Case Study: Adult with Learning Disability

The case I have chosen involves a service user that has been with the agency for a while now. He was neglected and cut off from his family during his childhood and has since been longing for a secure attachment or contact with a “family”. His condition brings about a lot of anxiety and this has made him very unsettled.

I am placed with the Luton Borough Council Community Adult learning disability team. The team is a statutory agency; its primary function is to provide support to adult with learning disabilities and their carers. Service users and their carers are pre-assessed or screened under the Fair Access to Care eligibility criteria. This process ensures that services are tailored to meet the needs of the individual. It ensures that potential service users with critical and substantial risk, needs and support are not lost in the system. While adults with moderate or low risk needs are given advice and provided with useful information that will help them to meet their needs.

The legislation relevant to this case includes the National Assistance Act 1948; National Health Service and Community Care Act 1990; the Mental Health Act 1983 (as amended by the Mental Health Act 2007), the Human Rights Act 1998 and the Data Protection Act 1998.

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Relevant policies include the Fair Access to Care; which requires local councils to grade eligibility criteria into four bands of need (critical, substantial, moderate and low) based on the seriousness of the risk to independence if problems and issues are not addressed. Applicants for services are assessed using the new Single Assessment Process first outlined in the National Service Framework (NSF) which incorporates the eligibility assessment, care plan approach, annual assessment, placements, advocacy and referrals. (Royal College of Psychiatry Website, 2010, para. 4.10)

A Pen Picture of the Service User.

To protect the privacy of the service user and other individuals involved I have anonymised their personal details. This is in line with the provisions of the Data Protection Act 1998 and the Data Protection Policy of the agency. Section 6.2 of the Act, states that “local authorities have a general duty in common law to safeguard the confidentiality of personal information which they hold in connection with their social services functions” DoH (2000) p.34. This legal responsibility is managed through the Data protection policy of the agency and monitored by team managers. Specifically I have changed the service user’s name to Mr X and all other actors are also not named.

Mr X is a 31-year- old; male with mild learning disability and a borderline personality disorder. He was born in Luton but brought up in Hastings. By virtue of his birth and the fact that he was first accessed for social care services in Luton; Mr X is deemed to be ordinarily resident in the Luton area under the National Assistant Act 1948. Section 24.1 of the Act empowers and mandates local authorities to provide residential accommodation for vulnerable people (made vulnerable by disability or age) who are ordinarily resident in their area. [OPSI (2008) p. 2]

His parents divorced when he was five years old, he has had very little contact with them since then. He is the eldest of three siblings. He has had no contact with his only sister following allegations made by her against him of sexual abuse. Contact with his brother who currently lives in Hastings is limited to the occasional cards and phone calls.

Mr X’s childhood was characterised by upheaval and deprivation. As a result he has found it difficult to form attachment of his own due to constant changes in his living arrangements. In 1999, while living in Hastings, he expressed a wish to move back to Luton. He secured a tenancy with a local housing association and was given intensive support by the local independent living team. This arrangement soon broke down because Mr X craved constant attention. He indulged in self-Injurious behaviour such as self-harm and a tendency to set fire to property.

The tendency to self-harm is not uncommon in people with learning disabilities. Research recently carried out in a specific area of Wales by Lowe (2007 cited in Heslop & Macaulay, 2009, p. 13 – 14) found that 9% adults and children over the age of five using learning disability services were considered to self-injure.

Furthermore Heslop and Macaulay (2009, citing Haw and Hawton, 2008; Hawton and Harriss, 2007; Milnes, 2002) p.15 reports that people with multiple life problems are more likely to self-harm. Key amongst these is relationship problems with a partner or family member. Other problems reported include: problems with employment (including unemployment) or studies, and financial problems. This may explain Mr X’s tendency to self-harm.

In 1999, after a series of threats to end his life Mr X was detained in a local hospital under section 3 of the Mental Health Act 1983. This was to allow Mr X to receive intensive treatment in a protected environment. Without immediate treatment Mr X would have been a danger to himself by reason of self-harm and to others by his fire setting tendencies.

According to Rethink (2010) p. 1 & 4; “The Mental Health Act 1983 (as amended by the Mental Health Act 2007) is the law under which a person can be admitted, detained and treated in hospital against their wishes.” It goes on to state that Section 3 allows a person to be admitted to hospital for treatment which must be necessary for their health, their safety or for the protection of other people and it cannot be provided unless they are detained in hospital.

Mr X was treated successfully and was reintroduced into the community in 2002. Since then he has lived in several residential and supported living settings (from Wales to Birmingham). Coping with life in the community has led to self-neglect, the accruing of debt and at times anxiety. As a result Mr X still requires intensive support.

In Jan 07 he left his residential placement in Telford to look for his mother whom he hadn’t seen since he was ten, with the intention of developing a relationship with her. While waiting to secure a placement, he lived with his mother and her partner.

The relationship with his mother soon broke down due to his violent and threatening behaviour. On one occasion he threatened to set the house on fire and his mother had to call the police. As a result he was detained under section 2 of the Mental Health Act to reassess his mental health. His condition was such that if untreated he represents a risk to himself and other around him.

According Rethink (2010) p. 2; “Section 2 of the Mental Health Act 1983 (as amended by the Mental Health Act 2007) allows a person to be admitted to hospital for an assessment of his or her mental health and to receive any necessary treatment. An admission to hospital under Section 2 is usually used when the patient has not been assessed in hospital before or when they have not been assessed in hospital for a considerable period of time.” Detention under this section is for a maximum of 28 days. It cannot be renewed but can be followed by a Section 3 order. In Mr X’s case, detention under Section 2 was appropriate because he was last assessed in 2002.

After his assessment and treatment Mr X was released back into the community. He requested for a flat of his own close to his relations. With his approval a supported living placement that met his needs was identified and secured for him at a local address in March 2007.

Contact was made with the local learning disability service on Mr X’s behalf so he could have local support, should he become anxious. The psychology team and the learning disability nurse attempted to work with him on a regular basis, however Mr X explained that he would like to move from the area and therefore their services were not necessary. As a result the services were discontinued to respect his wishes as not doing so may be viewed as being oppressive in practice and a breach of his human right.

The respect principle of the Mental Health Act 1983 (as amended by the Mental Health Act 2007), states that the diverse needs of the service user must be recognised and respected; their views, wishes and feelings, so far as they are reasonably ascertainable must be considered and followed wherever practicable and consistent with the purpose of the decision. There must be no unlawful discrimination. (Law Summaries, Sherwood Directory 2010, p.20)

The Webster Online dictionary defines discrimination as “unfair treatment of a person or group on the basis of prejudice.” As social workers we are expected to be anti-discriminatory and anti-oppressive in practices. These principles are captured in National Occupation Standard and the GSCC codes of practice. In particular Code 4; emphasises the need to respect the rights of service users while seeking to ensure that their behaviour does not harm themselves or the people around them. GSCC, 2010, p. 9. While value D; emphasises the need to value, recognise and respect the diversity, expertise and experience of the individuals, families, carers, groups and communities. NOS (2010) p. 8.

Mr X then moved to Birmingham and lived there for just over 14 months, his skills have developed over this time particularly in handling domestic activities such as cooking, cleaning and some aspect of budgeting for healthy meal, however he is unable to know if he gets the correct change in a sale.

Thereafter Mr X moved to Northampton to be close to his family. At this point a review was carried out and a care plan implemented. Mr X expressed the desire to learn to drive, do some voluntary work in the community and have a relationship. He undertook to stay in this accommodation for at least 3 years to engage in extended personal development.

But he only lived at the above residential home for a year. He found it difficult to settle and found the change of staff difficult to deal with. During his regular review Mr X agreed with the support of his advocate to be part of getting life programme, where he would be assessed on what he would like to do in future; as he had a desire to return to the Luton area he refused the offer. He recently abandoned his placement in Northampton and moved in with his maternal uncle. He has been in touch with the Luton council to request a placement in the Luton area. This move is Mr Xs interest at the moment.

From his records, his current support needs centres mainly around his personality disorder. He finds it difficult to get along with other residents and often complained of being scared of the people around him. This makes him anxious and restless, creating a desire to move again.

Whenever he feels events are not consistent with his expectations i.e. his desire to move, he becomes agitated. This leads to numerous phone calls to social services, the police and anybody he can get on the end of a phone line. Recently he threatened to take his own life by jumping off a bridge or taking an overdose.

This desire to constantly relocate has made it difficult for him to engage in extended personal development activities necessary for him to develop the interpersonal skills he requires. In addition he has not been able to establish long-term social links of his own.

The Placement

I was placed with the Luton Borough Council Community adult learning disability team. The team is an integrated team made up of various professionals including social workers, community care workers and community nurses. It provides a “One stop shop” / “Single Access” point for the teams’ target group, which are adults aged 18yrs – 65yrs with learning disabilities and their carers, who live within the Luton Borough Council area.

The role of the team within the social welfare spectrum is to provide comprehensive assessment of the needs of people with learning disabilities and their carers, which forms a basis for developing a package of support (care plan) to meet the assessed needs. The team also monitors the care plan through regular reviews to ensure that the plan has been properly implemented and that it is still appropriate. Changes are made to the care plan where appropriate.

Other services available through the team include:

• Advice and referrals to other services, such as day-time activities, supported employment or residential care, specialist health services
• The provision of specialist nursing services
• Assessment of carers needs and sign posting to relevant support services.
• Support for young adult transiting from children service to adult services
• Support for service users to access community based services.
• Coordinating the safeguarding of venerable adults process etc. (Luton Borough Council website.)

Referral is a very important part of what the team does. Many service users come to the attention of the team by way of referral from other professionals such as GPs, teachers etc. Also the team refer service users to other support agencies. For instance; service users who require employment (paid or voluntary) are referred to D4; a career support team within the Luton Borough Council. They assist service users to write their CVs, carry out job search, prepare for interviews and provide on-going supporting for service users in employment.

The team promotes anti-discriminatory practice and is committed to continuous improvement in the delivery of its services.

The Legal Mandate of the placement Agency

The legal mandate of the Luton Borough Council Community adult learning disability team derives from the National Assistance Act 1948 and the National Health Service and Community Care Act 1990.

The National Assistance Act 1948 gives “…local Authorities the powers and duties to promote the welfare of people ordinarily resident in their area that are blind, deaf or dumb, mentally disordered or substantially and permanently handicapped by illness, injury or congenital deformity (sec 29)” (Sherwood Diaries and Directory (2010) p. 11).

The NHS and Community Care Act 1990, “… signified an important development in the philosophy of community care and in the delivery of service called for in other legislations” (Sherwood Diaries and Directory (2010) p. 16)

Unlike previous legislation the NHS and Community Care Act 1990 lays emphasis on an assessment led care management approach (CPA) that is shaped to fit individual needs; in contrast to previous practice of “categorisations” of service users to fit pre-defined service packages. To succeed this approach requires a partnership between professionals (social workers etc.) and carers in assessing the needs and designing individualised / person centred care programs.

The Act also requires service providers to take into consideration the wishes of the service user in determining the type and level of any service required. This can lead to several conflicts some are discussed later in this paper.

According to Powell (2001 para. 15); the Act gives legal backing to the concept that the primary function of the public services should be to design and arrange the provision of care and support in line with people’s needs. That care and support can be procured from a variety of sources. There is value in the multiplicity of provision, not least from the consumer’s point of view, because of the widening choice, flexibility, innovation and competition it should stimulate. In this arrangement, it is vital that social service authorities see themselves as arrangers and purchasers of care services – not as monopolistic providers (Griffiths Report 1988: para. 3.4).

The current delivery arrangements adopted by the Luton Borough Council have a more recent history. Its origins can be traced to the Health Act of 1999 which sought to remove the “Berlin Walls” hampering collaboration and cooperation between various agencies by introducing a number of flexibilities into health and social care delivery. One such flexibility is the “One Stop shop” or “integrated provisioning” concept, through which health and local authorities provide a combined service through a multidisciplinary team.

Initial assessment of potential service users is carried out against a set of eligibility criteria known as the Fair Access to Care Services (FAC). There are four eligibility bands under FAC. Namely critical, substantial, moderate and Low. Each band represents a level of need. Priority levels are assigned based on the likely consequences if the needs of the service user are not met. The amount of help available from family and friends are also taken into consideration.

After the initial assessment, a care plan is prepared for people who meet Luton Borough eligibility criteria. The care plan documents what the service users’ needs are and the way in which these needs will be met. The care plan is agreed with the service user, their family and all those involved in providing care to the service user such as, nursing home, residential home etc.

The Legal Status of the Subject

Mr X is an adult with mild learning disability and personality disorder. Having gone through our eligibility criteria / screening; a care plan was developed for him. His care plan is reviewed regularly and his input is sought to ensure that the plan is relevant and continues to meet his needs and aspirations.

Sometime in 2007, he was detained under section (2) of the Mental Health Act, due to his violent and threatening behaviour to his mother and those around him. He threatened to set her house on fire and to kill himself. The aim of the detention was to carry out an assessment and provide the necessary treatment. He has since been discharged back into community care.

As his behaviour in recent times have not been violent or of any serious concern; there is currently no plan to detain him unless there is a serious deterioration in his condition.

Critique of the Social Policy Initiatives Relevant To My Placement Agency and the Subject

As mentioned above the NHS and Community Care Act 1990 marked a watershed in the development of social care policy in the UK. It was the first attempt to bring in the concept of marketisation into the provision of social care services. (Brambleby 2009, para. 15)

According to Powell (2001) para. 18, “Community care was to be used as a vehicle for the marketisation of the public sector. Thus, a ‘contract culture’ was applied to the provision of personal social services and social services departments would need to develop processes to specify, commission and monitor services delivered by other agencies. (DoH 1989: p. 23)”.

The prevalent wisdom at the time was that marketisation will encourage improvement in the quality and scope of services provided, promote innovation, lead to reduction in cost and provide greater choice for the service user.

The policy which is based on the triumvirate of ‘autonomy’, ’empowerment’ and ‘choice’ was endorsed by many commentators as the political and philosophical panacea for alleviating the deep and destructive problems confronting the community care system in the UK (Levick 1992, cited in Powell 2001, para. 1)

Many commentators have raised issue with the NHS and Community Care Act. For one many of the advantages advanced for the marketisation of the Community Care services were not achieved immediately as the process of these organisational changes were immensely complex (Powell 2001 para. 20).

Another flaw in the NHS and Community Care Act 1990 was that the specific grant diverted to local authorities in order to implement the outcomes of individual assessment and encourage the generation of services in the private and voluntary sectors was only ring-fenced in the short term. (Powell 2001, para. 18)

This has had specific and wide reaching effect on people with mild learning disability as local authorities are required by law to address available resources to those with greatest need. In situation where there is high competition for resources those with mild learning disabilities are often neglected.

Eligibility criteria are another area where the law is a bit unclear. According to Spencer-Lane (2010 para. 7);

“Once a local authority has completed an assessment, it must decide whether or not to provide services. Under the current law, eligibility for services is determined by reference to statutory guidance (Fair Access to Care Services (DH 2002) and Health and Social Care for Adults (WAG 2002) and often-overlapping statute law, such as the National Assistance Act 1948 and the Chronically Sick and Disabled Person’s Act 1970. In our view this structure is complex and at times impenetrable.”

According to the Law Commission Report (2008 p. 28) this has led to two main criticisms of this framework:

it produces wide local variations in eligibility for services: for example in 2006-07, a report by the Commission for Social Care Inspection found that 62% of councils in England operated at the highest two levels of substantial and critical; 32% included moderate needs; and 6% included all four bands;

This has led to local authorities increasingly restricting services to those with the highest levels of need. According to the same report: 4% of councils confined their help to the critical band only; councils raising their eligibility thresholds to substantial increased from 53% to 62% in 2006-07; and the trend is expected to continue as 73% of councils anticipate that they will be operating at substantial or critical levels in 2007-08.

The National Assistance Act mandates local authorities to provide accommodation for people with learning disabilities who are ordinarily resident in their area. This is good in the sense that it protects vulnerable people from becoming homeless. This is particularly true in the case of Mr X. However, Mr X may be viewed as taking advantage of the system by refusing to settle and engage in the community. He is aware that the agency is mandated to meet his housing needs and therefore uses that as a weapon whenever he wants extra attention.

This type of behaviour has significant implication for services delivery. According to Dobson (1999) p. 2, “many patients can not get the treatment and care they need partly because the system has found it so difficult to cope with the small minority of mentally ill people who are a nuisance or a danger to both themselves and others.”

One way to check this problem is to ask the more able service users to sign a charter which gives them certain responsibilities, such as the attending day centre and other developmental activities in return for certain privileges. Failure to abide with the charter should result in the withdrawal of these privileges. The additional cost associated with providing these privileges will be paid for by the time and resources freed up to deal with other cases.

Human Rights and Data Protection

The Human Rights Act (1998) effectively gives legal bite to the rights contained in the European Convention on Human Rights. The major rights relevant to the agency and the subject are

The right to life; every life is equally important. A disability does not make a service users’ life less important than anyone else’s.

The right to respect for private and family life; guarantees each individual the right to live as part of a family. For instance this gives gay and lesbian couples the same rights as other couples.

The right to dignity and being part of the community; guarantees each individual the care and support they need to have a good life. This means that people with disabilities should be able to join community activities along with everyone else.

(Sherwood Directory, 2010, p. 23)

The Act is there to ensure that statutory bodies such as local authorities, schools, the police, the courts and hospitals can and actually protect the rights of people with disabilities. The right to dignity is relevant to decisions about placements, accommodation and other services; it requires service providers to as far as is possible take into considerations the wishes of the service user.

This concept of choice is central to “Valuing People” a government white paper published in 2001 and updated in 2009. The proposals in the White Paper are based on four key principles: civil rights, independence, choice and inclusion. Valuing People takes a life-long approach, beginning with an integrated approach to services for disabled children and their families and then providing new opportunities for a full and purposeful adult life. It has cross-Government backing and its proposals are intended to result in improvements in education, social services, health, employment, housing and support for people with learning disabilities and their families and carers. MKADHD (Undated) para. 15.

As a result Luton Council is duty bound to continue to consider Mr X wishes to move even though it is costing the council a lot in terms of money and time. Another important consideration is that “under the Human Rights Act 1998 victims are allowed to bring action against a local authority if it has acted in a way which is incompatible with the terms of the articles of the European Convention on human rights” (Brammer 2007, pg. 110).

Applying this to the case; Mr X left the residential placement provided by the council deliberately making himself “homeless”. He refused to wait for the team to secure another suitable placement before leaving his current placement. He currently resides with his uncle (somewhere in Luton) but claims to be homeless. Mr X has threatened to harm himself and is now threatening to sue the local authority for not providing him with another accommodation.

As far as the Agency is concerned Mr X made himself homeless deliberately because he is deemed to have capacity; having been assessed under the criteria set out in the Mental Capacity Act 2005. The assessment was carried out to ensure that Mr X had capacity at the time. Under the Act, a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain. It does not matter whether the impairment or disturbance is permanent or temporary (Beresford and Sloper, 2008, p.40)

The Data Protection Act 1998 “provides individuals with new right of access to their personal data and imposes new obligations on data controllers; such as local authority social services department to operate good data storage practices and this applies to both electronic and manual records. (Brammer, 2007, p. 114). However, the Act gives the agency the right to retain information about the service user to be able to carry out its statutory duties and obtains the consent of service users or their carer to do so. The agency is required to appoint a data controller whose duty is to ensure that personal data is only used for authorised purposes and data not required is destroyed in the prescribed manner.

Applying this to the case I have not used Mr X’s original name. Information personal to Mr X have been made anonymous. Electric and manual information obtained in the course of putting this work together were duly authorised by the appropriate authority and manual documents have been destroyed in the prescribed manner. The case has been put together in such a way that it does not create any link to the actual service user.

The service user raised a few SOVA (Safeguarding of Vulnerable Adult) issues. The Care Direct Factsheet (2007, p. 1) defines abuse as “…a violation of a person’s human and civil rights by any other person (s). It may: be a single or repeated act(s); be physical, verbal, psychological, sexual, institutional, discriminatory or financial; or may be an act of neglect or failure to act.” The fact sheet defines a Vulnerable Adult as someone aged 18 or over who is, or may be:

In need of community care services because of mental or other disability, age or illness and

Unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation.

When an abuse is reported local agencies are required to treat each case with the utmost urgency to ensure the alleged victim does not suffer any more abuse. The agency has a multi-agency protocol that is followed in each case; to ensure urgent and appropriate action is taken. The police are almost always involved to ensure a record of the abuse is maintained for future reference. Advocacy, community support team etc. may also be involved. Each case must be dealt within 24 hours of the receipt of the report. Thereafter a strategy meeting of the relevant agencies is called to review the situation and agree a coordinated approach to deal with any outstanding risks.

In the case of Mr X, the Police were invited to investigate his allegations. No further action was taken as none of the allegations could be verified. Advocacy was involved to ensure that his worries and concerns were well communicated to the Police and his service providers. He was also advised on the steps he can take should he feel unsatisfied or unhappy with the outcome.

A critical analysis based in a policy critique of services provided by the Agency.

The agency policy on assessment and residential placement is very well structured; they define the agency duties, responsibilities, roles and boundaries. Initial assessment allows the agency to gain a clear picture of the service users’ condition and situation. The assessment includes detailed personal information regarding the service users’ relationships, any significant events and current situation. This provides the baseline for the assessment against the fair access to care services eligibility matrix.

One critic of the process is that it is open to abuse. The more able service users can master the process and thereafter exploit the lope holes in the process. In some ways one can argue that, Mr X has reached this critical point. He is very much aware that whenever he raises a red flag someone gets into trouble; as such this has become one of his favourite games. He makes up stories and keeps changing his stories as long as they lead towards his desired goals.

I believe that having a detailed long-term plan is critical to maintaining the support required by the service user. One short coming of this process is that not much seems to have been done in addressing the underlying issues i.e. his desire to move regularly. Perhaps Mr X’s care plan could be designed in such a way that he is allowed to change placement every 18 or 24 months. Putting this plan in place will allow the agency to plan ahead and ensure continuity of his development plan. One approach maybe to make sure that each successive placement has the facility to continue his development from where he left off at the previous placement. This approach is in line with the “Valuing People Now” white paper (DoH 2009, p. 6) which requires agencies to treat each services user as an individual, with the same opportunities and responsibilities. Each care plan should be individualised and does not necessarily have to fit with the norm.

On the other hand the current approach is costing the agency so much in terms of time and money as every care plan review involves going out to visit his current placement and visiting new ones to pick a new placement that meets his needs. This often means that resources have to be withdrawn from other tasks to handle his situation as it is often presented as an emergency. In addition each time he leaves a placement a new budget has to be put in place; this could create confusion especially with budgeting.

One of the setbacks in this policy is that while some people who need help are not reached or given enough attention others who know the system abuse it