Adult placements and person-centred approaches
Matching and introductions
Finding a suitable match and managing the introduction are key aspects of ensuring a successful placement. The scheme makes sure that the placement will suit the person and that the carer is able to meet the person's needs. These processes are defined in Standard 3 of the national minimum standards for adult placement schemes.
- the matching and introduction of an individual with an assessed and approved adult placement carer is one of the key person-centred tools of adult placement.
- because schemes may know little about the person referred, and the referred person may know little about adult placement, the matching and introductory processes are especially important in ensuring the placement is right for the person (and carer).
- meeting all a person's preferences and needs, and achieving a 'perfect' match, is seldom achievable. Placements are the best match available, as schemes have a limited pool of carers.
- however, schemes stress that a placement should not be made if no appropriate match is available.
- schemes emphasised the importance of taking time-commonly six months to a year-to develop and test the match between user and carer. Flexibility is essential.
Pam identified two possible carers that met Martin's specification. Harry and Chris lived in a village. Their home was lively without being frenetic, their adopted son was around the same age as Martin, they had dogs and cats and Martin liked animals. Harry and Chris' own children had grown up and left home but visited regularly with their partners and children; and there was also an older lodger.
Pam gave a copy of Martin's assessment to Harry and Chris. They recognised that it didn't give a full picture of Martin and felt that it was important to meet him. Pam arranged to bring Martin to meet Harry and Chris and see their home. They spent an hour or so together at that first visit and Martin had an opportunity to see the two spare rooms and decide which room he might like if he came to stay. Martin decided straight away that this was right. He didn't want to meet the other prospective adult placement carers.
Martin came to stay for three weekends over the next couple of months. His mum brought him and she liked Harry and Chris at once. Martin, Harry and Chris all found the wait before Martin was allowed to move in frustrating. The funding process extended the delay, although Pam worked hard to move things along (the placement agreement was drawn up in advance to trigger the funding; the licence agreement was drawn up and signed; the housing benefit application could only go in once a moving date was agreed).
The placement agreement meeting involved Pam, Martin, Harry, Chris and Martin's mum. The agreement set out what everyone was going to do and what Martin wanted from the placement. Everybody signed and had a copy of the agreement.
The literature review did not identify any research findings in this area of adult placements. However, there has been some research into matching in the fostering of children, which may have some relevance to adult placement.
SCIE Knowledge review 5 entitled Fostering success (8) discusses evidence that most placements from the community are made at short notice, and in most of these cases there is limited or no choice of placement. 'Fostering success' goes on to highlight two findings of interest:
- placements regarded by social workers as not fully suitable, and placements made in a hurry, in an emergency or without adequate information are more likely to break down.
- there is no evidence that placements 'matched on ethnicity' do better than those which are not matched. The study found that black boys placed long term with white families did better on some criteria. The reverse was true for black girls, but this was not significant.
One challenge for a scheme is to arrange a suitable match for someone who has had little experience of life outside a protected (family or care-home) environment, who has limited interests, expectations or ambitions, and who may not understand the concept of adult placement.
Schemes identify the need to spend time with the individuals and to involve the people who know them best in explaining adult placement and the way in which it works. People may need to experience the range of options open to them before being able to make a meaningful choice.
Another potential difficulty for schemes is balancing the different views of parents, social workers and scheme workers about an individual's wishes, needs or best interests. There may well be potential for conflict if the care manager is anxious to place the service user in a placement that the scheme does not think suitable. The carer may also have reservations, and there should be a mechanism in place for discussion and resolution that involves the service user.
The care manager clearly has a lead role in ensuring the service user's views are not lost in the process. A thorough assessment should identify, with the service user, how best to communicate, how to create a safe environment to facilitate communication, and what the service user wants from the placement. This information will help the adult placement worker and carer throughout the placement. It is even more important where there is no person-centred plan.
Being person-centred means going beyond the provision of a roof over a person's head and regular meals. It is about listening to and understanding the dreams and hopes of that person; what makes them excited; what makes them sad; what they would like to do with their lives. This information should form part of the placement agreement, which clearly states everyone's agreed roles and responsibilities throughout the placement.
Person-centred planning takes time and resources. It requires a high level of training and commitment from everyone involved. It needs cooperation and communication, and a commitment from local authority commissioners to adequately fund their schemes so that care managers can offer appropriate support to the service user and carer.
Pools of carers are limited, and so a perfect match is rare. It might be useful to think about advertising for someone with particular skills or interests to meet the needs of the service user.
Schemes in the survey worked on a formal or informal basis to develop a 'priority list' of the service user's needs and wishes. Introductions were offered to carers who met the essential matching criteria.
It is important that both the carer and the service user have as much information as possible about each other before a match is made. Many carers received inadequate information, so they were ill prepared for the placement. They believed that occasionally information was withheld because it was thought that they would not consider the match if they knew everything about the person being referred. Experience shows, however, that carers will accept people with difficulties if they trust the information that they are given and are confident that they will receive the training and support that they need.
Schemes recognised that some matching criteria were not essential if other aspects of the match were right. Occasionally these 'essential' criteria were heavily influenced by family or the social worker and were found to be of far less importance to the service user.
Experience from schemes (and evidence from fostering) shows that placements should not be made if the match is not right. Ill matched placements are likely to break down and are destructive for the person and the carer.
Although schemes are able to recruit carers specifically for an individual, this is a lengthy and costly process and care managers need to plan for the fact that the right placement may not be found for many months.
Henry, aged 94 with learning disabilities, wanted to leave the hostel where he had lived for 20 years (previously he had been in a large, long-stay hospital from the age of 17). The other residents were too noisy, and Henry wasn't allowed to come and go when he wanted. Ann worked at the hostel where Henry lived. When Ann's husband Gary picked her up from work, Henry would often show him his photographs. Occasionally Henry went to events at Ann and Gary's home. Ann had heard about the scheme, and when she became increasingly unhappy working at the hostel, she and Gary agreed to talk to Henry about living with them. After a number of visits organised through the scheme, Henry said he didn't want to go back to the hostel any more. At Ann and Gary's it was quiet, he had his own room, and he could go out and about whenever he wanted.
The introduction is a key aspect of setting up a placement. It needs to be flexible and discussed in full with the service user. For some it may be an extremely quick process, but for others it may take a year to reach a point where everyone involved is comfortable enough for the placement to be finalised. Once again, there would appear to be a significant role for an independent advocate.
This can be a very stressful period for the service user and carer. The introduction needs to be undertaken with considerable thought and sensitivity. If problems arise the carer needs to know who to go to for support, without fearing that the adult placement worker might be more concerned about the service user.
The adult placement worker should not be compromised by having responsibility for both carer and service -user. The care manager should continue to play a role and support the placement, maintaining an emphasis on the need to be person-centred and ensuring the service user has the time and support necessary to make decisions. This may also require the care manager to undertake some training with the carer about person-centred planning.
It is important that the person's family feels fully involved in the matching and introductory process (unless, exceptionally, the person does not want their involvement). Schemes stress that placements are much more likely to succeed if they have the support of the family. Conversely, placements (no matter how well matched) can be undermined if the family are unhappy with the match.
The adult placement worker maintained contact with the family over a period of months, helping them to understand what was important to their daughter, giving them a chance to reconsider as they learned more about adult placement and began to trust the adult placement worker.
The skills and knowledge of the adult placement (AP) carer
The adult placement worker will need to assess the skills of the carerand provide access to appropriate training if necessary, as well as supporting them through the transition.
Carers will inevitably have demands on their time from other placements or family members, and training will not necessarily be their priority. Nevertheless, for placements to be effective in the long term, development of knowledge and skills remains essential, particularly if carers are to apply person-centred approaches to their work.
Sometimes, it is necessary to make an emergency placement, and Department of Health national minimum standards(2) should be followed.
It can be very difficult to think about being person-centred when the main aim is to provide a placement quickly and efficiently. However, this should not prevent the service user's views being taken into account.
In some instances, the placement will be successful and go on to be long term. However, this cannot be assumed, and as part of the placement agreement, processes need to be in place for early review and monitoring.
Jim, now in his 60s, whose parents both had learning disabilities, spent his childhood in a Barnardo home but was moved to a mental hospital when he became disruptive. By the time he was 18 Jim was sleeping rough and had severe mental health problems and a criminal record, as well as learning disabilities. Jim had no personal experience of family life and did not really understand what adult placement meant. Jim was placed with Maggie and Bill on an emergency basis nine years ago-mainly because they were prepared to have him. The placement proved successful, and was made permanent, not as a result of person-centred pre-placement processes but because the scheme and carers worked slowly and carefully with Jim, helping him especially with communication, relationships, sexuality, and focusing on 'what he can do'.
These are key documents in the establishment of a placement.
- the service-user plan sets out in detail the way in which the assessed needs and the goals of the person will be met in the placement. It is defined in Regulation 20 of the 'Adult Placement Schemes (England) Regulations'. The process to be used drawing up the plan is set out in Standard 5 of the national minimum standards for adult placement schemes.
- the placement agreement is a written agreement between the adult placement scheme, the adult placement carer, the person in the placement and / or their representative and the placing authority (where there is one). It sets out the terms and conditions of the placement and the responsibilities of the adult placement carer. It includes the elements of the service-user plan that will be met by the adult placement carer in the placement. It is defined in Regulation 13 of the 'Adult Placement Schemes (England) Regulations'. The process to be used in drawing up the placement agreement is set out in Standard 5 of the national minimum standards for adult placement schemes.
The placement agreement and service-user plan are working tools. The placement is monitored against these two documents. It is important that both are clear and realistic and that they are in a format that is accessible to the service user and the carer.
The person placed and the carer should have been fully involved in the development of both documents. Where the person does not wish to take part in formal meetings, it is important to ensure that their views are fully represented (e.g. by meeting with the care manager or advocate beforehand to agree what should be included).
After a lengthy assessment and introductory period, Michael, who is recovering from drug abuse and subsequent mental health breakdown, was placed with Elaine and Tony. A placement agreement was drawn up before the placement started in order to trigger the funding (along with a licence agreement and housing-benefit application). Michael, his mum, mental-health-team key worker, adult placement worker and Elaine and Tony all contributed to the placement agreement meeting, and everyone signed and had a copy of the agreement. The agreement set out what Michael wanted from the placement and what everyone was going to do: Cath (the mental health team worker) will work with Michael to develop a daytime routine and handle his medication better. Elaine and Tony had already produced a short introduction to the house and family, including practical information (e.g. telephone and internet access) the scheme's 'house rules' (around confidentiality and respect) and some specific rules for the household (e.g. smoking, guests, privacy).