Learn, Do Not Copy!

Assess the Individual in Health and Social Care Settings: Sample Essay

Leading an Initial Assessment

By Daniel Dutton (September 2019)

In this essay I will be reflecting on a recent initial assessment for a new referral to my organisation in which I took on the lead role to ensure a smooth transition. 

I will also explore other forms of assessment and explain the importance of using active participation, person-centred approaches and outcome-based approaches throughout the process. Partnership working with clients, their family and other professionals will also be discussed as well as the methods I used to disseminate information and lead and manage my team during the period of change.

To protect the confidentiality of the individual that I assessed, he will be referred to as X throughout this essay. To aid clarity, accounts and reflections of X’s assessment are written in italic text with supporting information and theory written in normal text. 

Prior to X’s referral, I held the position of team manager for a single client in a supported living environment receiving 24-hour care and support services. He rented a six-bedroomed three-storey home from a private landlord and was looking for a housemate to share rent, bills and household responsibilities. My organisation had already attempted to find a suitable potential housemate for him on two previous occasions but they had both fell through for various reasons. 

Following X’s referral to my organisation, our clinical team believed that he would be a good potential housemate for my existing client and, as I would be managing his services, I was tasked with leading his transition and initial assessment.

I initiated the process by contacting X’s social worker to get some background information and arrange a meeting between all current stakeholders to discuss the transition. She informed me that X was a young adult with diagnoses of Attention Deficit Hyperactivity Disorder (ADHD), Autistic Spectrum Disorder (ASD) and a Learning Disability (LD). He had been living with his family until around six months ago when social services had to intervene because the home environment had become very difficult for the whole of the family unit due to tensions in the relationship between X and his mother. In the interests of the welfare of all members of the family, X voluntarily relocated to temporary accommodation in a residential setting for individuals with LD, whilst a more permanent solution was arranged.

The social worker said that she would contact everybody involved with X’s care and arrange a meeting to discuss how we would move forward. Upon arrival at the meeting, I was formally introduced to the social worker, a representative from X’s support team at his current residence and three members of the Intensive Support Team (IST), which comprised of a healthcare assistant, a psychologist and an occupational therapist (OT). Joining me was an OT from my own organisation. The IST is a small National Health Service (NHS) department that works with individuals with learning disabilities (particularly those with challenging behaviour) to support them to manage the difficulties in their lives and help prevent unnecessary hospital admissions.

The professionals at this meeting represented a varied cross section of public and private sector workers as well as both health and social care workers. Inter-agency partnership working can provide a more effective assessment process and delivery of care because it can reduce the repetition of work both on the part of the professionals (assessments) and the individual receiving care (form filling). In my own area of work, the individuals that I support often have complex needs, therefore partnership working is essential so that they are able to access specialist services easily and have more choice and control over the services that they use. There is also evidence to suggest that working in this way can cut emergency hospital admissions and delayed discharges (NHS, 2020).

To exemplify partnerships working well, I was informed in the meeting by X’s psychologist that X had been deemed to not have the mental capacity to manage his own finances and so had an appointee in place. By sharing this information, including the relevant paperwork with my organisation, it meant that we did not have to duplicate this work by performing our own assessments around money management (although we did make our own observations to ensure the accuracy of the information we were given).  

The government recognise the importance of partnership working and have, in recent years, embedded it into policy. The Health and Social Care Act 2012 along with the Care Act 2014 legislate that health and social care services should collaborate and share information and the Health and Social Care Integration Briefing Paper (Parkin, 2019) explores recent changes to policy in this regard and the challenges of integration.

The National Service Framework for Older People (Department of Health, 2001) introduced the Single Assessment Process (SAP) which has been used to integrate health and social care by providing a single point of entry and a person-centred assessment framework for the older generation. There have been proposals to expand the SAP framework to other adult groups such as individuals with learning disabilities or mental health conditions in the form of a Common Assessment Framework (CAF). As stated in the government publication ‘Our Health, Our Care, Our Say’ (Department of Health, 2006), “Assessment Framework is in place for children’s services. We have already developed a Single Assessment Process for older people’s services. Work is underway to build on this to develop a Common Assessment Framework to ensure less duplication across different agencies and allow people to self assess where possible.” This also includes the integration of the Care Programme Approach (CPA), which is used by mental healthcare professionals to assess an individual’s psychiatric symptoms and experiences, their psychological thoughts and behaviours and their risks and safety. Although these forms of assessment provide a person-centred approach, coordination and choice, care must be taken to ensure that personal information is only shared with those that need to know it to prevent breaches in confidentiality and, consequently, the Data Protection Act 2018.

Although these methods of assessment are being used for specific demographics or in certain geographic locations, there is no single process or theory in wide use in the health and social care sector. This means that the methods used by different stakeholders can vary leading to fragmentation in care planning and delivery. However, it also means that stakeholders have the opportunity to be flexible in the way that they assess each individual, which can lead to a more person-centred approach. 

Smale et al. (1993) suggest three models that can be used in care planning. The questioning model is service-led and facilitated by the care professional. They ask questions and listen to responses before formulating a plan. The procedural model is also service-led and involves using checklists and criteria so that the care professional can judge which services are a best fit for the individual. Finally, the exchange model views the individual receiving care as the expert in their own care needs and is a far more holistic and person-centred approach.

Historically, a needs-led assessment process has been used which focuses on an individual’s immediate health and social care needs and attempts to pigeon-hole them into an existing service that may be the ‘best-fit’ but holistically not suitable for their unique requirements. This is similar to how the procedural model works. 

Modern approaches such as the exchange model, SAP, CAF and CPA are far more person-centred and outcome-based, which can provide far more choice to the care receiver, takes into account their holistic needs and benefits from different agencies working together towards the same goals.

My own approach utilises the exchange model and has a foundation in Taylor and Devine’s (1993) cycle of assess, plan, implement and review. During the assessment stage, I identify all potential partners that may be able to provide information about an individual’s needs and arrange to speak to them individually or in a group to discuss how best to provide care and support services. This is performed in conjunction with my organisation’s transition checklist (Appendix A). The individual receiving care is the primary partner in this process and so is encouraged to actively participate in the process and is invited to all meetings about them. Care plans are developed based on this information and then implemented. An individual’s needs and wishes are constantly changing so care plans must be reviewed regularly to cater for this, restarting the cycle.

Because I try to encourage the active participation of the individual that is receiving care at all stages of the referral, assessment, transition, care planning and care delivery processes I was concerned that X was not present at the initial meeting. I was also concerned that X had no representation from either their family or an advocate, so I questioned the social worker as to why this was the case. I was informed that X had declined to come because he was shy and did not like large groups. And that the main representative from his family (his mother) was currently in hospital and so was unable to attend. The support worker from his current accommodation informed me that they had spoken to X and would advocate on his behalf, however this presented a possible conflict of interest to me.

As well as involving the care receiver in all aspects of their care planning, it is also important to have effective working relationships with their significant others such as family, friends and informal carers. These people have often known the individual for a long period of time and have a thorough understanding of their needs, wishes and preferences. By talking to them, valuable insights can be gained into what is important to the care receiver and how best to approach their care. This is especially true for the individuals that I work with as many have learning disabilities and may sometimes not be able to understand, express or communicate their needs themselves. Family will often be a very important part of an individual’s life and it is essential that they are given the opportunity to be involved in their care planning (providing that the individual themselves gives consent for this). In my experience, the information that is provided by family can be invaluable during the assessment process, however it can sometimes be somewhat unreliable – family can often put a more positive or negative spin on their loved ones or they may have an alternative agenda – so it is useful to verify what has been said with others. This can be achieved by speaking to a wide range of people that are familiar with the individual (both personally and professionally) as well as conducting first-hand observations. 

The importance of helping an individual to maintain relationships with their family should not be understated and care workers should strive to keep family updated with what is happening in the individual’s life and treat them as a partner in the individual’s care. Having a loved one being cared for by others can be a very stressful experience and good communication can help to alleviate some of the worry that they are experiencing. However, it is also important to remember that the relationship you have with a care receiver’s family is a working relationship and should remain professional at all times. 

For family members or friends that provide care to an individual, the Care Act 2014 extended the assessment process to include the needs of all non-professional carers so that they can gain access to any help and support they need, providing they meet the eligibility criteria.

During the meeting, we discussed the specifics of the care package including how many hours social services had commissioned for X as well as additional hours for the transition work, some of the needs of X and some of the behaviours he has previously displayed and how best to manage them. I made detailed notes throughout the meeting and developed a tentative  action plan for moving things forward. The plan included meeting with his potential new housemate and further regular meetings for them to get to know one another and ensure compatibility. Also, IST offered to arrange a workshop for my team to let us know how best to support X and answer any questions we had. I did feel slightly uncomfortable with making plans about X without his presence or involvement so I explained that I would like to meet X as soon as possible to talk with him about the transition and ensure that he was happy with the plans we had agreed. I wanted to ensure that he had every opportunity to actively participate in his own care planning and make changes to the plan if he wished.

Active participation means encouraging an individual that is receiving health and care services to take an active role in their healthcare planning and delivery rather than simply being a passive recipient. It is an essential component of a person-centred approach and empowers the individual with choice and control whilst respecting their rights and promoting independence. This can have several benefits for individuals including increased opportunities for social interaction, self-awareness, learning and development, autonomy, activity (physical benefits), self-confidence and self-esteem. It can also decrease an individual’s vulnerability and the likelihood of them being victims of abuse due to their increased independence, confidence and knowledge of their rights. Holistically, this can enhance the wellbeing of the individual considerably.

Wellbeing is a subjective concept and difficult to measure. It can be considered a feeling of happiness or contentment, however the factors that make one individual content and happy may not be the same for others. Ryff (1989) developed a method to assess psychological wellbeing, which comprises of six factors; self-acceptance, personal growth, purpose in life, environmental mastery, autonomy and positive relations with others. It is measured using the Ryff scale whereby individuals rate how much they agree with several statements using a scale of one (strong disagreement) to six (strong agreement). The responses are added up and a higher number indicates a higher level of psychological wellbeing. Correlation can be seen between Ryff’s factors of wellbeing and the benefits of active participation, which indicates that active participation improves wellbeing. 

Following the initial meeting, I immediately arranged to visit X to begin to get to know him and encourage him to take an active role in his care planning. I also met up with my existing client to let him know that he had the opportunity to have a new housemate to live with and to reassure him that there was plenty of time for them to get to know each other first and with an option to cancel the plans if he did not feel comfortable for any reason. However my existing client was very excited and keen to meet up with X. It was important to me to encourage active participation in the process from both sides and so I had prepared a list of possible dates and activities for them to meet up and get to know one another. My existing client was happy with all the dates, so I explained that I would speak to X to ensure that he was also agreeable.

My meeting with X began slowly due to his shyness and he found it difficult to talk to me, speaking in monosyllables or hiding his face. However, although he seemed shy, he did not demonstrate any heightened anxiety so I persisted with talking to him. As time went on, he began to open up more. I explained the transition plan and that his potential new housemate was keen to meet him. He expressed excitement and agreed to the dates for meeting up. I also asked if he had any questions or if there was anything that he did not agree to. We discussed what he was like as a person, the activities he liked to do, what he liked and didn’t like to eat and drink and other information that would help to build a picture of his needs and preferences. This included his spiritual and cultural requirements and medication – however, he was unsure about his current medication so I obtained this information from his support worker with his consent. I asked if it was possible for me to spend a couple of hours with him just to ‘hang out’ and observe how he liked to live day-to-day, which he was very happy with. During my time with him, I asked questions about how he would like to be supported and encouraged him to speak up if there was something he was unhappy with. This helped to build a rapport as he became more comfortable around me and he dropped some of the barriers that had previously impeded communication. I tried to discuss future goals with X, however he seemed disinterested in this aspect of his life and seemed to have difficulty understanding the concept of long-term planning and goal-setting, so I decided that this aspect would be better left for another day. 

In my experience working with individuals with learning disabilities, it is important to be persistent when trying to encourage active participation because an individual’s first answer may not necessarily be what they are thinking and often they may need additional time to process their thoughts before they formulate an answer. Therefore, patience is also very important.

The promotion of active participation also supports person-centred and outcome-based approaches to health and social care.

Person-centred practice is a way of providing care in a way that respects the views, values and beliefs of the individuals that are receiving it and involves them in their own care planning and delivery. The Social Care Institute for Excellence (SCIE, 2019) states “person-centred care moves away from professionals deciding what is best for a patient or service user, and places the person at the centre, as an expert of their own experience.

This means working with individuals to identify what their wishes are and communicating information to them in a way that they can understand so that they are able to make informed choices. As explained by the Royal College of Nursing Institute (RCNi, 2019) “…we may have to ask them what they want, using appropriate communication methods to actively encourage them to participate in their own care…”. 

It is important to note that person-centred practice and the active participation of individuals in their own care should be a proactive approach that is initiated and promoted by health and social care workers rather than a reactive strategy initiated by the care receiver. Sometimes, simply asking an individual what they would like is not enough, so there is a need for tools or processes to guide practice.

In their exploration of the relevance of person-centred planning in social care, Dowling, Manthorpe and Cowley (2006) identify four approaches to person-centred planning. They are the McGill Action Planning System (MAPS), Essential Lifestyle Planning (ELP), Personal Futures Planning and Planning Alternative Tomorrows and Hope (PATHS).

Originally designed to assist the integration of children with disabilities into mainstream educational institutions, the ideas behind the MAPS system may also be used during the initial assessment process in an adult health and social care setting. The process involves putting together a team to discuss the individual and their support needs and preferences. This team should include the individual themselves, their friends and family, the care provider and any other professional stakeholders such as the individual’s social worker or occupational therapist. As a group, these participants will discuss seven key questions about the individual; their history, their dreams, their nightmares, who they are, their strengths and abilities, their needs and their ideal day. It concludes with a reflection, whereby each participant is asked to convey in one word their thoughts about the process.

The information and insights about the individual gained from these discussions should then be used to “creatively dream, scheme, plan, and produce results” (Vandercook, York, & Forest, 1989). In essence, this means examining where the individual is now, how they got there, what their goals are and how the team will work with the individual to achieve them. Specific action steps for attaining their dreams and avoiding their nightmares will then be formulated. 

MAPS is useful because it shifts the focus from what an individual cannot do to what they can do. It encourages the individual to set goals as well as encouraging other members of the team to support the individual to achieve them. However, because the process is quite time-intensive, care providers may not have the resources in terms of both time and finances to facilitate it. In addition, all team members must be invested in the process and may require additional training to ensure positive outcomes.

ELP is a process that has historically been used to assist individuals that have transitioned from long-term admissions in institutions to local communities. It can be used to get to know an individual and what is important to them. It involves communicating with the individual and their significant others in plain language. This information is then used to identify the support that they require and how this can be implemented in a healthy and safe way.

The process begins with listening to the individual and their significant others to establish a thorough understanding of the things that are important to them and the way they want to live their life. Once this is understood fully, care staff and other professionals can develop detailed plans to support the individual, whilst balancing their wishes with the safety of themselves and others.

ELP is primarily focussed on the present day-to-day life of the individual rather than their future dreams or goals. It ensures that the individual is at the heart of their own support and that their needs, wishes and preferences (from their own perspective) are listened to and acted upon.

However, like MAPS, there may be time and monetary constraints to the implementation of ELP. In addition, there is also the need for staff to be trained in ELP to ensure that it is implemented correctly, which can be both lengthy and costly. “Current training in essential lifestyle planning entails two days of training in ‘person centred thinking’, two days of ‘facilitator’ training and one or more follow-on days.” (Smull and Sanderson, 2005).

Personal Futures Planning involves getting to know the individual and what they want from their lives. This is undertaken as part of a group with the individual themselves and their family as the main facilitators, supported by others that know the individual well such as friends, neighbours and carers. It can also involve ‘shadowing’ the individual during their day-to-day life to build a picture of them. Having obtained comprehensive information about the individual, the team work together to create a plan to assist the individual to reach their goals. It is more informal than other person-centred approaches as there is no set process (only guidelines) and participation is entirely voluntary. Each person is encouraged to speak freely and make a commitment to helping an individual attain the objectives that they have set themselves.

Again, this approach requires time, training and commitment from the people involved, which consequently results in higher costs for organisations that are providing care.

Finally, PATHS is a structured planning process that was developed from MAPS. The individual, their family and other stakeholders get together to discuss the individual’s dream of the future and then set a long-term goal to work towards (or achieve). The next step is to look at where an individual is right now and assess what will be needed in terms of skills, knowledge and relationships to achieve this goal as well as the existing strengths of the individual and any possible barriers that may impede progress. Finally, the group can create an action plan to assist the individual to achieve their dreams.

All of these approaches ensure that the individual receiving care is at the centre of the planning process, that their views are listened to and that any plans that are made are firmly focused on what is important to them. They all involve a ‘circle of support’ that can include professionals and non-professionals (such as family and friends). 

However, these approaches are all impacted by both time and monetary constraints as well as the additional training that staff must undergo to implement them effectively. Emerson and Stancliffe (2004) note that “Done well person-centred planning is a time-consuming process.”  Staff must also be invested in and have faith in these approaches for them to work well and both staffing levels and staff skill sets can be barriers to effective implementation of these approaches. As Packer (2000) states “One of the greatest barriers to achieving person-centred planning is the lack of belief among frontline workers and service providers that it is a real possibility”.

It is also interesting to note that there is no single established process for implementing person-centred planning – all of the approaches have been developed to cater for a certain kind of situation and then adapted to be used elsewhere. I have found that information about how to use them is often vague, obfuscated or hidden away behind paywalls, which makes it difficult for service providers and individuals to use them in their day-to-day planning, without signing up for expensive training. This confusion of how person-centred planning should be implemented filters down to frontline staff, many of whom have a good understanding of and belief in person-centred values but do not have the tools available to use it effectively. This view is supported by Nolan et al (2004) as “Person-centred planning is an oft-quoted but ill-defined concept, which nevertheless exerts a considerable influence on policy, practice and academic literature” and Nolan (2001) “…policy often espouses principles which are simple to express but highly complex to translate into practice.

It is my opinion that policymakers should ensure that information about person-centred planning is freely accessible and that clearer and more concise guidelines about how it should be implemented to best effect are devised and made available publicly.

Although legislation and policy still have some way to go, great strides have been made over previous decades in moving from a ‘one size fits all’ approach in health and social care to one that is person-centred and aims to provide bespoke services for each individual. This has strong links to the social model of disability which suggests that it is society and the environment that are disabling to individuals (in contrast to the medical model which looks solely at an individual’s physical/mental disability and searches for ways to treat or cure it).

Closely linked to person-centred practice is outcome-based practice. In a care context, ‘outcomes’ are the end result for an individual receiving care. By focusing on outcomes rather than just an individual’s needs, a more holistic approach to care can be provided. Individuals receiving care are encouraged to establish their own goals and the care provider works as a facilitator to help the individual achieve them rather than leading the care provision themselves.

This is in contrast to the previously-used needs-led approach, which focused on an individual’s immediate needs rather than their future goals. In this historical approach, the care provider would assess an individual’s needs and provide a package that met these needs with very little collaboration from the individual themselves and without taking into account other aspects of their lives.

There are several approaches to outcome-based practice. These include the Logic Model, results-based accountability, outcomes management and outcomes into practice.

Logic models are graphical representations that a show simplified view of the connections between the inputs, outputs and outcomes of a plan or program. They are useful because they summarise the causal relationships between activities and the end result, which can aid “…planning, evaluation, implementation and communication” (NHS – North of England Commissioning Support, 2016). One of the challenges of effective use of logic models is balancing the polarising requirements of detail and simplicity. If they do not include enough detail (perhaps because it is not feasible to predict all the factors of an output that produce an outcome) then important information may be missing. Conversely, too much detail can make logic models complicated and unwieldy. Logic models have also been criticised for “representing interventions as linear and mechanistic, and for overplaying the predictability of an intervention.” (HM Government, 2018).

Results-based accountability (also known as outcome-based accountability) was developed by Mark Friedman and described in his book ‘Trying Hard is Not Good Enough’ (2005). It is a framework for organisations to go from talking to taking action relatively quickly by working out how the people that are receiving services would be better off (outcomes and performance indicators), assessing the current situation and making new plans to achieve the outcomes in the best possible ways. It makes a distinction between population outcomes that measure the holistic effects of a community group as a whole as well as program outcomes that measure the success or failure of a particular service.

Outcomes management is designed to deliver better outcomes for individuals as cost-effectively as possible by supporting care receivers and other professionals to make decisions based on knowledge of how these choices may affect the individual’s life.

Outcomes into practice is based on research by the Social Policy Research Unit (Nicholas et al., 2003) and focuses on the outcomes valued by care receivers and care providers. Outcomes in this approach could be as simple as maintaining the status quo and not making any changes.

Outcome-based approaches give the care-receiver much more control of the care process from identifying the outcomes to setting the review dates and evaluating the results. They rely on using data from sources such as the individual receiving care, professionals and existing research to identify desired outcomes and the best ways to achieve them.

Like person-centred approaches, there is a need for training in outcome-based approaches as well as a significant budget for implementation. In addition, there must be a shift in focus for front-line workers. Nicholas and Qureshi (2004) state that “…the idea of ‘outcomes in practice’ may appear to have little relevance to most frontline practitioners, who may fear further entanglement in management bureaucracy and control mechanisms that do not reflect the skilled and complex nature of their work”. There may also be resistance from front-line workers as their role is reduced from a professional practitioner with expertise in healthcare-related decision-making to that of a facilitator for decisions made by the care-receiver.

However, despite these barriers, an outcome-based approach allows the individual to have choice and control over their care provision and tailor it to their own requirements, which can have a positive effect on their overall wellbeing. It means that care providers can be held accountable for their services and promotes partnership working between the care provider and the individual receiving care. The increased dialogue between care provider and receiver also means that care providers can take a more holistic view of the care receiver and be more flexible and innovative in their solutions. This is in contrast to the historical needs-led approach, which dealt only with the immediate healthcare need.

To ensure that individuals have choice and control over decisions and take an active role in their own care, it is important to ensure that they are provided with the information they need from healthcare professionals. As an expert in their field, a healthcare professional may be able to offer ideas or solutions that the individual did not realise were available. Care services should be monitored and reviewed regularly and the care receiver should be kept up to date with what is happening. Additionally, communication should be in line with the individual’s needs. This includes communication with regards to obtaining consent from the care receiver to involve others in their care planning delivery and any requests for information about them from other professionals.

Person-centred practice is also an essential component in obtaining consent because an individual that has engaged with a healthcare professional and taken an active role in their care planning and delivery can be deemed to have implicitly consented to the care that is provided. Consent can be verified verbally during day-to-day practice and in more serious cases, such as when undergoing a surgical procedure, written consent will be required. Written consent requires detailed and accurate records being made of all discussions and decisions.

All individuals should be assumed to have the capacity to make their own decisions unless they have had a capacity assessment that deems otherwise, as guided by the Mental Capacity Act 2005. Even if an individual has been judged to not have the capacity to make a particular decision, this does not mean that they are unable to make other decisions related to their care.

Although there was a slow build-up towards person-centred planning from the 1970s when individuals with disabilities were moved out of long-term institutions and into mainstream society, things really began to change in 2001 when the government published their ‘Valuing People’ white paper. This document sets out the government’s proposals for “…improving the lives of people with learning disabilities and their families and carers, based on recognition of their rights as citizens, social inclusion in local communities, choice in their daily lives and real opportunities to be independent” (Department of Health, 2001). This set the foundation for the government’s future vision for health and social care services and committed funds for modernising day services, moving more people out of long-stay hospitals and developing specialist local services for individuals with challenging behaviour and complex needs. Extra funds were also made available for self-advocacy organisations and direct payments were made more widely available. This white paper also introduced the term ‘person-centred’ to government policy.

The movement towards a person-centred approach was also recommended in the NHS Plan (2000) which identified a need for personalisation in health services and the Wanless Report (Wanless, 2002) which focussed on enablement and empowerment, with patients as partners in their care.

The Mental Capacity Act 2005 promoted person-centred planning by providing a framework for the decision-making process for individuals that may be unable to make decisions for themselves about their care. In the guidance, all adults should be assumed to have capacity to make decisions about themselves and the onus is on whoever doubts their capacity to prove that they do not. All practicable steps should be taken to support an individual to make a decision and making unwise decisions are not indicative of a lack of capacity. When a decision about an individual is made on their behalf, it should be done so in their best interests and thought must be given about whether the outcome could be achieved in a less restrictive way. The effect of the Mental Capacity Act 2005 is that care providers must respect the rights of the individuals they support and that individuals must be involved in decisions that are made about their own care. Robust processes are in place to ensure that others can only make decisions about an individual as a last resort when all other options have been explored and these decisions must be made in the individual’s best interest.

Around the same time, other policies supported the move to a person-centred approach in health and social care services. The green paper, ‘Independence, Wellbeing and Choice’ (Department of Health, 2005) promoted and extended the use of direct payments so that ‘people are given more choice, higher quality support and greater control over their lives’. ‘Improving the Life Chances of Disabled People’ (Prime Minister’s Strategy Unit, 2005) promoted independent living, supported a smoother transition between children’s and adult services and improved the support and incentives available for attaining and maintaining employment for individuals with disabilities. The white paper, ‘Our Health, Our Care, Our Say’ (Department of Health, 2006) set out the government’s proposals to reform and expand community health and social care services by providing increased choice, promoting independent living and improving access to community services. This was followed by ‘Putting People First’ (HM Government, 2007), which was a nationally agreed protocol that clearly set out the future direction for the reform of adult social care services. This included the mainstream implementation of person-centred planning and self-directed care.

Building on the NHS Plan (NHS, 2000) and the NHS Constitution (NHS, 2009), ‘Personal Health Budgets: First Steps’ (Department of Health, 2009) initiated a pilot to investigate the viability of collaboration between an individual and healthcare professionals on how NHS money should be spent on their health and wellbeing, with the aim of giving the individual more choice and control in their care and treatment. The result of this initiative was found to have had a positive impact on the quality of life and wellbeing of the individuals that used it and was also cost-effective, so from April 2014 the option to request a personal health budget was rolled out nationwide.

The Health and Social Care Act 2012 pushed the personalisation agenda further by requiring Clinical Commissioning Groups to promote the involvement of each patient and sets out actions that they must take to ensure that each person receives appropriate person-centred care.

Also in 2012, the government published the Adult Social Care Outcomes Paper (Department of Health, 2012), which was designed to measure how well services achieve the outcomes that are most important to service users (an outcomes-into-practice approach). It introduced an outcome-based approach to adult social care and was used to set priorities, measure progress and improve accountability and transparency.

This was followed by the Care Act 2014 which placed a statutory duty on local authorities to identify adults that may need care or support and assess their needs. This should be done in collaboration with the individual using a person-centred approach with a focus on the individual’s well-being.

Following my initial meeting with X, I continued to have regular follow-up meetings with him to share progress and gain more insights into how he would like to be supported. I obtained his consent to consult with other professionals that he had worked with and built a solid picture of his needs, wishes and preferences. I had the opportunity to observe and discuss his money management skills and came to the same conclusion as his psychologist that he did not have the mental capacity to manage his money. I do not have a lot of experience with carrying out mental capacity assessments so if I was unsure of X’s capacity to make any decisions, I would have recognised the boundary of my role and referred him to our in-house LD nurse. 

We agreed that it would be prudent for us to budget his money for him to ensure that he was able to pay his rent and bills and that his tenancy was not put at risk. To facilitate this we collaborated on a risk assessment and I ensured that I gave him enough information and time to understand the reason for it. 

During these discussions, he divulged to me that many of the arguments he had with his mother were around money and was the primary source of tension in the relationship between them. This was confirmed to me by his support team. His mother was his appointee, so I asked if he would prefer to have an independent appointee manage his money for him – an option which he had not known was available. After explaining how this would work and giving him time to process the information, he decided that this would be a good idea. I referred this to his social worker who agreed with my recommendation and began the process of sourcing an appointee for him. She also contacted his mother to explain what she was doing and the reasons for it.

As well as meeting with X myself, I had also arranged for him and my existing client to meet up to participate in some activities together. The first meeting was at the existing client’s home so that X could take a look around and decide if it was suitable for him. The two potential housemates chatted, listened to music, compared musical tastes and had a game of pool together. They both seemed to enjoy one another’s company and were eager for X to move in as soon as possible.

I arranged subsequent activities (bowling, disco, driving range and lunch) for when different members of the team were on shift with the existing client. This was to ensure that X got to meet several members of the team that would be working with him as well as for the team to get to know X a little better. I also wanted to use these meetings to get feedback from my staff team that would aid me in the assessment process. My team consists of an eclectic group of individuals with various different backgrounds, skills and character traits, which means that they will often notice things that myself and others have overlooked.

This involved speaking to the team to inform them of the assessment process and to ask them if they felt that X and the existing client were compatible and could live together based on their observations. I explained that the main goal of the assessment process was to increase the quality of life for X and we all had an important role in ensuring that we identified and recognised what his strengths were as well as the things he would require support with. I also asked them to build a rapport with X and put forward ideas about how we could best support him. I kept the team regularly updated about the assessment process and encouraged them to ask questions about X’s transition.

I also had regular meetings with other partners in the process including the social worker, X’s mother, IST and X’s current support team. I encouraged all parties to make positive contributions, with the professionals providing specialist advice and family members providing personal information. It was particularly important to me to ensure X’s mother was informed of the assessment process, especially as she would be losing her role as her son’s appointee. I explained why this was necessary and that her son’s money would be managed competently and honestly. I also explained that she still had a very important role in the assessment process because she knew her son better than anyone and her insights would be of great value in supporting him and giving him a better quality of life.

Towards the end of the assessment process, I sat down with X and we collaborated on the final drafts of his support plans and risk assessments, using all the information I had gathered from the various partners. I also documented them ensuring that he was happy with all aspects of his proposed care and support and offered options throughout the process so that X could make informed decisions.

The next stage was to ensure that X’s support team were provided with all the information they needed to support him. As well as having a documented care and support plan, I also arranged a team meeting to discuss X’s support and what would be required as well as arranging the workshop provided by IST.

Unfortunately, at around this time, there were some major changes to the dynamics of my team, which presented some challenges. I’d already planned for the recruitment of two new team members to cover X’s shifts, however I then lost two highly experienced and senior members of the team due to internal promotions. These were swiftly replaced, however I was now tasked with ensuring that the four new team members were not only prepared for the arrival of X but also inducted with the existing client and understood their support requirements.

When a new team comes together or there are big changes to an existing team, it can present challenges for the manager because team members are often working outside of their comfort zone and seeking their role and purpose within the team dynamic. Part of effective management is being able to lead the team through this difficult phase and establish stability.

Tuckman’s (1965) model suggests that teams must go through four stages of development; forming, storming, norming and performing. At the ‘forming’ stage, team members require a lot of direction and support as they are often unclear of their purpose and are wary of other team members due to unfamiliarity. Managers must give clear direction through effective communication as well as being sensitive to the discomfort team members may be feeling in their new environment. Once some familiarity has developed, team members become more confident and conflicts can occur between them and the manager as differences of opinion are expressed. This is the ‘storming’ stage and team members will often put the blame for any problems on the manager because they are seen as different from the rest of the group. A manager must be mentally resilient during this stage and manage conflicts swiftly and assertively. Harmony is achieved at the ‘norming’ stage when conflicts have been adequately handled and team members understand their own and the team’s purpose and direction. The fourth stage, ‘performing’ is achieved when all team members diligently perform their work to expected standards or higher. This is when the team is at its most effective. Tuckman later added a fifth stage called ‘mourning/adjourning’. This is the natural end to the team as it disbands following a brief period of reflection on the work they have completed and the goals they have achieved. This can be very stressful for team members, particularly if they have worked in the team for an extended period of time.

Even when a team is established and performing, teams can face challenges that must be effectively handled by the manager. The manager’s main aim will be to keep things running smoothly and efficiently and ensuring that momentum is maintained. Again, effective communication (including negotiation) is crucial to support team members and keep everyone working together towards the team’s goals. It is important to identify and understand the unique traits, skills and knowledge of each individual team member so that they can be utilised in roles where they are most effective. When team members are performing tasks that they feel they do well and that they are appreciated, they will be content in their work and potential conflicts can be avoided. Asking for and valuing the opinions of team members can also contribute to them feeling valued in their employ. 

Belbin (1981) undertook research regarding the different roles of team members and how effective teams could be built (and ineffective teams avoided) by controlling the dynamics of the group. Belbin identified nine team roles that must be present for a team to perform well – the same individual can have multiple team roles, so this does not necessarily mean that a team must have nine members. Belbin’s research can help develop balanced teams with the right people doing the right tasks for maximum performance.

The management style used can have a great influence on team performance. Lewin et al (1935) identified three types of management style; autocratic, democratic and laissez-faire. Autocratic managers give instructions to team members and do not consult them in the decision-making process. This works well when tasks are time-sensitive or there are performance issues within the team, however it can result in team members feeling under-valued and disenfranchised. A democratic manager asks the team for their input before making a decision and will value everyone’s opinion. Although this can make team members feel valued and give them ownership of a task, it can also lengthen the time it takes to make a decision as different viewpoints must be taken into account. Additionally, it can result in team members making decisions about things that they do not have sufficient knowledge or experience in. Laissez-faire managers trust their team members to make decisions for themselves and give them full autonomy for achieving a task. Although this can work well with competent and highly-motivated individuals, it can result in projects going off-track and decisions being avoided or taking a long time to be made.

Trait theory (Allport and Odbert, 1936) suggests that each individual manager has a natural tendency towards one of these management styles and will not perform well if they are in a situation whereby a different management style is required. However, Fiedler’s Contingency Theory (1967) argues that a good manager is flexible in all management styles and the style used will be dependent on the situation.

Whichever management style is used, it is essential for a good manager to build and maintain trust and accountability within their team. All team members must be held accountable for their work and this builds trust between them. The manager is not excluded from this – in fact, a manager should exemplify trust and accountability by being honest, transparent and authentic in order to demonstrate these traits to their subordinates. If the manager makes a mistake that affects their team, they should apologise, explain what went wrong and what they will do to make things right and prevent it from happening again. This builds trust and openness throughout the team and behaving in this manner means that the manager can expect the same behaviour from other team members. Team members will also understand that that they will be held accountable for their actions (or inactions) when there are failures in performance. It is important for the manager to be sensitive in these situations and not publicly berate the team member, but instead discuss the issue in private to find out why the task was not completed satisfactorily. It could be that factors outside of the team members control contributed to the failure. Consistency is key as any deviations from the manager’s usual system of managing accountability could be considered to be favouritism or victimisation, which will result in disharmony within the team.

When it is necessary to provide team members with negative feedback, managers should be aware that different people respond to criticism in different ways and confronting individuals about poor performance can be uncomfortable for both parties. However, issues must be addressed and not ignored. It can be beneficial to provide positive feedback regarding a different aspect of their job role first to help balance the critique before addressing the need for improvement. Clear instructions about what is expected from them going forward is crucial and it is also important to listen to their point of view. An action plan for improvement should be documented and, if necessary, the disciplinary process should be explained as well as any legal ramifications that could potentially occur if performance does not improve. At all times, respect should be given to the team member and the discussion should revolve around the performance issue rather than the individual themselves.

Much like handling performance issues, conflicts within a team should also be managed sensitively, professionally and with respect. Conflicts can arise due to disagreements about working practice or clashes between personal views and beliefs. Thompson (2006) developed the conflict management strategy, RED, which comprises three steps. The first is to recognise the conflict and not ignore the issue. The conflict should then be evaluated to assess the potential consequences of it being allowed to develop. And, finally, it should be dealt with. Another approach is the CONECT method, developed by Larson and LaFasto (1989). This involves both parties opening a dialogue to attempt to resolve the conflict and is the primary method used by my organisation in the form of conflict resolution meetings, which are facilitated and mediated by a manager. Before the meeting, both parties must commit to improving the relationship and pledge to be honest and keep the meeting confidential. Then they should listen to each other’s perspectives and why they believe change is required. Finally, each individual should agree to change one behaviour in the interests of the relationship. A decision should be made on how these changes should be tracked and measured and a review meeting scheduled to discuss if the changes are working.

With the loss of two of my experienced team members and the addition of four new members to the team, I arranged a team meeting to discuss the recent changes, keep everyone updated and set the teams direction so that everybody was aware of what was expected of them. 

Due to the inexperience within the team and X’s imminent transition, I felt it necessary to take an autocratic approach to management by explaining what was happening and directing team members with clear instructions of what I needed them to do and what was expected from them. However, I did explain to the new team members that I usually operate with a more democratic approach and promote a team decision-making process when things are not so time-sensitive. I informed the team that I recognised that with so many changes this could be a difficult phase for us but had confidence that we could pull together and get through it.

I identified that certain team members had shared interests with X. For example, one team member is an avid golfer and X enjoyed going to the driving range. Another team member has a similar taste in music. I recommended using these as starting points to develop a bond with X. I asked one of these team members to take on the role and responsibility of X’s key worker and to work closely with him to develop a trusting relationship. Another member of my team is highly trained and experienced in medication administration and handling and I tasked them with managing X’s medication because one of his medications was a controlled drug and required additional safeguards and paperwork to comply with regulations.

Although the team is made up of a diverse range of individuals, we all share the same core professional values and standards relating to health and social care as guided by the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England (Skills for Care, 2013). There is also a lot of support, cooperation, respect and understanding between team members because we all recognise that we have a difficult and highly stressful job and that helping one another is necessary to maintain morale and achieve positive outcomes. Management are always open to new ways of working and team members are encouraged to innovate and test their ideas, which leads to job satisfaction and increases in self confidence and self esteem. The team is very open and transparent in their work and when mistakes or errors are made, they are reported immediately to reduce the damage and reflect on to ensure similar mistakes are not made in future. I model these positive aspects of my team’s culture myself to set an example to others.

The positive culture within the team also supports our vision and strategic direction, which is guided and governed by legislation, regulation and research. Legislation such as the Care Act 2014 and government policy such as ‘Valuing People’ (Department of Health, 2001) impact on the way we provide care, in addition to the regulatory requirements of the Care Quality Commission (CQC). We must provide care services in a safe, effective, caring and responsive manner that is well-led according to CQC’s Key Lines of Enquiry, upon which inspections are based.

Strategic direction filters down to team-level objectives, which have the general aim of increasing the health, wellbeing and quality of life of the individuals that we support. For example, we set the objective to ensure that everything was prepared for X’s move on a particular date, including removals firm, paperwork and medication to reduce the likelihood of any last minute issues and minimise X’s anxiety.

The transition went smoothly and X quickly settled into his new home. It is essential to review care plans regularly to ensure that individuals are receiving the correct care and to assess whether their needs have changed. Care plans are working documents so they are added to and updated whenever necessary, however we also formally review care plans every three months. For a new transition, it is company policy to review care plans at least two months following the client’s care provision starting, however I believe a two week review is more effective because I have often discovered that no matter how well the initial assessment and planning is performed, a full picture of the individual’s needs are not fully evident until a team is working with them day-to-day. Care plans and care plan review meetings are recorded on my organisation’s digital care planning system.

After a week, my team and I began to discover that some aspects of X’s care planning were not suitable for him so we began to work with him to make changes. 

Both X and the professionals I spoke with during the assessment agreed that because of X’s vulnerabilities, including but not limited to a lack of road safety awareness, he should have support staff with him when he accessed the community. However, he would often leave the house unaccompanied without informing staff, which led to staff being concerned about his whereabouts and safety. This presented a dilemma between our duty of care and X’s rights to freedom, independence and privacy because, as an adult, we had no right to prevent him from leaving his home or to force our presence on him. This was referred to his social worker along with evidence that a Deprivation of Liberty Safeguard (DoLS) be put in place to protect him and his social worker filed the application. This was then updated in X’s care plan.

A behaviour that we had not been made aware of was for him to deliberately damage property when he was feeling low. This quickly resulted in the relationship between him and his housemate deteriorating because he was damaging his housemate’s property. We made it clear to X that this sort of behaviour was not acceptable, was not fair on his housemate and that it would put his tenancy at risk because he had also damaged his landlord’s property. We asked how we could support him to stop doing it but he was unable to offer any insights. From the pattern of recorded incidents, it appeared that the need he was expressing when causing damage was to gain attention, so we adjusted his support plan to ensure that all staff would regularly check in with X to ask if he was okay and if he wanted any social interaction. I also contacted the other professionals to inform them of the situation and steps we had taken.

Unfortunately, despite our best efforts and the introduction of other interventions, X continued to choose to cause damage to his own, his housemates and his landlords property as well as not respecting his housemate’s and staff’s personal boundaries. This led to a deterioration in the mental health of his housemate and we decided that it was no longer practical or in their best interests for them to live together. X was informed of this and we worked together to source alternative living arrangements where he would the sole occupant.

We had a review meeting with IST and the social worker to discuss the issues we had encountered and X’s alternative living arrangements. Further interventions and processes were put in place to reduce the likelihood of X causing damage to his new home, along with related risk assessments. 

After X had moved into his new home, I reflected on the assessment process to try and understand what had gone wrong and how I could do things better in future. I felt very bad for both X and my existing client because I felt that I had let them both down by not noticing the potential issues sooner. I felt particularly guilty about the mental anguish experienced by my existing client inside his own home and wanted to ensure a similar situation would not arise again. I believe that I was perhaps a little naive to take everything that I was told about X at face value. This was confirmed to me later following an overheard private conversation between the social worker and IST whereby the social worker said that his original accommodation (before my organisation began providing his support) would not accept him back due to the damage he had caused to their property. This was very disappointing and frustrating because it meant that his previous support staff knew about this behaviour but made no mention of it during the assessment process. Had I known this, I would have been aware that he would not be compatible with my existing client and I could have suggested he move into a house on his own from the outset. The only reason that I can see for them to withhold this information is to try to ensure that my organisation did not pull out of the transition process. I also learned that X’s mother, who I believed was being supportive during the assessment process had regularly told him to “do what you want” and “[ignore] the rules”. 

This made me feel very discouraged and cynical about the assessment process because I had put a lot of work into it and a lot of trust in others. But I was ultimately working with information that was incorrect and had developed a care plan that was not suitable for the person that it was designed for. Myself and my team felt let down by the other professionals. 

However, I tried to remain positive about what had happened and decided to use it as a learning experience. I learned that professionals that have a client on their caseload may be economical with the truth because their ultimate aim may be to get the client off their books. They may put a positive spin on things to ensure that the transition goes through. Of course, this won’t be true of all professionals but it is important to be aware that this could happen and to keep an open mind so that inconsistencies in accounts are noticed. Going forward, I will be a lot more thorough in my assessments and if my existing client wants to continue his search for a housemate, I will recommend a week or two trial with a contingency plan in place to swiftly change things back if it does not work out.

References