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

Stage 1 - Beginnings

Case Information

  • Ahmed and Kawthar (all names and identities are fictitious) are a couple both aged 76, and living in the Borough of Northport, England, where the percentage of people aged over 70 has risen in the decade since 1991 by 45 per cent. Whilst there is increasing demand for high quality health and social care services for this age group, there are serious pressures on resources. These have led to an initiative in the form of the (fictitious) FirstCare BestCare project, which provides threefold Intermediate Care - rapid response, crisis intervention and rehabilitation - conforming to National Service Frameworks (NSFs).
  • Kawthar's sister contacts the out-of-hours service at the local Community Care Resource Centre and says her sister is having difficulties sleeping. In brief discussion, she reluctantly offers the information that her sister is kept awake trying to feed her husband, who is not sleeping well and is refusing food.
  • The Resource Centre contacts FirstCare immediately. BestCare, provides a rapid response service to people aged 55 and over who require care which is previously unplanned. It is envisaged that during the first 48 hours of this crisis-based service, either the crisis will be resolved or the person will transfer to the longer term BestCare, at home, in residential care or involving a mixture of both. BestCare care packages are based on the principles of promoting the quality of life and independence of people receiving services.
  • The aims of FirstCare BestCare are to respond effectively to crises in people's lives and provide services which minimise their dependence on residential, including hospital-based care, thereby meeting the goals of relevant National Service Frameworks (NSFs).
  • FirstCare and BestCare are run by a multidisciplinary staff team, working on principles of holistic practice. The team comprises social workers, doctors, nurses, district nurses, occupational therapists, physiotherapists, technical instructors and administrative support. Some, for instance the physiotherapists, occupational therapists and technical instructors, spend more time in BestCare than in FirstCare. Other services, such as domiciliary care, are bought in as necessary. Referrals are achieved, and assessments effectively carried out, using links with local Community Care Resource Teams and CareLink services. Nursing and occupational therapy services are supplemented by local agencies providing professional services to individuals.
  • The social worker Stella, from FirstCare, does not feel enabled to visit Kawthar and Ahmed without the couple's permission. She telephones the family home, at first receiving no reply. On the third call, a man answers. She assumes it is Ahmed. His English seems limited. He appears not to understand her.
  • The social worker is aware of many possible explanations for the situation as presented. It is possible Ahmed is ill, or has mental health problems, for instance. She is aware Kawthar did not come to the agency herself. She may have been inhibited or unwilling. There are possible cultural, religious and racial aspects. She may fear her husband will be removed from her care at home. The social worker considers it essential to inform herself about these immediately by contacting a person from an identical ethnic and religious background to Kawthar and Ahmed. A doctor colleague in the team offers information and advice and some preliminary observations about possible medical explanations for Ahmed's apparent condition. She appreciates the doctor reminding her of the necessity to involve a health practitioner immediately if there is any concern about the medical condition of Ahmed.
  • Another possibility is that there is poverty in this household. What does the practitioner know about poverty? How should the practitioner respond to indications of poverty in the family? What organisations may help with family poverty? Is there a Welfare Rights Department in the agency? Is there a local CAB office? These will often visit the homes of older people and help them complete relevant benefits forms.
  • The social worker is concerned to find out immediately whether there is a crisis in the household. They may need crisis intervention. The social worker asks why has Kawthar's sister come in? She speculates that there may be desperate things happening. The question is what lies behind the action.
  • The social worker is aware the response has to conform to the law, to the National Service Framework (NSF) and local agency policy.
  • She decides to visit on the basis that her duty of care overrides the need to seek prior permission from Kawthar and Ahmed.
  • The social worker, visits Kawthar. She finds out Kawthar's husband, Ahmed, is severely undernourished and dehydrated.
A number of questions are generated by the process of evidence based practice. These are, first, practice-linked (Key Questions) and evidence-linked (Research Focused).

Key Questions


The practice-linked questions broadly follow the sequence of the evidence-based approach, focusing in turn on theories and concepts, needs, outcomes and services. In other words, they illustrate the ideal process the social worker goes through of clarifying what the situation is about, seeking information about the needs of the person receiving services, identifying the level and intensity of the justification for intervention and specifying the response, in terms of services provided. This suggests three separate but linked questions, embedded in the practice throughout this case:
  • What did the social worker consider?
  • What did the social worker decide?
  • What did the social worker do?
Moving on, here are the key questions triggered by this paragraph, bearing in mind this is a preliminary list, before the social worker proceeds, largely focused on justifying proceeding further.

Values-based Questions

Values questions come first and arise from the social worker's personal and professional beliefs and assumptions. These will be threaded throughout the work the practitioner does with Ahmed, Kawthar and other family members:
  • How do values of respect for persons and person-centredness correspond with the values of Ahmed and Kawthar's ethnic community?
  • What should the social worker do at the outset to try to ensure family members are empowered?
  • What cultural and language factors does the social worker need to take account of at the outset?

Other questions are more practice-led, covering three embedded and linked questions:

  • What did the social worker consider?
  • What did the social worker decide?
  • What did the social worker do?

Practice-led Questions

  • What is going on in this household? What interpreters are needed? What does the practitioner need to know about religious beliefs and culture in order not to offend the family members?
  • Are they Muslim?
  • What information can Kawthar give about herself?
  • What information can Ahmed provide?
  • What information can other family members, such as Kawthar's sister, give?
  • How far can the social worker or care manager tackle the dilemma of whether the care plan is client-centred/needs-led or resources-led?
  • How can the social worker maintain awareness of the needs of people from ethnic minorities?
  • How far is the practice in this case anti-racist?
  • What are the practitioner's legal duties, powers and responsibilities?
  • What are the agency's policies?
  • What strengths are there in this family?
  • How can the social worker encourage and build on the strengths of the family, such as the apparent wish of Kawthar to stay independent and manage for herself?
  • To this end of staying independent, what risks might family members be prepared to take for themselves?
  • How does the social worker ensure the practice is according to
    • values and ethical standards
    • cultural, religious requirements
    • agency Policy e.g. on Confidentiality
    • National Occupational Standards
    • NSF
    • Codes of Practice for Social Care Workers and Employers?
  • What practice needs developing in order to avoid contravening Vulnerable Adult policies (concerning Adult Protection)?

Research Focused Questions

We turn now to the kinds of evidence which will link with, or back up (if we are fortunate) the thinking, decisions and actions of the social worker about whether, and if so how, to proceed. You should bear in mind the evidence based approach is just that, an approach, not an answer. Research-mindedness is an attitude to cultivate. Just as research findings often are complex and generate further questions and debates, so practice cannot rely on them to justify decisions and actions and close doors to further discussion and doubt. Research will make those discussions better informed.
At this point, we need to recognise different sorts of evidence relate to and are inherent in practice. Some relate to values, others to concepts and knowledge and others to skills. They are all research-based, and thus constitute the evidence justifying practice. But the messiness and complexity of the situations social workers deal with means there is no single piece of scientifically conducted research, with proven results, which guarantees that doing the job this or that way will produce the desired outcome.

Whilst there is not a hard and fast division, some of the questions are more knowledge-based, others are more skills-related:

Knowledge-based questions

  • What possible causes are there for Ahmed's sleep problems?
  • Does Ahmed have a history of medical problems which would be accompanied by sleeplessness?
  • The psycho-geriatrician has seen Ahmed and offered a preliminary diagnosis of dementia. There is no perception of dementia in the household. Is this because of cultural differences? Are there other possible explanations of Ahmed's symptoms? Is Ahmed experiencing the rapid onset of dementia?
  • How do practitioners involved with the couple promote best practice, given the language difficulties of communication?
  • What can be found out in general about how members of Ahmed's ethnic community regard and respond to dementia?

Skills-related questions

  • What level of risk is there to Ahmed if a full assessment confirms he is suffering from dementia and if he continues untreated in his present condition?
  • How can practitioners empower family members whilst ensuring this level of risk is managed and they can cope with it?


Relevant Knowledge

Ethnicity and Racism

It is necessary to acknowledge that the social worker is not from the same ethnic background as the family. The practice is more likely to be effective if the social worker accepts this limitation on her part. Also, there are questions about how effective communication is, in view of some family members having difficulties speaking, writing and understanding English.

Not only ethnicity but also racism needs to be considered in care planning. The following are good sources of information:

Cameron, E., Badger, F. and Evers, H. (1996) 'Ethnicity and Care Management' in Phillips, J. and Penhale, B. (eds) Reviewing Care Management for Older People, London, Jessica Kingsley chapter 10 pp. 117-33
Eribo, L. (1991) The Support You Need: Information for Carers of Afro-Caribbean Elderly People, London, Kings Fund Centre
Ahmad, W. and Walker, R. (1997) ‘Asian Older People: Housing, Health and Access to Services’ Ageing and Society 17/2:141-165.
Ahmad, W. (ed) (2000) Ethnicity, Disability and Chronic Illness, Open University Press.
Ahmad, W. and Atkin, K. (eds) (1996) ‘Race’ and Community Care, Open University Press.
Robinson, L. (1998) ‘Race’, Communication and the Caring Professions, Open University Press.

Relevant National Standards of Care

DoH (2001) National Service Framework (NSF) for Older People London, DoH provides performance measures ensuring progress and improvement of services for older people in residential care, hospitals, day care and in their own homes.

For further details and discussion of the modernisation agenda in community care see:
Means, Richards and Smith (2003)

For overview of mental health provision for elders see
Audit Commission (2000) Forget Me Not, Mental Health Services for Older People, Audit Commission.
Audit Commission (2002) Forget Me Not, Mental Health Services for Older People (Update 2002), Audit Commission.


Communication skills

  • Effective interaction when working with people requires good communication skills. Joyce Lishman's book is a good source of material on these skills. Lishman, J. (1994)
  • The social worker needs to ensure that an independent person is available as and when required to act as interpreter for best practice.
  • The social worker works on the NSF (DoH, 2001) principle that it is her responsibility, not that of the person receiving services to facilitate communication with Kawthar and Ahmed and other members of their family. She needs to avoid jargon and do everything possible to reduce barriers and power differentials. She makes a second visit shortly afterwards with a community nurse member of the team from a similar ethnic background to Kawthar and Ahmed. This person is an able interpreter. The social worker has in mind Standard 7 of the NSF concerning the need to promote mental health and response appropriately to people suffering from depression and/or dementia.
  • The social worker needs to refer to research contributing to best practice in communicating and working with a person with dementia.
Killick, J. and Allan, K. (2001) Communication and the Care of People with Dementia, Open University Press.

Assessment

  • The legal mandate for assessments is provided by Section 47 of the NHS and Community Care Act 1990.
  • Assessment for older people is driven by the single assessment process, using holistic approaches. This includes ensuring all aspects of a person's circumstances and life are considered by all practitioners involved in the assessment process.
  • The process of care management is dealt with in stages in official guidance:
    Department of Health/Social Services Inspectorate (1991) Care Management and Assessment: Practitioner's Guide London, HMSO.
  • Different models of the assessment process are examined: the procedural model involving matching the service user to specific criteria; the questioning model where the social worker identifies needs and takes decisions based on expert knowledge; and the exchange model where people receiving services are empowered to be equal partners in their assessment. The exchange model is explained by Smale, Tuson, Biehal and Marsh (1993). The person using services is regarded as the expert in his or her own problems. The exchange with the practitioner is based on the view that the practitioner holds resources in problem solving. To illustrate this in assessment with older people see

Richards, S. (2000) ‘Bridging the Divide: Elders and the Assessment Process’, British Journal of Social Work, 30/1:37-49.

  • Assessment does not take place in a vacuum. Neither should it involve merely a set of procedures, questions to be asked from lists on a page, ticks to be put in boxes. Assessment is well described by Beverley Hughes in her practical book on working with older people in community care.
Hughes, B. (1995) Older People and Community Care, Open University Press.

Assessment theories, contexts and practice

Miller and Byrne (1998) guide the practitioner through the process of assessment. Assessment is not only a technical activity. The social worker needs to be aware of theories and assumptions embedded in different approaches to assessment. Also, assessment takes place in various contexts. The outcomes of assessment must be interpreted with reference to these contexts.
The critical practitioner is able to make links between the practice and these contexts.

What do we mean by contexts?

Contexts include the circumstances of the person using services and the carer and their environment, as well as the social worker, other practitioners, their agencies, legal, policy and organisational settings.

Two Useful Approaches to Assessment

1. Sheppard provides a useful framework for assessment. It is used to analyse the nature and level of support required. It distinguishes four types of support: practical (e.g. provision of transport), psychological (e.g. changed sense of powerlessness or low confidence), emotional (e.g. listening to the person's expression of distress) and informational (e.g. information on the nature and origins of depression). The framework links the needs of users with social support systems. It focuses attention on the accompanying planning tasks and on the resources required.
Sheppard, M. (1995) Care Management and the New Social Work: A Critical Analysis, London, Whiting and Birch

2. Kisthart's strengths model of assessment can be regarded as person-centred because the client is regarded as the expert. The approach is based on examining the aspirations and dreams of the client and constructing both short and long-term goals to meet them.
The advantages of the strengths approach are: it motivates clients because they have set their own goals; it normalises the helping process; it emphasises the social rather than the medical model; and it empowers the person receiving services and the carer.
Kisthardt, W.E. (1992) 'A Strengths Model of Case Management: the principles and functions of a helping partnership with persons with persistent mental illness' in Saleebey (1992).

Cost-effective care planning

The study by Challis and colleagues of early trials of care management, compared Gateshead and Kent. It found that it is possible to achieve cost-effective services based on a needs-led, client-focused approach, provided the care planning is segregated from the assessment of needs, thereby avoiding a resource-led approach.
Challis, D. et al (1988) 'Community Care for the Frail Elderly: An Urban Experiment' British Journal of Social Work 18 Supplement pp. 13-42
For more up to date assessment from same team see, for example:
Bauld, L., Chesterman, J., Davies, B., Judge, K. and Mangalore, R. (2000) Caring for Older People, An assessment of community care in the 1990’s, Ashgate.
Ware, T., Matosevic, T., Hardy, B., Knapp, M., Kendall, J. and Forder, J. (2003) ‘Commissioning care services for older people in England: the view from care managers, users and carers’, Ageing and Society, 23/4:411-428.
     
       
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