Improving outcomes for service users in adult placement - Commissioning and care management
Making good placements - Care management support
National minimum standards require that the scheme supports the adult placement carer and the whole placement, while the care manager retains responsibility for the service user. This arrangement recognises the duty of care managers (including NHS personnel under the Care Programme Approach) to assess and re-assess individuals’ needs, and to plan and deliver local council care services, in consultation with service users and their family carers. It also helps ensure the safety of the placement and avoid conflicts of interest.
Malcolm, aged 22, knew he needed a complete change in order to come off drugs and recover his mental health. His key worker from the mental health team, Len, told him about adult placement. Len supported Malcolm through the lengthy referral and matching process, and at last Malcolm moved in with his adult placement family, under a placement agreement specifying everyone’s role. Although Malcolm is now settled in his new life, Len still meets with him every six weeks to see how he is doing in the placement, check that his self-medication programme is on track, discuss any problems he is experiencing, and talk about the part-time job that Malcolm hopes to start soon.
The first-stage practice survey found that social workers rarely remain engaged once the placement is settled (community psychiatric nurses and psychiatric social workers significantly reduce their involvement), and adult placement workers increasingly support both the service user and adult placement carer in the placement. The study also noted adult placement carers’ resentment of growing scheme worker involvement with the service user.
Discussion group participants confirmed the low profile of care management/social work in adult placement. The referring care manager may provide follow-up for six weeks to three months (although some adult placement carers said even this is unusual), until the person appears settled in the placement, then withdraw. The mechanism and terminology for this vary: 'close to out of hours team’; 'open to team’ or 'banked’, where there is no named worker but no need to re-refer; 'held for review’.
Nearly all participants approved the principle of care management support for service users and scheme support for adult placement carers, and would like to close the gap between theory and reality. Participants, however, described a reactive, 'dipping in’ social work role - to re-assess, find additional money, or review. Most care managers would like continuing social work involvement with adult placement service users but say workload and funding pressures make this impossible. While recognising pressures on social workers, one service manager suggested that attitudes and flexibility are also issues.
A few local authority participants believe adult placement scheme staff should support service users. Even within the same local authority staff hold different views: learning disability social workers in the independent living team said they only commission the accommodation, not the support, while the learning disability team social worker said: 'We commission, [the scheme] provides; if the person needs ongoing support, is [the scheme] doing its job?’ Only Brent Adult Placement Service actively promotes scheme worker support for both service users and adult placement carers (but recognises the conflict with regulatory requirements); in several other schemes this happens by default. Participants stressed the need to 'learn, adapt, talk’ and 'plan together’ to ensure service users receive the support they need in the placement. In two localities, care managers deal directly with adult placement carers, bypassing the adult placement worker.
Local authorities are looking at ways to improve practice: Staffordshire SSD is developing a contract with the adult placement scheme whereby social workers will support the placement (normally the scheme’s responsibility) as well as the service user, if the service user has complex needs and it is agreed the scheme lacks essential, specialist skills. Sheffield’s mental health team is developing a service level agreement with the scheme, setting out the respective roles of the care manager and scheme.
Adult placement carers’ view of care management (social work) in adult placement is disheartening, however. Carers discussion group participants reported minimal social work involvement in the placement (the exception is short-term 'respite’ placement). While cases may not be formally 'closed’, contact ends when the placement is seen to be satisfactory; if a social worker moves on there is usually no named replacement - 'social services are that into crisis management’ according to one carer. Some adult placement carers thought it did not matter whether or not there is a social worker: scheme workers are helpful, but mainly 'adult placement carers do it themselves’. Others thought social workers would be useful 'if they were doing social work’ or were there 'to fight for the service user’ (e.g. to keep a day place). Adult placement carers also reported that 'services we’re told we can have [e.g. advocacy, college] are not there’.
Senior managers should:
- Ensure that adult placement service users receive appropriate and sufficient support from a named care manager/social worker throughout the life of the placement, in line with their statutory duties and the regulatory requirements of adult placement services.
Line managers should:
- Ensure that care managers and other practitioners understand the adult placement model (care manager responsible for ongoing support to the service user, scheme responsible for support to the adult placement carer); the kind of support a person needs in adult placement (and how this is different from other services); and the purpose and importance of continuing care management involvement in the placement.
- Ensure that the system is sufficiently flexible so that care managers can respond quickly when alerted to a problem in the placement by the service user, adult placement carer or scheme worker to avoid a crisis situation and unnecessary breakdown of the placement.
Adult placement schemes should:
- Ensure that senior managers understand the importance to the safety and integrity of the placement of support from a named care manager/social worker for the person in the placement.