The Scottish Government

« Previous | Contents | Next »

Listen

ON THE BORDERLINE?
PEOPLE WITH LEARNING DISABILITIES AND/OR AUTISTIC SPECTRUM DISORDERS IN SECURE, FORENSIC AND OTHER SPECIALIST SETTINGS

CHAPTER SIX ASSESSMENT OF NEED AND CARE PLANNING

6.1 Chapter 3 described the processes and mechanisms for identifying someone as having a learning disability and/or ASD. This chapter explores the ways in which, once identified an individual's needs are assessed and care plans developed. Assessments are distinguished between: specialist clinical assessments following initial screening or identification; assessment of additional health, social care, education/training and offending/behaviour related needs; and risk assessment.

SPECIALIST ASSESSMENTS

6.2 The unit recording forms indicate that across the secure settings assessment or diagnosis of learning disabilities and/or ASD was seen as a role for clinical psychologists, clinical forensic psychologists, or, in the prison service, forensic psychologists, and, less frequently, consultant psychiatrists.

6.3 From the more detailed case recording forms, however, 2 findings emerge in relation to non-health care settings. First, in some instances assessment or diagnosis did not seem to involve psychiatric or psychological input. Second, where there was clinical input it was only occasionally from a specialist in learning disabilities.

6.4 In secure accommodation for children, for example, assessment may be undertaken by a psychiatrist in learning disabilities, but it may also be made by an educational psychologist.

6.5 Similarly, in the prisons, there was evidence in one case of the assessment being undertaken by a Forensic Learning Disability Team, including a psychiatrist specialising in learning disabilities. Others had been assessed or diagnosed by consultant psychiatrists or clinical psychologists, or the person's GP and/or the prison medical officer.

6.6 The route to learning disability services for people in prison would be via the prison mental health teams. Visiting psychiatrists would refer on to specialist services. For example, one person identified by the prison as having an IQ of 50, was being referred to the local learning disability service with a view to transfer to a specialist in-patient unit. This person had, however, been convicted. Two prisons raised the difficulties of obtaining specialist input for someone who was only in for a short period. One visiting psychiatrist described how, if someone was "not in for a long sentence, or not detainable, and had no prior contact with learning disability services, then they may not be seen by learning disability services".

6.7 One prison expressed the view that rather than referring to a forensic psychiatrist they should be able to refer direct to "psychiatrists who are specialists in learning disabilities". Potentially this could ensure not just specialist but also timely input.

6.8 No specialists in ASD were referred to in either the non-health care or health care settings.

6.9 In any specific case there may not be a demand for input from a specialist in learning disabilities or ASD. There may though be a case for arguing that the involvement of specialist learning disability services at the point of assessment may also encourage 'ownership' or on-going responsibility by these services, where appropriate, for people identified within the secure settings.

ASSESSMENTS OF NEED

Additional assessments

6.10 From a pre-selected list on the unit recording forms secure settings were asked to indicate the range of additional assessments that, in principle, would be available. The list included physical health care, mental health care, offending and/or other challenging behaviour, social welfare and education and training. In general, all units responding anticipated being able to access the range of assessments. In-patient units for people with learning disabilities (outwith the State Hospital) were less sure about being able to obtain assessments of social welfare or education/training needs.

6.11 Across the different settings just under two-thirds of the 39 units responding to the question on the unit recording form felt that arrangements for obtaining these additional assessments 'worked well'. For a significant minority, however, this was felt to work 'less well'.

6.12 Unit recording forms also asked respondents to indicate whether additional assessments were undertaken once someone was identified as having a learning disability and/or ASD.

6.13 Of the units responding to this question a few indicated that they would not undertake additional assessments. These include: one long stay rehabilitation unit for people with learning disabilities; 5 of the psychiatric units on the State Hospital site; and 3 of the 6 psychiatric units. It is not evident why these units would not anticipate undertaking additional assessments. It may be that the wording of the question, which referred to additional assessments following identification, may have misled respondents. Alternatively, it may be that once admitted the focus in these units would be on treatment following prior assessments.

6.14 The data from the case recording forms present a less ambiguous picture. The forms asked for information on additional assessments undertaken either in the previous 12 months or since admission, whichever was most recent. Table 6.1 summarises the responses for the sample of people in each setting for whom case recording forms were completed.

Table 6.1 People receiving additional assessments following identification, by type of secure setting

6.15 The majority of people appear to have had additional assessments. The 'Don't Know' responses perhaps again reflect a misunderstanding. From interviews with staff of the secure accommodation units, for example, it is clear that children and young people routinely undergo extensive multi-disciplinary assessment of need and this is regarded as a core function.

6.16 All 4 of those in learning disability in-patient units who had not had additional assessments had recently been transferred following the closure of other units. Assessments of need may have been undertaken prior to transfer.

6.17 Of the 4 people within the prisons who had not had additional assessments 2 were on remand. This may limit opportunities for the units to arrange more detailed assessments.

6.18 The data from the case recording forms suggest that additional assessments would be undertaken for 5 overlapping reasons:

• To obtain information on someone newly referred, including to provide information to a court or Children's Hearing panel to inform decision-making
• In response to a specific need, or a change in need
• To inform care or treatment plans
• As part of on-going routine assessment
• To inform discharge or future planning

Scope of assessments

6.19 From the case recording information data it appears that across settings mental health and physical health care needs were being assessed. Offending behaviour and/or 'other challenging behaviour' were also reviewed. Fewer people however appeared to have their social welfare and education/training needs assessed. This is illustrated in table 6.2.

Table 6.2 Social work and education/training assessments undertaken by type of secure setting

6.20 It can not be assumed that everyone requires a social welfare or education/training assessment, but given the reasons cited for undertaking assessments the comparatively infrequent assessment of social welfare and education/training needs is significant. A number of inter-linked reasons may account for this emerging pattern, and may also begin to suggest why, for some units, obtaining additional assessments is felt to work 'less well'.

6.21 First, resource availability. The specialist unit for people with learning disabilities on the State Hospital site, has a level of on-site social work input described as double that available to the continuing care wards. This may partly explain the greater number of social welfare assessments. Within the prisons, criminal justice social work departments may not have the capacity to routinely assess people identified as having a learning disability and/or ASD, especially if they are not being released on licence. Other in-patient units, outwith the State Hospital, particularly those providing long stay care may also not have ready access to social work resources for assessment.

6.22 Across settings, issues of capacity and the limited links with and between different agencies may mean that there are fewer opportunities for cross-agency joint working at the point of assessment. This emerges particularly in relation to the prisons where education and social work departments, for example, may undertake their own independent assessments.

6.23 A number of these issues are underlined when attention turns to contributors and co-ordinators of assessments of need.

Contributors to assessments of need

6.24 Across settings there is evidence of multi-disciplinary assessment, but the number and range of contributors is variable.

Secure accommodation for children

6.25 The secure accommodation units included within the sample shared an ethos of seeking internal and external multi-disciplinary/multi-agency working. This is demonstrated by the range of people involved in assessing the needs of one young person. These included the young person, their family and GP, community social work team, consultant psychiatrist, clinical forensic psychologist, educational psychologist and unit teaching and nursing staff. In addition contacts were made with health, education and social work professionals involved with the person before they were admitted.

6.26 Staff within the units commented not just on the involvement of different disciplines but the integration of different inputs:

"The beauty of X school is that they work in a multi-disciplinary way. For any one case they will get together as a team …Don't just do one's own bit but identify things to refer on or discuss."

The prisons

6.27 Within the prisons there is an evident aspiration, across disciplines, to take a multi-disciplinary approach. But there are barriers limiting the breadth and depth of joint working. The quantitative and qualitative data suggest 2 patterns: joint assessment across a small core of disciplines; and independent assessment.

6.28 Data from the case recording forms reveal that the core disciplines involved in additional assessments were prison nursing staff, medical officers and prison officers. In addition, in some cases, social work/ criminal justice social work and consultant psychiatry contributed. In one case study prison the RNMH-trained nurse would be able to contribute to assessments of people identified as having a learning disability. There may also be contact with professionals known to the individual prior to incarceration. But beyond this core the range of those involved in assessments appears limited.

6.29 Of the sample of 4 people who received additional assessments only in one case was it indicated that they contributed to their own assessment. No families were involved. Also absent were assessments by clinical psychology, education/training and speech and language therapy. The latter is especially significant given that 5 out of the 9 people for whom case recording forms were completed were believed to have communication difficulties. For 3 people these difficulties were seen as being due to both cognitive and speech difficulties.

6.30 The second pattern within the prisons is of independent, rather than joint assessments. Unless someone was on ACT, the SPS suicide strategy, contact between health care and social work may be "limited". Prison unit managers in one prison also alluded to what they perceived to be the constrained capacity of the prison social work department to attend "team meetings".

6.31 Prison-based education staff may undertake their own assessment and develop a learning plan, but the prison health care centre would not necessarily know if individual prisoners were using the education centre.

6.32 Criminal justice social workers based in one prison raised another obstacle to jointness: a lack of clarity over responsibility for undertaking community care assessments for prisoners. The prison team related how the local social work department community care team saw these assessments as being the responsibility of criminal justice team. The prison-based team, however, felt that they had neither the expertise nor the knowledge base to undertake community care assessments. Further, they were not clear whether these assessments came within the scope of the social work department's service contract with SPS.

The State Hospital

6.33 Across the State Hospital units the data suggest a breadth of clinical input to assessment, including medical, nursing, psychology, OT and speech and language therapy, as well as teaching/training and security staff. Hospital social workers would also anticipate undertaking assessments on all admissions. The breadth of contributors may be a testament to the introduction of integrated care pathways, enabling each discipline to contribute to the "pool" of assessments. But, although there was some contact with professionals who had known individuals prior to admission, there may be an argument for saying that assessment is largely 'inward facing' - reflecting the disciplines and expertise available on the State Hospital site.

6.34 Given the length of stay of many of the State Hospital patients the apparently limited input from external agencies in 'assessment' may not be surprising. But, as in the context of the prisons, it may raise questions about on-going 'ownership' and responsibilities for individuals. This may have implications for forward planning.

6.35 All 7 people in the sample from the specialist learning disability unit on the State Hospital site and their families were described as contributing to the assessments. This was less in evidence on the other wards. No advocates were involved in relation to people on the learning disabilities unit, one, however, contributed to an assessment on another ward.

In-patient units for people with learning disabilities and for people with mental health problems

6.36 The in-patient learning disability units shared a similar pattern to the State Hospital units in terms of the breadth of in-house clinical input to assessment. Speech and language assessments had, however, only been undertaken in relation to 3 of the 8 people believed to have communication difficulties. Given the length of stay of some people it may have been that these assessments had taken place at some prior point in time. In 2 cases community based social workers were involved in the assessments. There was also some contact with professionals who had known the individuals before admission.

6.37 The majority of the sample of people in the learning disability units had contributed to their own assessments, but in only 4 cases were families also involved. This could be in part due to the inappropriateness of relative involvement, or lack of on-going contact. In only one case was an independent advocate involved.

6.38 Across the small number of cases in psychiatric units outwith the State Hospital, the range of contributors to additional assessments was quite extensive, including medical, nursing, psychology, OT and social work members of clinical teams. In addition to external contacts familiar with the individual, 3 people and their families, out of 5, contributed to the assessments. Independent advocates were involved in 2 cases, the welfare guardian of one of these was also involved.

Co-ordinating and recording assessments

6.39 Having access to a range of different assessments does not necessarily add up to a whole picture. To ensure integration as well as joint working also relies on mechanisms for co-ordinating and recording additional assessments.

Co-ordinating assessments

6.40 The case recording form data suggest that across settings 3 different approaches were adopted to co-ordinating the assessment.

Multi-disciplinary team responsibility. The majority of the prisons and the wards on the State Hospital site interpreted 'co-ordination' as a joint function, albeit in the case of the wards, one that was led by the Responsible Medical Officer

A medical or nursing responsibility. In the majority of the learning disability units medical or nursing staff were seen as responsible for co-ordinating assessments

The function of a specific individual. The additional assessments of one young person in secure accommodation were co-ordinated by the assessment unit manager; an MHO and a social worker were responsible for co-ordinating the assessments of one person each in the psychiatric units. "Keyworkers" were described as co-ordinators for 2 people in learning disability units

Recording assessments

6.41 In the policy context of Joint Future and the gradual introduction across all community care groups of single shared assessment, the mechanisms used to record assessment is a further indicator of joint working.

6.42 Across the sample, 2 of the in-patient learning disability units and 2 of the psychiatric units specifically referred to using single shared assessment. One State Hospital unit also referred to "shared assessment". Elsewhere reference tended to be made to multi-disciplinary team notes or treatment plans. For one person in prison, and 11 people in in-patient learning disability units, however, information was recorded in medical and/or nursing notes only.

RISK ASSESSMENT AND OTHER TOOLS

6.43 The case recording forms asked respondents to indicate what, if any, risk assessments, had been undertaken in relation to the individual over the previous 12 months, or since admission (whichever was most recent).

6.44 Suicide/self harm was the most frequently cited form of risk assessment across the sample. For example, 8 of the 9 people in the prison sample had been assessed under ACT, the SPS suicide prevention strategy.

6.45 Risk assessment is also a central function of the SPS sentence management process. One prison for example, described the work of the multi-disciplinary risk management group in obtaining risk reports. A psychologist on the group, however, had not to date been asked to undertake an assessment on someone with a learning disability.

6.46 In the majority of cases and secure settings the 'tools' used were the 'clinical team' or local assessment tools. One in-patient learning disability unit referred to RAMAS (Risk Assessment and Management System). One secure accommodation unit in the sample made specific reference to using YLSI - a needs and screening tool adapted for adolescents for use by non-clinical staff.

6.47 The secure accommodation units described a battery of different assessments. One unit indicated that for children or young people with sexually aggressive behaviour this would include risk assessments specific to sex offenders.

6.48 Although not a specific focus of this study, 2 themes emerged from an overview of the risk and other assessment tools used. First, the expertise vested in clinical teams or individuals tends to be the main 'tool' used. Second, where specific tools are used they tend to be 'generic'. It is not clear to what extent they can, or are able to be adapted for people with learning disabilities and/or ASD.

CARE PLANNING

Care planning

6.49 The above outlines the assessment processes in each of the selected secure settings. In chapter 7 the responsiveness and capacity of settings to meet identified needs is described. The link between these 2 is the care plan. Unit recording form responses indicate that for the majority of units care planning was an aspect of their work that they felt worked well.

6.50 No definition of a care plan was given in the case recording forms, but across secure settings the majority of the sample for whom forms were completed had what respondents regarded as a care plan. The proportion was slightly lower in the prisons, but even here 5 out of 9 people had some sort of plan of action.

6.51 Convicted prisoners also have the option of participating in the SPS sentence management process. An action plan will be developed following a needs and risk assessment. Although the focus is on offending behaviour and risks of re-offending, as suggested earlier, the process provides an opportunity to identify and address specific care needs as well as pre-liberation planning.

Person-centred care planning

6.52 There are clearly attempts to prepare plans in response to identified individual needs. In the prisons, for example, attempts may be made, in liaison with hall staff, to adapt a routine to meet the needs of an individual with learning disabilities and/or ASD.

6.53 Within the secure accommodation units the emphasis was on tailor-made care planning. As the respondent in one unit commented:

"The care plan is geared towards the young person, their own strengths and needs."

6.54 Treatment plans for people on the State Hospital include a nurse based plan formulated by the keyworker and the patient. The Patient Activities and Recreation Service (PARS) was also increasingly tailoring services to meet individual needs. Describing how one of the PARS staff now attends clinical team meetings one practitioner commented:

"This did not happen in the past. This is an enormous change and is of great value. Staff are now sitting down with patients to find out personal likes and dislikes and any deficits to address..and, with the OT looking at specific activities. Feeding back assessments then forms part of the treatment plan."

6.55 With the exception of the secure accommodation units for children, what does not come across strongly is a sense of the plans produced by the different settings being person-centred: that is, part of a collaborative process which is informed by the individual, as far as practicable. The information collected for the current study is perhaps insufficient to draw conclusions, but as the example from the State Hospital suggests, processes may be in transition and approaches with a common currency 'outside', may be slower to take a foothold in secure settings. It was suggested in one secure setting, for example, that person-centred approaches in the context of planning for discharge may be an unfamiliar concept with which some staff may still feel uncomfortable.

Care plan function

6.56 The care plans for children and young people in secure accommodation would include health, education, care and relationships/contact needs. Once formulated the plan was seen as serving 2 functions: to inform the sessional work to be carried out in the areas identified; and to begin the process of forward planning. One secure accommodation unit, for example, described how an "exit plan is sought from day one so that people do not feel they have been taken from the community and left in [unit]".

6.57 The 'treatment plans' for people in the State Hospital were similarly dual purpose, including informing current activity and discharge planning. One respondent described how treatment plans were now a mechanism for "starting to plan discharge from the point of admission".

6.58 Within the prisons the care plans focused on supporting and managing the person in the secure setting.

Monitoring and reviewing care plans

6.59 In healthcare settings responsibility for monitoring the care plans was seen as a medical or nursing and/or multi-disciplinary team responsibility. In 3 health care settings, outwith the State Hospital, a social worker or 'care manager' was identified as solely or jointly responsible for monitoring the care plan.

6.60 Social workers from a child or young person's area of residence would be responsible for monitoring the care plans of their clients in secure accommodation.

6.61 Within the prisons responsibility for monitoring plans lay with prison officers and/or nursing teams. In one case social work, nursing and prison officers were seen as jointly responsible.

6.62 The frequency with which plans were reviewed varied from 'on-going', particularly in the prisons through weekly, quarterly, 4-monthly, to annually for 6 people in learning disability units.

6.63 Looked After Children reviews would be held in relation to young people in secure accommodation. For those referred via the Children's Panels a multi-disciplinary review would be held to formulate recommendations for the hearing.

6.64 The State Hospital reviews, held quarterly or 4-monthly, would involve patients and their families to the extent that they are informed of the review in advance and subsequently receive feedback. A feedback form has been designed so that someone with a learning disability can understand what is discussed. In the feedback session with the RMO the individual can also have their advocate present. Nevertheless, neither the individual nor their family are invited to attend the reviews. This is in contrast to the ethos in the secure accommodation for children where young people are "actively encouraged" to attend reviews, as are families, where appropriate.

EXAMPLES OF PRACTICE

6.65 Across the settings there are examples of joint assessment and multi-disciplinary working:

• In one prison, for example, in response to the identified needs of one person with Asperger's syndrome, the prison healthcare centre was proactive in contacting the court based social worker and the psychiatrist preparing a report. On the basis of the information jointly provided the court placed the person in a specialist resource on a supervision order
• The holistic approach to assessment described by the secure accommodation units
• The State Hospital integrated care pathway

6.66 A number of examples were given where care planning was used to effect change:

• State Hospital staff described how, following a visit to observe an approach used in the US they undertook a comprehensive review of one person's care and treatment. This then informed the care plan
• One secure accommodation unit described how in developing a care plan they would seek to "manipulate success" for a child, planning the day to avoid areas which might cause difficulties such as stimulating the child to throw a tantrum

DISCUSSION

6.67 From this review of the processes of assessment and care planning in secure settings 4 key issues emerge.

6.68 First, people with learning disabilities and/or ASD across the secure settings are to a great extent receiving additional assessments.

6.69 The second finding, however, is the variable depth and breadth of those contributing to the assessment and care planning. This has a number of dimensions. Across non-health care settings there is apparently limited involvement of specialists in learning disabilities. This may have implications insofar as assessment, including risk assessment, tends to draw on expertise and tools not specific to the needs of people with learning disabilities and/or ASD. A lack of input at the stage of assessment may also have implications for on-going responsibility for people once they leave the secure care setting. The State Hospital and learning disability units appeared to be able to draw on the greatest range of professions to contribute including specialists in learning disabilities, but to a lesser extent agencies and professionals from outside. Again this may have implications in respect of forward planning for people.

6.70 A third finding relates to the degree of 'jointness' or partnership working in assessment. This too has a number of dimensions. First, although there is multi-disciplinary working in the sense of contributions to assessment and care planning, what comes across is a series of multiple, rather than a single, shared assessment. Further, there is still the potential for different components of a service to undertake multiple assessments, for example prison health care, social work and education. In addition, with the exception of the secure accommodation units, there is variable involvement of the person with learning disabilities and/or ASD, their advocate or their relatives in these processes.

6.71 Finally, what does emerge is a sense of parallel processes in operation for people with learning disabilities and/or ASD in secure settings and those available, or proposed for people living in the community. As already noted, the mechanism of single shared assessment has yet to make an impact in these environments. The review of learning disability services, The same as you? (Scottish Executive, 2000) proposed the development of Personal Life Plans for everyone who has a learning disability and wants such a plan. Even more than single shared assessment, this has yet to appear in the discourse of these units. The one exception is the annual report prepared by the specialist unit for people with learning disabilities on the State Hospital site. This refers to the development of Personal Life Plans as one of a number of "specific issues yet to be addressed". The same as you? also recommends the appointment of Local Area Co-ordinators to support people and ensure services are in place to meet their needs. The implications of this too for people in secure settings could warrant further consideration.

KEY POINTS

• Comparing across the settings, the secure accommodation units for children had access to the widest range of contributors to assessment from both within and outwith the units
• Within the prisons, there is evidence of multi-disciplinary input but the range of resources appears more circumscribed. There also does not appear to be a systematic approach to actively involving users in the assessment process
• The State Hospital, learning disability and psychiatric units appear to have a broad range of assessment resources to draw upon. These are largely internal to the units
• Both in relation to the State Hospital units and the in-patient units for people with learning disabilities, there may be a lack, in one form or another, of external voices to contribute to assessments. This includes independent advocacy or relatives, where appropriate
• Co-ordinating assessments may be a single or joint responsibility. Recording mechanisms too, may be a single set of notes or profession specific
• Risk assessments tend to be based on professional expertise or generic tools
• The majority of people in the sample had some form of needs led, if not person-centred, care plan
• Care plans prepared by the State Hospital and secure accommodation for children had the dual purpose of informing current activities and interventions and planning for the future. Within the prisons the focus at the care planning stage tended to be more on the here and now
• From the descriptions of assessment and care planning it would seem that a number of recent relevant policy initiatives, including single shared assessment, personal life plans and the involvement of local area co-ordinators do not yet have currency within the secure settings in which people with learning disabilities and/or ASD may find themselves

« Previous | Contents | Next »