Improving outcomes for service users in adult placement - Commissioning and care management
Making good placements - Review and change
Regular review of the placement plan and service user plan is required by regulation, and an annual review of the care management care plan is required by Fair Access to Care guidance. (17).
Ahmad is 35 and has learning disabilities. He lives with his family and has two days a week 'kinship’ support with an adult placement carer, and occasional short-term breaks with another service provider. He works as a volunteer with a day service horticultural project. Previously, each service was reviewed separately, which was confusing and overwhelming for Ahmad and everyone else. Recently, the social services department consolidated all service reviews for each individual service user: Ahmad’s care manager has organised an annual meeting involving Ahmad, his mother, the scheme worker, day service key worker and respite carer, for a 'holistic’ review of Ahmad’s whole care plan package.
The first-stage survey found that both service users and adult placement carers are unclear about the difference between the care management care plan review, the placement review, and other monitoring and review meetings, and do not find them particularly helpful. Social workers known by the service user are rarely involved in placement or care plan reviews (see also Person-centred practice).
Discussion groups confirmed the first-stage project findings. Participants reported a trend among social work departments to appoint separate reviewing officers (in effect accepting there will be no continuing care management support in the placement). The pros and cons of dedicated reviewing officers were debated. One authority employs dedicated reviewing officers, but a service manager reported that 'no one applies for or stays long in’ these new posts, as there is no opportunity to build a relationship or rapport with the service user; reviewing officers are therefore the least experienced staff. A care manager, however, thought that the 'fresh eyes’ of dedicated reviewing officers are beneficial. Service users’ views are needed on this issue: a reviewing officer may be adequate if a 'named person’ is there to support the service user (see Advocacy).
Most participating councils carry out different reviews for each service used (e.g. day service and college, as well as adult placement). In one locality, reviews are 'done when they come up on the list’, but care managers and scheme staff agreed that adult placement service users are not always in the IT system so 'fall through the net’. In another, reviews are decided 'case by case’ (there is no policy). In Herefordshire the care management review is the placement review; scheme workers try to attend reviews of other (e.g. day) services used by the service user.
Adult placement carers also feel strongly that reviews are 'paper exercises’, carried out (if they take place at all) without regard to the service user. For example, invitations to attend the review were sent out by a care manager - 'but they didn’t listen to who the service user wants to come’. Several placement carers said the care manager did not visit the service user but 'just copied the same [assessment] form - it’s identical!’ Adult placement carers have their own issues: as day centres close under local authority 'modernisation’ programmes, there is an assumption by social services that the person will be cared for 24 hours a day by the carer - not an arrangement likely to meet the person’s assessed needs, and in any case many adult placement carers have daytime jobs.
Several adult placement carers were angry that social workers and other practitioners do not listen to them or take them seriously, or recognise that 'we know the person best’. Many thought they were patronised or treated disrespectfully: 'It’s a horrible feeling when someone comes into your home and doesn’t respect you.’ They felt social workers 'think we aren’t objective’, 'treat us as clients’, 'call us WMAs - well-meaning amateurs’. One carer had been asked to keep time sheets for support provided to the service user.
Adult placement carers also noted difficulty in getting social work attention: the service user must acknowledge there is a problem before social services will get involved, but this is 'too conceptual for someone with a learning difficulty’. Without active social work in the placement, a problem can easily become a crisis. 'When adult placement carers keep coping, problems are not a priority for social services.’ 'Adult placement should be an ordinary family, but we don’t have the same rights as a [birth] family.’
While some care managers believe their role is to 'keep a watching brief’ on the service user’s future needs, to discuss with and support the service user to 'move on’ or change service, in many placements scheme workers take on this role. Clarification is needed about the procedure by which a person goes back into the system for re-assessment if there is major change in the placement, and about whose job it is to help make wished-for changes happen.
Participants discussed the need to listen to what the service user is saying. People can 'move on’ and become more independent within their placement. The emphasis on independent living ('my own front door’) prevalent in learning disability and Supporting People services is not right for everyone: 'Don’t set people up to fail’, as one scheme worker said. Scheme staff spoke of challenging social workers who 'always choose the most "independent” - the cheapest’ option, as well as those who are content with a settled placement and want to 'let it be’. 'Without the care manager [review and re-assessment], the scheme officer may note changes but nothing will happen.’ Service users do not always understand that there are options for change.
Line managers should:
- Ensure that care managers carry out their duty to re-assess the service user and review the placement, and that they attend placement reviews, recognising that the scheme worker represents the adult placement carer, not the service user.
- Consider merging the annual care management review and the placement review (including other services provided to the service user).
Care managers should:
- Ensure that the placement review focuses on the needs and wishes of the service user, and that the person’s voice is heard at the review meeting (with support if needed), or by other means if the review meeting is too intimidating.