Case Study on 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 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.

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 users 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 Xs 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 Xs 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 hadnt 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 Xs 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 Xs 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 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 peoples 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 consumers 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 , such as the National Assistance Act 1948 and the Chronically Sick and Disabled Persons 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.