Improving outcomes for service users in adult placement - Commissioning and care management
Making good placements - Assessment
Most adult placement service users access funding through local authority care management (care coordination for people with mental health problems). For people referred through care management, the national minimum standards require a full care management needs assessment (Single Assessment Process, Fair Access to Care or Care Programme Approach). Best practice established through NAAPS guidance calls for involvement of the referring care manager to ensure the interests of the referred person are represented, and their needs met, throughout the referral, matching and introductory processes (14).
Paul has mild learning disabilities, autistic tendencies, mental health issues and limited speech. He has a history of violent episodes triggered by seemingly insignificant events (sudden noise, food prepared in a different way, failure to understand an attempt to communicate). Working with Paul, his family and residential school staff, Paul’s care manager prepared a record of Paul’s behaviour, his preferred communication method, and the triggers and effective strategies for responding to his rages. With this information (supplementing the standard needs assessment) the care manager and adult placement worker were able to find an adult placement carer with the experience, knowledge and family situation to provide a supportive home for Paul and help him develop in a positive way.
The first-stage practice survey found that only those people recently referred for adult placement are likely to have had a care management assessment, and the quality of information about the referred person is often poor.
While agreeing that assessment is key to making a good placement, discussion group participants reported a wide variation in assessment practice, and in the quality of information received at referral.
Project participants were clear about the unique qualities of adult placement - in particular its family- and community-based nature, and the stability and continuity of support to the service user - as distinct from other service options. In many localities, however, adult placement is not widely known or understood among social care commissioners and practitioners and so not always on the service 'menu’ (see Adult placement profile). Project discussions highlighted the importance of commissioner/care manager knowledge of what adult placement can offer and why it might (or might not) be a person’s preferred service.
Schemes seldom receive the information they need to make a good match, and almost always carry out their own, detailed assessment. Even some new referrals have very out-of-date assessments - over 10 years old in one case. Adult placement workers and carers spoke of the 'lack of information following the person’, from the person’s previous home and between the person’s current service providers.
While scheme officers faulted care managers for failing to provide adequate information about prospective service users, care managers believe it is families - who may feel desperate to find support - rather than referrers who fail to reveal information. 'Confidentiality’ is sometimes invoked inappropriately to excuse withholding information.
Some adult placement carers also had strong views on the failure to provide them with accurate or sufficient information about the person placed with them. They felt they were likely to be told either 'only the bad things’ (e.g. a crime committed) or, more likely, 'a rosy picture of 20 years ago’, but not told about daily routines and habits. Care managers generally were not involved in the introductory stages of the placement; adult placement carers reported that care managers only saw the person once or twice before the placement was made. Several had had particularly bad experiences. In one example, the person placed had previously made allegations of abuse but this was not shared with the adult placement carer, who subsequently had allegations made against her as well. One parent later confided to an adult placement carer that 'I didn’t tell you that because I didn’t think you’d take him’. Sometimes a family may not intentionally mislead but may not see some behaviour as a problem if it has developed slowly over time. If the care manager does not know the person or carry out a careful assessment, such behaviour is likely to be missed. Insufficient or misleading information is not fair on the service user, who will have to move on if an unsuitable placement has been made.
Participants differed about what they felt was helpful and/or appropriate to discuss in advance, but many thought that some kind of informal, pre-referral chat about the person’s needs and wishes and possible, suitable placement vacancies helps both care managers and schemes to make effective placements with a minimum of delay.
Participants agreed that schemes should insist on a full assessment before accepting a referral for placement. One scheme reported that, although it requires that referrers provide a full care management assessment, not all care managers do so; if the scheme insists, the referred person may not get the placement. Several schemes said referrers made telephone assessments, without meeting the assessed person. Another reported that assessment amounted to no more than: 'Does the person meet the council’s eligibility criteria?’ Several schemes said data was simply transferred from the local authority’s assessment form to the scheme’s form without further contact with the referred individual.
Most local authorities have changed, or are in process of changing, to the Single Assessment Process (SAP) or equivalent procedure, and schemes’ assessment protocols are changing in response to this.
- Sheffield Adult Placement Service is developing application guidelines for referrers, to be completed at the point of enquiry. These set out placement-specific information indicating why a person wants and needs adult placement. Following introduction of the SAP for all social services referrals, the scheme no longer uses its own assessment form, but hopes the new guidelines will help care managers fill the gaps in the SAP and provide a better 'sense’ of the referred person. (For Care Programme Approach referrals, the scheme continues to require its original assessment form.)
- Staffordshire Adult Placement Service is altering and shortening the scheme assessment form to avoid duplication with new SAP forms (required by the council for all client groups), to improve the completion rate by care managers, and to make it more adult placement-specific and specialist.
- East Sussex Supported Accommodation Team currently undertakes its own assessment, building on other available assessments, asking the person about their history and past experiences. As East Sussex changes to the SAP the team will re-think its assessment requirements in light of results of these new-style care management assessments.
- In Essex, the SAP has been in place county-wide for four years. Each referral to the Home Share Day Care scheme is accompanied by a SAP form and care plan; the scheme only undertakes an environmental risk assessment (and provides service user and placement plans).
- Herefordshire’s new detailed support needs assessment, authorised by the Partnership Board, was piloted in 2005 and replaces the community care assessment for people with learning disabilities.
Some care managers and scheme staff noted pressures to bypass requirements: for example, a referrer requesting a placement, or even a particular carer, without assessment; or pressure to free mental health hospital beds quickly. A care manager with a heavy caseload may consider adult placement requirements as 'a whole load of hassle’. One care manager said prospective service users see assessment as an obstacle to getting a placement.
Participants reported that a person may fail to obtain an adult placement because of the local authority’s narrow eligibility criteria or overprotection of team budgets. In one locality, a man diagnosed with a learning disability and mental health problems did not meet either team’s eligibility criteria so was not offered a placement although all parties agreed the placement was appropriate. Elsewhere, another man was denied a placement when two service teams disagreed over whose budget might fund him.
Schemes reported delays in placing people because of problems obtaining housing and other benefits, and considerable confusion about benefits among service users, families and adult placement carers. Localities have different approaches to providing financial assessments and benefits advice. In Essex, every person seen is referred to the financial assessment and benefits advisers. In East Sussex the adult placement scheme - recognised as accommodation experts in the county - supports housing benefit applications for people referred. The scheme believes 'adult placement carers need training on handling people’s money as service users go on to housing benefit.’
Senior managers should:
- Ensure that care managers and their line managers have a clear understanding of the unique qualities and flexibility of adult placement when considering service options for prospective service users.
- Ensure that their assessment protocols provide complete, placement-specific, specialist information about a referred person, in order to obtain a full picture of the person and make the best possible match with an adult placement carer. The adult placement scheme can give guidance on information needed to supplement the local authority’s standard assessment form.
- Ensure that an individual is not denied a placement because of disagreements between teams (e.g. learning disabilities and mental health) about who is responsible and/or which budget charged.
- Ensure that computerised assessment systems are individualised and person-focused, and do not result in tick box-type assessments.
Line managers should:
- Ensure that care managers recognise and adhere to adult placement procedures and protocols which represent best practice and are required by regulation.
- Consider requiring care managers to carry out assessments jointly with adult placement schemes, especially for complex assessments. Collaboration among all stakeholders, followed by joint decision-making, is more likely to result in a successful, stable outcome for the service user and the family.
Care managers should:
- Provide a recent, full care management assessment with each referral. Regular contact between care managers/coordinators and schemes - before formal referral and throughout the placement process - will help both parties to be ready to make timely and appropriate placements.
- Endeavor to provide the adult placement scheme with all information needed to make a good and safe referral.
- Plan early to ensure service users receive clear and timely information about housing and other benefits.
Adult placement schemes should:
- Ensure that referral processes are as streamlined as possible and mesh with local authority processes to avoid unnecessary duplication.