerment
Prevention
Proportionality
Protection
Partnership
Accountability
The Mental Capacity Act can clearly be seen in these principles. Starting with empowerment and prevention is a clever way to remind us who is at the centre of any decision and then our proportionate intervention which may need us to protect, if an individual is unable to make the decision – But, when we are protecting, it is essential we understand our responsibility to work in partnership and be accountable for our actions.
I love these principles – They make everything so clear.
And then ‘self neglect’ as a type of abuse – spoils it.
The empowered person, with capacity, makes unwise decisions that may be judged as self-neglect by others. Are we really to see this as an abuse? Is that useful? Especially, as the definition of abuse used in the Statutory Guidance, describes abuse as involving another person or persons. At what point are providers to consider self-neglect as abuse? I can imagine that will be when the individual is making lifestyle choices that the provider does not agree with or like. I am fairly convinced that the contributors who created the principles are not the same group who decided upon the changes to the types. It may have been more useful for us all, if they were.
As long as we truly recognise that in order to safeguard, we must uphold and understand The Mental Capacity Act – (DOLs), and we will all be on the right track.
Safeguarding is everybody’s business – so is understanding The MCA.

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