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Good Practice: Adults
This assignment will focus on a case from practice, demonstrating the challenges in promoting independence specifically in vulnerable elderly adults while balancing risk and autonomy. Furthermore, this work will demonstrate problem solving skills, drawing on legislation, research and principles of good practice in the context of Adult Services from an inter-professional perspective.
The Department Of Health defines a vulnerable person as:
“Someone who is or may be in need of community care services by reason of mental or other disability, age or illness and who is or may be unable to take care of him or herself against significant harm or exploitation.” (DOH 1999).
Background of case:
Mrs A is eighty two years old, has mild learning difficulties and lives alone in her own home since the death of her husband one year ago. She has a daughter who visits occasionally due to their difficult relationship. Mrs A was referred by her GP as she had been feeling unwell for some time; she has diabetes and sometimes forgets to take her medication. Mrs A has refused help in the past by various care services due to lack of trust and sees their involvement as an intrusion in her private life.
Working within the field of the elderly in adult social services is described as Gerontological Social Work (Nathanson and Tirrito 1998). There are specifics needs that older people experience, the more informed a social worker is about the elderly and their requirements the better chances are that the social worker will provide the right services.It is essential to gain a clear understanding of economic, social and cultural factors and life perspective followed by an understanding of the need for service.
The Valuing People policy is the first White Paper in almost forty years since Better Services for the Mentally Handicapped (1971).The aim then was to close large institutions and to integrate people into the community (www.mind.org.uk). Valuing People aimed to transform the lives of adults and children with learning disabilities through a person-centred approach and to enable people to become empowered in order for them to be included in society. This policy is one in a series of policies that are an example of the political driver of change such as the White Paper, ‘Our Health, Our Care, Our Say: A New Direction for Community Services (2006) that are aiming to transform social care and to give service users more choice and to make the system more personalised (Johnson & Williams, 2007).
The 1989 White Paper, ‘Caring for People’ states the duties of local health authorities to assess people needing social care and/or support. It is based on the assumption that community care is the ‘best’ form of care available. The White Paper states that the proposed changes are intended to, first of all, enable people to live as normal a life as possible in their own homes or in a homely environment within the community. This is especially important in the long-term needs of the elderly, whom have long expressed their wish to be able to stay in their homes. Furthermore, local authorities must provide the right amount of care and support to enable people to achieve maximum independence and provide people with a greater say in their lives and the services they need. This is particularly significant with elderly people. Many older people are not in need of 24-hour care that a nursing home would provide they may just need a small amount of help, maybe for a couple of hours a day.
Although the majority of people over the age of 65 live independently and have no major care needs, a significant minority do have some problems with physical and mental health. 1 in 10 elderly people suffer from forms of senile dementia. It can be seen that it is simple day-to-day things that most elderly people require assistance with. Their main wish is clear; they simply want to stay in their own homes or in the homes of their family. (HMSO 1989).
The Social Worker requires Mrs A’s consent to an assessment and if eligible, a care plan, while making it clear that she has the right to refuse. When working in partnership with a service user and their family, the worker needs to take account of Trevthick’s (2002) fifteen points to effective partnership working. These include explaining to the family their role and power to intervene. A clear mandate is the basis of a partnership-based intervention and sensitivity given to power imbalances involving family consultation and participation in decision-making and problem solving (Bray 2001). The whole team working with Mrs A have a duty to be aware of her individual rights to confidentiality, choice, dignity, respect, autonomy, cultural, and equity.
“Elderly people need to be active participants rather than active recipients. The task is not to look after, but to motivate, empower and promote self-esteem.” (Hughes et al 1995).
A number of vulnerable adults are oblivious to the fact that they need any help; therefore it is essential that when a concern is highlighted, it is acted upon instantly to prevent the situation deteriorating. Many adults are also too proud to ask for help and as a result recognition of their vulnerability is only identified as shown in Mrs A’s case by a GP. Detection of vulnerability may also be triggered by an admission to hospital or a concernedfriend or family member contacting the social services department. During a visit by the social worker, it is clear that Mrs A had been seriously neglecting her needs; she is underweight and neglecting her hygiene. The misuse of medication is in itself a risk of covert self abuse, and could have resulted in her death.
Abuse can take place in many different contexts and it is important not to exploit a vulnerable persons civil rights. Mrs A has mistrust with other people becoming involved in her life. Therefore when and how to intervene builds on the concept of significant harm introduced in the Children’s Act. When making an assessment of an individual, many factors need to be considered, for example, the extent of vulnerability and risk of repeated acts that meet the criteria of the Community Care Act 1990. To ignore the assessment of older people can be an example of ageism in its own right, contributing to an elderly person feeling disempowered.
Assumptions about older people include older people are poor, lonely, are ill, no longer contributing to the economy and seen as a burden. When working with older people it is important not to make these stereotypical assumptions and generalise. Not all the elderly have the same characteristics; a sixty five and a ninety year old are classed as one group. “Although aging is inevitable, and people experience similar patterns and problems of aging, there are also wide-spread differences in aging patterns” (Applewhite 1998:5). Acknowledging that each individual will be at a different stage in his or her life, needs and circumstances will vary, including different ethnic minority groups to avoid making ageist assumptions and avoiding all stereotypes and stigmas. To work effectively with older people, one must develop anti ageist practice. Midwinter (1993) says that old age is like having returned to a second childhood where others will make decisions for you.
Working in partnership, the Social Worker and the GP/nurse may encourage Mrs A to engage respite care (enablement) for up to six weeks to avoid being admitted to hospital. During respite care an assessment of her needs will evaluate the level of support that will be required (if any) when Mrs A returns to her home. Mrs A’s daughter may request that her mother be put into a care home, while Mrs A is adamant that she can care for herself at home with some support. Within the risk assessment process family members may worry about the social worker’s ability to recognize potential risk for their relatives, therefore a balance between extending barriers in some areas of risk and minimizing risk in others areas needs to be made. Using a utilitarian approach, it is the social workers job to assess the whole situation and work for a solution in the best interests of all concerned. (Banks 2001:28). The Social Workers ultimate aim is to support Mrs A’s rights to control her life and make informed choices about the services that she receives (GSCC 1.1).
Good practice dictates working in partnership with service users to encourage greater trust and empowerment of clients. In turn, they are likely to feel more confident in talking about their fears, and worries and possible abuse. Health and Social care agencies working together is only a part of an overall strategy to protect vulnerable adults from abuse. Enabling service users to recognise abuse and knowing how to alert others to this is another strategy. It also ensures an agreed approach that all involved are aware of and can monitor. Protection is provided by the clarity of the situation. It is important that health and care social workers act as good role models in terms of worker-user relationships as this helps the service user to recognise when the relationship is abusive. In addition, it is important for professionals to enable service users to know how to protect themselves, such as building positive self-esteem through knowing their rights and knowing how to complain. (Public Interest Disclosure Act 1998).
An Adult Protection policy will identify and help support Mrs A’s decisions for her care and help her to understand risks and the services available to her. The social worker has to constantly question their own judgement and ensure they listen to the service user’s view while assessing if Mrs A is capable of making an informed choice taking into account her rights and the needs of her family. It is a requirement to assess if Mrs A has the capacity to make her own decisions and if she is incapable by reason, for instance, of mental illness under the Mental Capacity Act 2005, the decision will be made for her. If it is deemed that Mrs A has capacity she has the right to live in whatever way she chooses; should her choice includes staying at home without help from services her health could be at risk and she may enter a ‘revolving door’ policy in and out of health care provision.
Providing support to Mrs A does not eliminate her susceptibility. If an individual is living alone and receiving services to support their needs, they still have a level of vulnerability. Elderly people at home are more at risk from abuse by strangers than if they were living in supported accommodation. They are at risk from people calling and gaining access through force or intimidation, who either steal from them or charge very expensive rates for minor repairs. They are also at risk from physical and sexual abuse as there is no one there to stop the perpetrator. Mrs A has health and social care needs and is seen to be at risk from self-neglect and possibly neglect by others, including services if insufficient or inappropriate support is provided to adequately support her well being. (Pritchard, J 2008).
Home may be Mrs A’s choice, however the assessment will consider balancing risk and autonomy. The social worker can identify Mrs A’s strengths and skills and identify ways in which these can be improved upon. There are services available that can supply security systems to protect from theft, and physical abuse, and other environmental variables, these are implemented with clear guidelines and the coordination of multi agency workers, working together to deliver a programme of care in the best interest of Mrs A’s needs and individual choices. Parsloe (1999) stresses that there is a strong presumption that older people should exercise choice and be given opportunities to take risks towards maintaining their independence and self-determination unless or until their capacity to do so is seriously impaired. This notion is acceptable, but as seen with Mrs A there is also a high risk of illness due to poor self medication; this is sometimes overlooked as the risk-taking model is more promoted than risk minimisation. People are allowed to take a well-informed risk so long as they do not endanger themselves or others GSCC (2002). A presumption in this case is that Mrs A has capacity: the challenge here is to recognise that service users ‘have the right to take risks and helping them to identify and manage potential and actual risks to themselves and others; (GSCC 4.1).
The provision of the practice setting is governed by law which consists of primary and secondary legislation together with government guidance which must be followed by all local authorities. Section 46 of the National Health Service and Community Care Act (1990) sets out community care plans and lists the available services which include laundry services, meals on wheels, social work support and residential care. This act places a duty under section 47 on social workers to conduct a needs-led assessment if it is apparent that a person might need community care service.
Once a community care assessment is carried out, the care manager will make a decision about whether to provide support or not to the service user. Fair Access to Care Services (FACS) provides an eligibility framework for adult social care to identify whether or not the duty to provide services is triggered. Should the criteria be met, a multi disciplinary team approach working together to ensure Mrs A’s choice to stay at home is paramount with regard to her rehabilitation and care plan. The team have a duty to provide a network of support that promotes independence and to monitor Mrs A’s ability to care for herself in the community. Multi-agency working of care planning and the single assessment process has encouraged greater inter-agency working together, with the client’s needs being central to the process. Rather than working separately, and each agency providing their own service without reference to the others, joint working encourages a sharing of approach and less replication of services.
A pilot of Individual Budgets was introduced for two years in 2005 to 13 local authorities. Individual Budgets is a system that brings resources together from different funding streams into a single sum that can be spent flexibly in accordance with a service user’s needs and preferences. Service users are free to choose the money as a direct payment or request the local authority to provide services, or even use a mixture of both A care worker can be sought from the LA or a personal assistant (PA) appointed by Mrs A , paid for with direct payments ensure that her autonomy and choice is maintained. In practice, an agreement can be made to review Mrs A’s care and remove the care if it not required or increase the care package should additional need be identified at a future review.
Direct payment stems from the four principles of Valuing People that are rights, inclusion, choice and independence. The Government’s vision was that the uptake of direct payments would give people more choice in how they choose to live their lives. However, the uptake of direct payments since the introduction of the Community Care (Direct Payments) Act (1997) had been slow, mainly due to a lack of awareness and people, including professionals, can be very wary of change and taking on the unknown.The government therefore introduced new legislation in 2003 to make it a duty for local authorities to offer direct payments (www.dh.gov.uk), but figures (2006) reveal that out of a possible million people only around 46,000 had taken up direct payments (www.eastern.csip.org.uk). It raised issues that service users experienced and set out eleven objectives which included people facing lack of choice and control, social isolation, housing, health, and poor partnership between professional agencies, voluntary groups and families.
The main stakeholders from the implementation of Valuing People are people with learning disabilities themselves and their families/carers, as they were instrumental in pushing the government to push through the policy.The government is clearly one of the main stakeholders and it could be argued that this was an economic driver of change. Latest figures from the Individual Budgets Pilot study reveal that the costs of people using budgets compared to commissioned services is not much different, but long-term, costs will be reduced as people become more independent and their support hours are reduced (www.dh.gov.uk).
The introduction of ‘Putting People First’, published by the DH in December 2007is a shared vision and commitment to the transformation of adult social care over a period of three years. Key elements are: prevention, early intervention and re-enablement, personalisation, information, advice and advocacy. This presents change for people who receive services and importantly for social care workers that will need to implement these changes in their work. The changes in social care that have been taking place since the policy have meant that the role of the social worker is changing and the publication of the Local Authority Circular “Transforming Social Care” (2008:4) described the role of the social worker as being “focused on advocacy and brokerage, rather than assessment and gate keeping”. This involves improved skills in listening, working in partnership with service users, families and other professionals and empowering people to take control of their lives. The changes are proving challenging because it means a shift in the balance of power and allowing people to take more risks. A person-centred approach to supporting Mrs A is the method used within this case study, before direct payments this had been more about supporting people in the community.
The principles ofrights, inclusion, choice and independence set out as the vision in Valuing People have clearly been achieved in some people’s lives, and is effective for service users such as Mrs A who prefer to maintain their privacy at home and choice of care through direct payment. It can be seen to transform service user’s lives in that they are living independently and feel included in society.There are many people living in residential care; they spend most of their hours in centres and lead very oppressive lives.McCabe,M. (2006:12) describes the failings of institutional care as having “inflexible routine, lack of choice, dependence on others and lack of privacy” and community care creating maximum dependency.However, care needs to be taken so that people are still supported when they do live independently, specifically service users who have spent years in residential care and not prepared them to live in their own homes; adequate risk assessments are needed to address any areas that could leave them vulnerable.
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National Assistance Act 1948 London, HMSO.
National Health Service and Community Care Act 1990 London, HMSO.
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Public Interest Disclosure Act 1998 London, HMSO
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