Short-notice care home closures
Assessment and choice: Examples and tips
In this section we provide you with more detailed information about the various elements of assessment and choice that you will need to consider. It includes excerpts from local authority protocols, policy documents from the assemblies and governments of the UK and feedback captured during the development of the website.
Family carer story
This story from a daughter-in-law has been anonymised and illustrates the negative impact of a compulsory move when choices are limited.
'Who is to determine what good practice is? The resulting outcome can only be the best indicator.
In my experience the closure of a housing complex that was warden-aided led to the re-homing of its elderly occupants, one of whom was my father-in-law.
He did not get the move of his choice (to live nearer to me) because that was barred by the city boundary restrictions. He looked at several places in the permitted area and then plumped for one which he thought would be comfortable. The staff there were only available during the day. He had a fall in the night, lay unable to summon help for many hours and ended up in hospital for over a month. His health rapidly declined while there and he was deemed to have dementia. This meant he was not allowed back where he had been living and had to be placed in a home for those with dementia with tragic consequences as he soon died.
The place he had lived happily for many years is still boarded up with none of the promised developments made.
What can be learnt from such outcomes is the need to listen more to the views of those affected. There had been opposition all along. Any move an elderly person has to make should be in accordance with their true and positive choice with minimal disruption.'
Supporting people to make choices
People's fears about moving, changes in care staff and increased charges will be very real and some will need intensive support. There must be sufficient, competent care practitioners to respond to residents' social and personal needs and choices, such as existing friendships with other residents, preferred geographical location and an ability of family and friends to visit. This period will also provide the opportunity for people to review the model of support they have chosen and consider alternatives. Some people may prefer to move to a different model of care such as extra care housing that may not have been an option when original decisions were made about residential care. Where people are considering alternatives to residential care, support services could include reablement.
It is possible that reassessment will reveal the need for people in residential care homes to have nursing care. This could have financial implications and increase the cost for the funding agency or for self-funders. In this latter case the lead professional will need to consider the financial arrangements on merit for each person so affected. (It should be noted that this problem should not arise if the needs of self-funders have been regularly reviewed during their stay.)
It is important that families are supported as they may feel anxious and worried. These concerns can range from seeking assurances about continuity of care, maintaining standards in the home and a concern for staff. It is likely that they will be concerned about personal aspects such as financial implications and a fear that their relative may be 'returned' to their care.
(Source: Social Care Association 2011)
Life story work
The aim of life story work is to enable people to affirm and maintain their identity and personhood through the creation of their own life story. This can be in any format that suits the individual best - photos, tapes, film clips, writing down their words - and is a way of capturing the things that have been and remain important to them in their life. As well as helping the person reminisce about their life, a life story book is a powerful way of bringing the person to life for staff working with them who have not known them previously. The model of using life stories is in line with policy initiatives to develop more person-centred care and enabling individuals to exercise choice and control. Knowing people better as individuals enables staff to provide more sensitive and appropriate care that can reduce frustration and agitation and therefore minimise the need for more intrusive forms of physical or pharmacological constraints.
Further information can be found at www.lifestorynetwork.org.uk
Local authorities will need up-to-date information about accredited providers, the availability of vacancies and agreed fee levels in formats appropriate to share with residents and relatives. Depending on local circumstances it may be necessary to seek information beyond the local authority boundary, for example in a small unitary London borough or where the home is located on the border of a neighbouring authority. Some residents may also want to move nearer to their relatives or friends which may mean finding alternative accommodation in a different part of the country. In these circumstances commissioners should liaise with their colleagues elsewhere on matters such as agreed fee levels. A local authority must arrange residential accommodation for an individual in accordance with their preferred wishes, provided that:
- the accommodation is suitable in relation to their assessed needs
- to do so would not cost the council more than it would usually expect to pay
- the accommodation is available
- the provider is willing to meet the council's terms and conditions. (Department of Health 2004)
Principles and rights
The wellbeing, needs and rights of vulnerable adults are paramount. This cannot be assured without appropriate communication and consultation with next of kin, and other formal and informal representatives of people who use our services.
Appropriate communication must take into account the language and communication mode appropriate to the individuals involved. Where possible, information should also be made available in a way such that individuals can reflect upon it after verbal communication is used.
Consistent and timely communication with all involved parties is necessary, as are secured and archived comprehensive written records.
Consultation with others is subject to obtaining informed consent from service users. Where an adult is unable to consent or make important decisions because of mental incapacity, the Mental Capacity Act 2005's code of practice and regulations will apply to financial, serious health treatment and accommodation decisions. Best interest decision making until then is subject to common law and case law.
Self-funders will be entitled to the same advice and assistance as others who are funded by statutory and voluntary organisations.
Agencies will need to work together and take account of the following principles when relocating vulnerable adults (bearing in mind this is more difficult in a crisis or in a situation where there is pressure and stress to make decisions and take action):
- minimising distress and disruption of services, including strategies for dealing with agitation, aggression or other forms of challenging behaviour
- least restrictive options
- respect for family life
- equality and diversity
- realising potential.
Interim moves can be disruptive for individuals and their families and these will therefore be avoided unless there are extenuating circumstances that make them unavoidable.
The importance of protecting friendship groups when planning and actioning new placements for residents will be recognised and individual and group preferences accommodated wherever practical.
All agencies operate within the boundaries of resource constraints. Realistic expectations and planning should be engendered that makes the best use of available agency and pooled resources.
(Source: Sandwell MBC August 2009)
Assessment and care planning
The assessment is the opportunity to ascertain and document whether and how needs have changed since the resident’s admission to the home. It also enables them and their relatives to express their wishes about where they want to move to and to be involved throughout the decision making process. An assessment should be obtained for all residents, including self-funders with their agreement. It should consider issues of mental capacity and any risk factors associated with the actual move from the home. Assessments of need are particularly important in situations of enforced closure because of poor care, when the quality and accuracy of care records cannot be relied upon.
Areas to be covered by the assessment process
- Cultural and spiritual needs
- Clients' views
- Circumstances of admission/changes since last review
- Health needs
- Mental health, emotional needs
- Personal care
- Social needs, personal relationships
- Relatives/carers views
- Home's' views
- Other issues
- Needs identified
(Source: Hertfordshire County Council, June 2010)
Residents who are funding their own care must be offered the same level of advice and support as those who are publicly funded. The duty to assess rests with the local authority of ordinary residence, although there might be scope to negotiate with the local authority where the home is located for them to carry out the assessment.
- Ensure that self-funding service users are offered the support of a care manager. The self-funding service user is free to decline the support of a care manager but this facility must still be offered.
- transport to a new home of their choice
- support in moving or transferring personal possessions
- accessing the same level of information on the closure process
- relevant support to carers and families
- details of vacancies within the area
- details of local advocacy services
- support in contracting with an alternate provider.
Choice and the Mental Capacity Act
The Mental Capacity Act requires everyone in the first instance to assume that the individual has the mental capacity to make decisions; a person must also be supported to make their own decisions, as far as it is practicable to do so. The Act requires 'all practicable steps' to be taken to help the person. It is a key principle of the Act that all steps and decisions taken for someone who lacks mental capacity must be taken in the person's best interests. The best interests principle is an essential aspect of the Act and builds on the common law while offering further guidance.
Residents who lack mental capacity and are 'un-befriended' in a home which is under threat of closure, or is being closed, may require an independent mental capacity advocate (IMCA). It is compulsory for the local authority and/or the NHS body to consider whether an IMCA should be instructed, so it is therefore advisable to give the IMCA service early warning that their service may be required. In respect of adult protection concerns, instructing an IMCA must be considered irrespective of whether that resident is 'un-befriended' or not.
Where the home closure is undertaken as an emergency and there is not enough time to commission an IMCA to support decision making, an IMCA should be used after the move to audit the decision making process and ensure decisions were made in the best interests of the individual.
(Source: Kent Adult Social Services, March 2010)
Mental capacity and advocacy
Enshrined in the Mental Capacity Act is the principle that people have mental capacity unless otherwise proven. Even when their mental capacity may be limited, they may still be able to make some clear choices or decisions. The Act emphasises the importance of supporting incapacitated service users to make decisions and has created a statutory entitlement to advocacy through specialist independent mental capacity advocates (IMCAs). In specified circumstances, IMCAs will support and represent people who lack mental capacity and have no family and friends to speak for them.
The legislation requires local authorities to refer individuals to the IMCA service where decisions about a change of residence are required, and local authorities may refer where decisions are required at a care review or where there are adult protection procedures. Local authorities and NHS bodies have a duty to instruct IMCAs where accommodation arrangements are being made on behalf of a person lacking mental capacity without friends or family.
( Source: Welsh Assembly Government 2009)
Working with families
'Priority must be given for holding an early meeting with relatives and representatives - build this into formal processes involved in assessment and care planning. In Northamptonshire, when we have any significant issues with a provider that cause us to place them in default we now insist on calling a meeting with relatives and their representatives so that they are clear as to the action we are taking and why. Whilst some resistance should be expected (some people see us as bureaucrats unnecessarily “sticking our noses in”), from experience I have gained following numerous closures and subsequent moves to better care homes, these relatives and representatives were simply ill-informed and had no idea of what they could reasonably expect - either from the care home itself or from the local authority.
Whilst it's more difficult to call a meeting when an immediate closure is required, there is a need to effectively communicate with all service users and their relatives/representatives effectively on a one-to-one basis using whatever means time constraints permit.'
(Source Phil Jones, Service Manager Contracting and Contract Management, Northamptonshire Social Services}