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Introduction Beginnings Making sense of the information Deciding what to do Reviewing the plan

Stage 3 - Deciding what to do

Case Information

  • Kristina identifies problems of social transition - from dependent to independent adult. The social worker discusses with Kristina what she thinks her problems are, itemising them in more detail: prioritising them, breaking them down into small stages; making a written agreement and allocating the tasks; taking a stage at a time and achieving small successes incrementally in a limited, specified time period of a month at a time.
  • Care needs to be taken to ensure that the assessment of the situations of Marta, Jan and Kristina is not agency centred but is user and carer centred. The assessment should be needs led rather than service led. It should be multi-disciplinary and should involve them integrally in the process.
  • Team members identify a danger of assumptions made due to knowledge gaps about the culture of the family. This may lead to discrimination.
  • The team adopt a holistic approach. They decide to work with all three members of the family in different ways to improve their quality of life, individually and collectively. Three practitioners are allocated to work with the three family members, individually and jointly.
  • The social worker intends to work with Kristina to meet her emotional, personal health and educational and social needs. This is an ambitious goal. Kristina has identified all of these as her own ideals for herself. The social worker develops these with Kristina as part of the person centred approach to planning.
  • As part of her immediate goals, Kristina wants to go to work. She wants skills and she wants to go out socially, with girlfriends and eventually with men. These are her problems, her goals prioritised by her. The social worker enables her to apply for a job. She secures a job as waitress in a local hotel in Fenton.
  • Kristina has heard the local Further Education college runs GNVQ and NVQ courses in catering for people with disabilities. She wants to go to college. She needs help in learning the route, via a bus before she can travel it herself. It takes many times. The social worker employs a volunteer to help Kristina practise. Kristina has found out that the college runs courses specifically to meet the needs of disabled people and has facilities to enable carers and personal assistants to attend. At the local further education college, Kristina could choose to join a course to learn skills in Information Technology and social interaction. She enrols on a numeracy course. This enables her to cope with guests in the dining room at the hotel.
  • Following a task-based approach, Kristina's tasks are broken into sub-tasks so they don't become too demanding and too stressful, and so unattainable. At the same time, the advantage of her applying to be a waitress is that the hotel work can be varied and demanding in the dining room, with many tasks to be performed such as interacting with guests, rather than in the kitchen or as a chamber maid. Perceiving this, the worker avoids stigmatising Kristina and discriminate against her. She enables Kristina to find work which brings her into contact with people rather than perpetuating her isolation.
  • With Marta, freedom from Kristina relieved Marta of the task of carer for that time. Marta returns to considering her goals. She joins a choir at the local further education college.
  • On the negative side, Kristina's actions over the following few weeks later cause concern by Marta. Kristina fails to return home one night. the police trace her, after she is seen in the Fenton shopping arcade. She is accompanied by a young man known to the police. She later tells the social worker she was approached by a young man aged 19. He asked her to have sex with him. She refused but gave him details of where she was at work. He called on her at work several times over the next two or three days. On the last occasion she went to his flat with him and had sex. His friends were there. She did not want to have sex with them and escaped. She accused him of raping her but later withdrew the allegation.
  • Although Kristina is over 18, there is still a concern for her safety. This triggers the Vulnerable Adults policy, based on No Secrets (DoH/Home Office, 2003). Some practitioners in the team have argued this should have happened earlier. The activation of the Vulnerable Adults policy leads to a Strategy Meeting followed by a Case Conference. As part of this, it is necessary to resolve issues concerning the involvement of Jan and Marta as carers and Kristina as the client.
  • Even though Kristina withdrew the allegation, some practitioners in the team argue the agency is still statutorily bound to pursue the investigation of the alleged rape with the police. Members of the Vulnerable Adults Steering Group includes police and people with experience of rape counselling, who can advise practitioners in the team about practice dilemmas and related issues at this point. The duty of care, local risk procedure in the context of statutory Vulnerable Adults policies and the risks to Kristina have to be balanced against her stated wish to resume her plans for independent living and work without delay.
  • There is another incident. This time Kristina apparently cat-called a man outside work. He hung around. She kept displaying and making suggestive comments to him. he followed her after work and, according to her, raped her. She tells her parents on arriving home. Her father rejects her and tries to throw her out. She runs down the road in a very distressed state.
  • Kristina is very upset her father hasn't believed her allegation of rape. She takes some pills and collapses at the bus station. A bus inspector finds her slumped on a bench and calls an ambulance. She has muttered about trying to kill herself. The para-medical staff assume she has taken an overdose. She is admitted to a psychiatric ward in the local general hospital, voluntarily. She stays there two days and nights.
  • The hospital staff, led by the consultant psychiatrist's assessment, are preparing to discharge Kristina on the second day. There is a meeting at the hospital involving the multi-disciplinary team and Kristina. This is a Pre-Discharge Planning Meeting and it follows health trust policy, through the hospital discharge procedure. The psychiatrist's assessment is the incident has been exaggerated. The pills were identified as vitamin pills and were non-lethal. She has said she did not intend to kill herself. As an aside, the nurse’s report to the social worker she has talked about sex a lot to staff and other patients while on the ward. The psychiatrist considers this matter can be referred back to the practitioners already working with Kristina and her family. There is deemed to be no need for formal psychiatric involvement in following up Kristina.
  • Kristina's parents are very anxious about what is happening to her. They need much reassurance. The other practitioners working with Jan and Marta check out with them whether they wish to change their minds and request a separate carers' assessment. The social worker is trying to understand Kristina's bizarre and contradictory behaviour, which is making her increasingly vulnerable, in terms of her life skills and the strategies she develops to cope with her new, challenging and somewhat intimidating lifestyle. She finds it exciting and stimulating. But she feels lonely and insecure and easily rejected as well. The social worker hypothesises Kristina is overcompensating for this by trying to ensure young men like her and are attracted to her.
  • A plan is devised in the work with her to enable Kristina to extend her repertoire of social skills of interaction with other young people, so as to give her a range of techniques, so she doesn't resort to the extreme of offering to go to bed with every young man she wants to meet and chat with further.
  • For a time, after Kristina exposes her breasts in the canteen at college, the care manager discusses this with college staff and the key worker and decides she should stop attending for a while and return to attending the day centre for a while.
  • This has some success. After a month, Kristina rejoins the college course.
  • At a subsequent review, it is stated Kristina no longer deals with change, novelty and the fear of rejection by becoming seductive, outwardly aggressive, or directing her aggression inwards and harming herself. Her key worker considers this could be attention seeking behaviour, a cry for help. Again, strategies are devised to give her alternative ways of seeking help, which don't leave her increasingly vulnerable and at risk of harm.
  • There are cultural and generational aspects to the practical problems of dealing with diversity within the family. How do Kristina's parents equip themselves as carers? For instance, what do they believe and feel about their daughter's sexuality? Do they believe she has the right to have a sexually active lifestyle? They may say they don't want Kristina as their disabled child to learn about sexuality. But this is oppressive and a denial of rights. Kristina's confidence may be undermined by this attitude. This raises questions about what and how each family member been taught, how she/he learns and what training is available.
  • The social worker persuades Kristina of the benefits of joining a self-help group for young women and to her surprise Kristina readily agrees to attend a meeting on a trial basis.
  • The overall care coordinator for the family needs to check to ascertain if any family member is, as it were, be losing out in this household? How should the somewhat marginal situation of Jan, as father in the family, be acknowledged and his needs tackled? Jan is losing his job. His wife is becoming independent. What can the agency offer? Is there a briefing service or Polish Club which can help Jan in particular? Jan's care coordinator discusses this with him, finds out there is and, of his own volition, Jan starts to attend a fortnightly luncheon club.

Key Questions

  • How will practitioners work with Jan, Marta and Kristina to prepare the task centred plan?
  • How will practitioners prioritise the risk and vulnerability of Kristina which has emerged from recent events in her life?
  • Will Kristina, in particular, accept help?
  • What implications does Kristina's behaviour have for the assumptions practitioners have made about her Down's Syndrome being mild?
  • What objectives do practitioners need to set?
  • Given that no specific legislation can protect Kristina, as a vulnerable adult, what policies and procedures can protect her?
  • Will Kristina be on the Care Programme Approach (CPA) now (See note under Relevant Knowledge below), given she may have had a diagnosis of reactive depressive episodes, from the consultant psychiatrist, even though the risk is not considered high and she is likely only to be on the standard level of CPA?
  • If Kristina has been put on the CPA, how can good practice be ensured, through her having a risk, crisis and contingency plan, as legally required?
  • Over what period of time should the work extend?
  • Who will do the work?
  • What will the work cost?
  • Are resources available for the plan?

Research Focused Questions

  • What evidence is available about the effectiveness of what is planned?
  • What is the evidence of the consequences of doing nothing?

Relevant Knowledge

Kristina would be on the CPA only if the hospital had not discharged her. otherwise, she would remain with the learning disability team.

Empowering Kristina so she is confident enough to complain if the service falls short of standards may lead to her being labelled as a nuisance. This creates a dilemma for the practitioner but is a basic practice principle.

The publication Valuing People (DoH, 2001) requires that the National Service Framework (NSF) for Mental Health is applied to learning disability. This implies it includes the CPA. There is a risk that the mental health needs of clients with learning disabilities may be neglected. This aspect needs careful monitoring.

Direct payments

Direct payments can be made to Kristina so that she can buy directly services for which she has been assessed. This is carried out under the Direct Payments Act 1996. If Kristina is to live independently in a flat in town, she can employ a worker to come and help her with the cleaning and shopping, checking on her if she is not well.


Kristina is in priority need when wandering around Fenton, under Section 189, Part vii of the Housing Act (1996). This states people vulnerable through age, disability or illness are entitled to special accommodation. Young people considered at risk of physical or sexual abuse may be considered vulnerable, according to the Code of Practice on Homelessness.

Task-centred work

In the first place, the practitioner and the client make what Reid (1978) calls a contract and what Doel and Marsh (1992) call an agreement. Reid finds verbal contracts less intimidating for clients. Doel and Marsh prefer written ones because they are clearer. Kristina is happier with a verbal arrangement.

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