Practice and procedures

With the introduction of the 2003 Act, social workers acting as MHOs became 'designated MHOs' and were even more formally involved in long term engagement with adults with mental disorder and their families. This continuity of contact is particularly important in respect of adults with long term conditions such as dementia and learning disability. MHOs, however, cannot operate alone: they need to apply their legislative duties and exercise powers, alongside other social workers and other key practitioners in the support and protection of adults with mental disorder.

Across the Acts, social workers often act as named welfare guardians and supervise private/relative guardians. They can also have active roles within working care plans for Compulsory Treatment Orders (CTOs), assessing and providing care and support services.

Outwith formal powers, social workers routinely work with mentally disordered adults providing support through a variety of role titles in social work or health and social work integrated teams. Working with adults with dementia with complex needs is a routine part of social work practice. Many social workers are also council officers as identified in the 2007 Act and are familiar with local adult at risk procedures. Applying formal powers across legislation for adults at risk, without collaboration can constitute unsafe practice. Applying formal provisions and underpinning principles in the context of effective joint working is how practice should be developed. The Acts have locked social workers and medical practitioners together as never before both in the application of formal provisions and in response to the assessment and management of risk alongside individuals and families.

Within the 2003 Act, joint working is essential is when protecting adults at risk. Inquiries under section 33 usually involve a social worker or a MHO alongside a medical practitioner, jointly assessing risk and responding to the impact of mental disorder on the adult's health, safety and welfare. Pursuing warrants and involving police colleagues in gaining access to adults and arranging transfer to a place of safety is standard practice. This can be stressful and demanding work and social workers need the support of all colleagues in complex and risky practice environments.

Collaborative working is well established between social workers and key practitioners, such as general practitioners (GPs), approved medical practitioners (AMPs) and responsible medical officers (RMOs). However, in the area of adult support and protection one has to be mindful of problems such as have been highlighted in previous MWC Inquiries, e.g. poor communication, poor sharing of information, not pursuing formal powers where necessary and poor care planning. Adult at risk procedures, risk assessment formats, evidence-based risk enablement and adult protection plans seek to minimise these problems and promote collaborative working.

Collaboration with service users is the primary working relationship. Espoused in the Charter of rights, adults with dementia should have access to accessible information and the support to enable them to exercise their right to participate in decisions which affect them. There should be full participation in needs assessment, planning and arranging care, support and treatment.

Across the Acts, this relationship is confirmed where the principle of service user participation is a common, indeed a statutory, imperative. Legislation has rightly so, over the years, moved from a 'do to' position to a 'do with' philosophy. Practice is empowering of service users and carers. This is demonstrated practically across the legislation with the application of the principle of participation, with an empowerment focus and with attention being paid to ensuring access to advocacy services.

Personalisation talks of service users having 'choice' and 'control'. This is demonstrated practically where the social worker involves a person with dementia in the preparation of a support plan and co-produces the plan as a vehicle to support inclusion and to promote desired access to community-based recreational, social and spiritual supports.

Self-directed support (SDS) allows people to choose how their support is provided to them by giving them as much ongoing control as they want over the individual budget spent on their support. In other words, SDS is the support a person purchases or arranges to meet agreed health and social care outcomes. SDS offers a number of options for getting support. An adult with incapacity, however, may need a financial guardian to obtain and manage the budget on their behalf.

The person's individual budget can be:

• taken as a Direct Payment (a cash payment)
• allocated to a provider the person chooses (sometimes called an individual service fund, where the council holds the budget but the person is in charge of how it is spent)
• held by the local authority which can arrange a service for the supported person
• the supported person can choose a mix of the above options in order to access different types of support.

The social worker, in crossing the Acts with and for adults at risk, needs to be aware of the functions and contribution of key bodies involved in the support and protection of adults affected by mental disorder, e.g. the Mental Health Tribunal, Mental Welfare Commission, the Office of the Public Guardian, the Sheriff Court, and third and independent sector agencies. The social worker should be comfortable working within local authority departments and across its range of services, e.g. legal services, community care, environmental health, education, child care services, housing, etc. and should seek advice and support in complex, high-risk cases.

The application of legislative duties and powers requires tight joint working, where a social worker may both lead and participate in its delivery; for example in adult protection plans (perhaps acting as a council officer) or in care management systems (as a care manager).

Care management is currently a medium for the long term support and protection of adults at risk and where assessment and care planning determines what needs have to be met, how they are going to met, and who and what would meet these needs. It should provide an adequate and responsive framework of care and support, with clear roles, sound communication systems and regular monitoring, all inbuilt; the process tailoring services to individual needs. For adults at risk with dementia, comprehensive and often specialist assessment is required as is intensive care planning and vigilant implementation, monitoring and review.

Care management was introduced in 1991 following the implementation of the NHS and Community Care Act (1990) (the 1990 Act) and updated in 2004 to reflect Joint Futures priorities in the context of the single shared assessments framework. It was acknowledged that care management should be targeted at people with the most complex needs, such as those with dementia, as an activity undertaken by practitioners across health and social.

An essential aspect of care management is of course assessment, and assessment across legislation for adults at risk needs to encompass a range of requirements, eg:

• Of need, where an assessment of needs for community care services is required to access services. The basis of to be found in the 1968 Act s12A as amended by s55 of the 1990 Act.
• Of carer need (assessment as confirmed in the Community Care and Health (Scotland) Act 2002 Act [the 2002 Act); where carers, relatives and friends of people with mental disorder have a particular role, with features in common with other carers, but with needs that are distinctively theirs. Where having to cope with difficult behaviours and risk presents particular personal and emotional stress for carers. Their needs for information and support is very much tied to the needs of the adult, indeed acting as proxies in the care and treatment of people with mental disorder; all the more important to ensure adequate and appropriate support after assessment. This resource devotes a section to working with carers.
• Of welfare, where often an assessment of welfare risk is needed on behalf of an adult, considering what welfare decisions maybe needed on a longer term basis where the adult lacks the capacity to make such decisions for him/herself. A suite of powers, reflective of needs, risks, and impaired capacity in these matters, may then (if necessary) be sought via the sheriff. Social workers should be mindful of the issue of deprivation of liberty when considering the use of s13ZA of the 1968 Act.
• Of capacity, where assessment of capacity should be specifically related to the matters in hand and commensurate to need or risk. In other words, a person with dementia may be incapable of selling a house but capable of deciding what to wear. Guidance amends practice to ensure assessment relates to an adult's condition and circumstances.
• Of risk and management of risk, where the application of the 2007 Act demands risk assessment and adult protection planning, taking account of the principles and definitions, and involving the adult at risk and others at all stages, responding to communication needs and capacity. A risk assessment would weigh up the advantages/disadvantages, gains/losses to the adult's quality of life, or freedom, or independence which might result from actions, within defined comprehensive plans for support and actions, with clearly defined roles, responsibilities, timescales/deadlines and intended outcomes.

In protecting adults at risk with dementia, risk assessment is essential. Social workers, alongside medical practitioners, assess risk while pursuing formal powers, eg:

• the 2003 Act - assessing risk to health, safety and welfare; ill treatment, neglect, deficiency in care, risk to property; offences e.g. risk of sexual offences
• the 2000 Act - assessing risk to personal welfare, finances or property
• the 2007 Act - assessing risk of harm, etc.

Risk assessment, of course, needs to encompass a range of risk areas, e.g. risk to and from others, from self, personal welfare, health, property and finances. A risk assessment also needs to consider a range of needs and circumstances, including referral for a community care assessment. It may also require and incorporate financial, accommodation and benefits assessments, and specialist assessments, such as assessment of capacity, confirmation of mental disorder, and appropriate legislative and treatment options.

A suitable care management system reflects and responds to the complexity of need and the seriousness of risk; and, in some cases, depending on the seriousness of risk factors and whether local programme criteria relate, the care programme approach (the CPA) would be considered.

The CPA was implemented to manage risk in complex circumstances. It can help by providing a structured and intensive form of care management which ensures regular review, good collaboration and a focused, targeted approach between agencies; a way of standardising practice. It provides a risk assessment and a relapse management plan, which may assist vulnerable people achieve long term continuity of care and stability, urgent attention for those at risk or who pose risk to others, and planned, prompt and appropriate admission to hospital.

In supporting and protecting adults at risk affected by mental disorder, a social worker needs to be aware of the management of mental illness, such as dementia, and the differing medical perspectives and frameworks contributing to health care and community care assessments, and how and where to obtain specialist assessments. Social workers need to understand policy, perspectives and frameworks that both promote and impinge on levels of risk, e.g. barriers, poor communication, poor sharing of information, confidentially issues and data protection. We can learn much from relevant MWC deficiency in care inquiries (e.g. the Mrs V report ), predominately to counter and protect against these deficiencies when dealing with risk.

Inquiries and investigations need to be applied in a collaborative and procedural context. Local vulnerable adult procedures were updated after the Scottish Border's case and on the implementation of the 2007 Act. Most procedures have similar processes, e.g. reporting and responding to allegations of harm in defined timescales, potentially leading to investigations, case conferences, action if necessary, delivered in a joint agency context, e.g. West of Scotland adult at risk procedures (extract):

• referral to the local authority within 1 working day and contact with emergency services if required
• initial action within 5 working days to assess referral and to decide if the allegations constitute harmful or non-harmful concerns
  • harmful concerns may lead to investigation;
  • non harmful concerns may result in referral to an appropriate agency for support;
• a formal investigation within 8 working days of the referral
• a recommendation for appropriate action, e.g. an application for a protection order within 10 working days of the referral
• an adult protection case conference within 10 working days to receive the report of the investigation and consider longer term action
• an adult protection plan to be prepared within 10 working days of the case conference.

In protecting adults at risk with dementia, a risk assessment needs to have a consistent format across the agencies and adult protection plans need to have relative content with an emphasis toward protection and management of risk. To assist here the Joint Improvement Team (JIT) introduced risk assessment and adult protection plan formats to coincide with the implementation of the 2007 Act and the development of local adult protection procedures. They prescribe what risk assessments and protection plans should include.

The format has four components:

• core information/data, which should be carried out where an assessment if carried out under adult at risk procedures
• communication requirements, which identifies who is to be involved in the risk assessment and informed of the outcomes
• risk assessment
• the adult protection plan, where an adult protection case conference views necessary.

The protection plan formats cover details such as chronology and patterns of risk, obtaining views of all, listing, detailing and describing risk; providing the who, what, why, where, and when; and the protective factors, recommendations, conclusions with immediate and long term needs and notification to all involved.

An adult protection plan provides the basic structure for managing and responding to risk. The plan would follow the case conference, can stand alone or alongside existing or other care plans, confirms lead workers and a core group, confirms details of support and protection support and the roles of each professional and ensures the active engagement of service user and carers. It defines actions, ensures information sharing, contains a contingency agreement, and confirms review date(s). It should have an alert on local databases indicating a plan is in operation and it would record distribution. It covers support and treatment, control measures (including any legal actions), direct contact with the person, risk management with the perpetrator, information-sharing arrangements, and risk management coordination.