Adult placements and person-centred approaches
There is no specific standard relating to moving on in the national minimum standards, but the notion of independence is implicit.
Maria and Neville share a placement with Derek, who is actively planning a move to supported living. Maria (who has mental health problems) also has a 'map' and person-centred plan which identifies moving on as her goal, but she is not motivated or ambitious to do so; moving will be 'in her own time'. Neville refuses to have a plan at all.
- the practice survey found that some carers had difficulty thinking about the person moving on, because they felt close to and protective of the person in the placement.
- other carers had difficulty in thinking about the person moving on because they were financially dependent on their adult placement income and not confident that the scheme would make another placement with them quickly enough.
- older established carers, who were often recruited to provide a 'home for life', saw their key role primarily as safeguarding the person, and did not find it easy to understand or adapt to new ways of working, or see the value of a person moving on.
- all these adult placement carers may therefore (consciously or subconsciously) influence the person's views about moving on or leaving the placement, and yet the practice survey showed adult placement carers are well placed and equipped to help service users plan for the future.
- all of the schemes visited were increasingly working towards a model of adult placement as a 'stepping stone' toward living independently, and yet independent living was rarely the goal of the people visited.
- this was even the case where it had been identified as a long-term goal in their plan.
The carers in the placements visited were helping service users increase their confidence, self-esteem and independence skills, and take part in activities outside the placement (though often with the carer). These carers seemed well placed and equipped to help the service user plan for the future. One carer had been paid by the scheme as a 'kinship' carer for the person who had left the placement to live in supported housing.
Robinson and Simons'(20) study of people with learning disabilities in adult placements found that 'Most people wanted to stay in their long-term placements. However, there appeared to have been little attempt to help the minority who would have liked to live elsewhere'. People were mainly positive about their short-term placements, but 'their responses to our questions suggested a feeling of powerlessness and lack of ability to influence events around them.'
What does 'moving on' actually mean for service users?
Moving on is extremely complicated. It can mean different things to different people, and it may be useful to think of the term in a much broader sense. For example, for some it might be living in a safe environment as part of a family; being employed, involvement in the community or activities. In other words, 'moving on' might not just be about leaving the placement but developing skills, confidence and going at a pace that has been set by the service user as part of their person-centred plan.
It could also mean a transition to independent living (with support as appropriate). The practice survey illustrated some of the difficulties that there can be in ascertaining whether the person placed does in fact want to move on and some of the (often unconscious) pressures that can prevent the person from even thinking about leaving the placement.
For some people, the thought of leaving their placement may feel like a betrayal of their carer or, as identified in the literature, they may feel powerless to make any change. Either way, they will need support to make a decision that is right for them.
Terry, who is 29 and has a dual diagnosis, has lived with the Williams since he was six (the Williams became adult placement carers so that they could continue to care for Terry; he sees the Williams as his parents). Terry says that he would like to have a flat of his own one day but this deadline keeps slipping. Five years ago his social worker offered him a flat of his own-Terry has avoided this social worker ever since! The Williams work with him on daily living skills, but doubt he will ever achieve 'his' goal of independence.
So, the adult placement scheme worker and care manager should be sure that moving on is what the service user wants. Given the finding by Robinson and Simons above, it is clear that this is a process to happen over a period of time and not something that can be rushed. Service users need the opportunity to explore what it means, what the options are, and then, once they have the information they need, make an informed decision.
In person-centred planning terms this would mean that:
- there is a clear vision of the desired outcome-people having the lives that they want and everyone using a person-centred approach in their work. The outcome is not just lots of person-centred plans.
- there is an understanding of current circumstances and their implications in achieving the desired outcome.
- lessons are learned from existing planning efforts.
- we must be clear about the skills, structures, relationships and organisational culture that would make achieving the desired outcome more likely.(4)
The adult placement carers should be involved in any person-centred planning process-their involvement will help to demonstrate their support and reduce the sense of betrayal that the person may feel in thinking about moving on.
A planned move may also be delayed or thwarted by lack of appropriate accommodation for supported housing, or it might be necessary even though it is not the person's choice or a positive change. When a carer chooses (or is forced) to retire, the service user must 'choose' from alternatives provided by social services (though in practice, the scheme often seeks another adult placement and tries to achieve a smooth transition).
Who should support the service user to move on from the placement?
The practice survey showed that carers are in a good position to support the person in planning for their future and in any move on from the placement. In order to do this well, they will need good emotional and practical support from their scheme. The scheme's main responsibility during any transition period, therefore, is to support the adult placement carer.
The person will need support from outside the scheme in their move on from the placement. Family, friends and advocates play an important role here, but key will be the care manager or care coordinator who has knowledge of accommodation and support options.
Those with responsibility for supporting service users should recognise that they may experience emotional struggles in moving on from placements. Service users may need support to express how they are feeling and help to understand these feelings. People around service users will need a high degree of sensitivity in order to understand whether they wish to change their minds about the move or need support to carry on with the move.
What about the impact on the carer?
Moving on is potentially traumatic and distressing for everyone, and that includes the carer and their family. There are examples where contact between carer and service user is on-going, as identified in the following example from the practice survey, and a previous example about in the 'Moving on' chapter about kinship support.
Edward was found with severe amnesia but was identified through a missing persons trace as having local links. Unable to cope in social situations, Edward would become distressed and go into foetal position. He was placed with Frank and Gina who over 18 months familiarised him with the area, creatively supporting him through his trauma. Edward began to go out on his bicycle so he could speed away when he saw someone he knew. Frank and Gina supported a renewal of his relationship with his four children, and through his training to become a nurse. Now a qualified nurse, he lives independently but has continuing contact with his former adult placement carers.
Nevertheless, supporting a person to move on can be difficult. In addition to feelings of loss and bereavement, the carer may feel they are failing the service user.
The adult placement worker should think about how to help the carer acknowledge that the placement is no longer right for the person, and how the separation might be handled. Moving on can also be seen as an enormous success on the part of the carer, and this should be recognised.
Additionally, most carers are financially dependent on placement fees, so long waits between placements, together with lack of severance pay, can be a disincentive to supporting the person to move on. Schemes need to consider possible solutions: for example whether they are able to pay some sort of retainer to the carer.