CAPACITY

Relocation, relocation
In line with government policy of supporting people to live where and with whom they wish, Karen Bamford and Rachael Kasch have developed accessible information and a speech and language therapy process for screening, consultation and referral which puts people with learning disabilities in control.
READ THIS IF YOU WANT TO HELP REDUCE ANXIETY OVER CHANGE PEOPLE MAKE THEIR OWN MAJOR LIFE DECISIONS SHIFT THE CULTURE FROM CARED FOR TO INDEPENDENCE experience of alternatives, a reluctance to consider any kind of change or a genuine desire for this type of setting. Where the persons current accommodation is indicated as their first choice, we are involved in supporting this decision; we either advocate for them to remain there or to relocate to a similar situation with their present level of support. Where the individual lacks experience of other housing options, we provide ideas to carers of how to support them to find out about different types of properties, for example through visiting friends, relatives and show homes. After an agreed period we re-visit the Talking Mats to discuss whether the persons preferences have changed.

Karen

Rachael

any people with learning disabilities do not choose where they live or with whom. Recent government directives have focused on changing this situation and supporting people to live in their own homes as owners or tenants, sharing with groups of friends or living in residential care (DH, 2009). As speech and language therapists this has implications for the focus of our intervention and areas in which we can support these directives. The kind of accommodation people have influences how they view themselves and are viewed by others. Research shows that people who are confident and happy with where they live develop skills and independence and are motivated to seek links with their local community (McConkey, 2007). In 1969, 58,850 people with learning disabilities lived in long stay institutions in England and Wales. Now people are living in their own homes and taking responsibility for tenancy and ownership (Mathieson, 2004). However, in 2001, only 6 per cent of people with learning disabilities chose who they lived with (DH, 2009). Since the introduction of the Mental Capacity Act (MCA) in 2005, the speech and language therapy service in South Birmingham Community Health has been involved in an increasing number of capacity to consent assessments. In 2008 and early 2009 we were involved in a small number regarding change of accommodation on an individual basis. Several social care homes and medium sized residential campuses closed, and more individuals were indicating a preference for the type of accommodation they wanted

to live in. We therefore consulted local advocacy agencies, housing development officers and supported moves social workers regarding how we could support people with learning disabilities to be actively and meaningfully involved in the process of moving house. We developed a process map for change of accommodation which covered communication support from initiation of the move through to the move itself, in three stages (see flowchart in the members area of www.speechmag.com).

Stage 2

Stage 1

We work alongside other agencies, carrying out joint assessments with social workers, housing agencies, advocates and so on. During the first stage, we establish the individuals understanding around change of accommodation (a flowchart is available in the members area of www.speechmag.com), and their ability to use this information to make a decision. We also frequently identify a lack of knowledge from individuals and their families regarding the range of housing and support options available, due to their limited life experience and expectations. For people with communication difficulties, we use a Talking Mats format (also favoured by Venditozzi, 2009) to gather information about an individuals preference around where they currently live and what their ideal living circumstances would be (figure 1). Where the mat for an individuals current accommodation and their ideal housing are the same, we discuss whether this is due to their lack of

The next stage is based on the persons preferences, needs and financial circumstances. The individual is supported by the multidisciplinary team, including family and carers, to make a decision regarding the types of accommodation and support to be sought. Supported living is defined as support to help individuals to live independently in their home and in the community. If this is identified as appropriate, a further decision is required regarding the individuals mental capacity to sign up to a tenancy (for renting a property) or mortgage agreement (for purchasing a property). If a person lacks the mental capacity to sign a tenancy or mortgage agreement, then an application must be made for them to be represented financially by the Court of Protection. Tenancy has been a problematic issue for the agencies involved in recent times (figure 2). Because of the rigidity of mortgage agreements, there is considerably less possibility of adapting these to meet the needs of individuals with communication difficulties; this could only carried out on an individual basis and has not been experienced in our area to date. We have therefore concentrated our main resources on supporting the understanding of individual tenancy agreements. Tenancy agreements are a new concept to many people with learning disabilities due to the tendency towards a cared for culture that still resonates, whilst we move into a long

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011

CAPACITY
Figure 1 Talking Mats Figure 2 Possible issues with tenancies No clarity about legal requirements of tenancy Mental Capacity Act (2005) states that no-one else can sign tenancy on someones behalf Court of Protection application can be a lengthy process No legal precedent regarding requirements or responsibilities Different messages from different agencies Other people involved are invested in the results of a capacity assessment, making an unbiased assessment difficult (for example application to Court of Protection, if someone lacks capacity, would stall the process for a considerable time)

Figure 3 Object format option

awaited new generation of independence. Pieces of work need to be carried out to inform individuals of the constituent parts and implications of a tenancy agreement. We compiled an information booklet outlining the different aspects of tenancy (What is Tenancy?) for people with different levels of symbolic understanding, using Widgit Symbols, Picture Communication Symbols (PCS) and photographs. We also have an option to discuss a tenancy in object format where appropriate (figure 3). Because of the large numbers of people requiring assessment, and a move towards more efficient ways of working, we developed a basic tenancy screen for other professionals to use where our expert knowledge regarding communication is not required. We support this with the use of guidelines, tips and modelling or consultancy. Following this, three options are available: 1. Where a decision can be made by one of the professionals already supporting the person, they complete appropriate capacity documentation. 2. Where a capacity decision cannot be made by one of these people due to communication difficulties highlighted by the screen, they consult speech and language therapy. 3. Where the screen cannot be completed due to complex communication needs, they make a referral to speech and language therapy. When we receive a referral, we compile a

capacity report outlining the clients ability to understand, retain, weigh up and communicate about the different aspects of a tenancy agreement. A multidisciplinary team decision is then made alongside the landlord as to whether this is sufficient for the contract to be enforced. Tenancy agreements have been drawn up based on capacity assessment findings on an individual basis (for example with vocabulary used and specific pictures chosen by the client). Many have been successfully approved and entered into by landlords.

Stage 3

Moving house is anecdotally one of the most stressful life events. Change is often associated with increased levels of anxiety due to lack of perceived control, painful past experience and the fact that it is often imposed, particularly on those with learning disabilities. We want to ensure that we address this to provide as smooth a transition as possible. Once a property is identified for the client, we provide advice to carers about practical ways of supporting clients through the move. This advice is focused towards the individual and their experience, ability and needs. For example, we support carers to develop visual timetables with the individual to record all the events related to moving, such as buying new furniture, decorating, and visits. Having written the process map and utilised the pathway to support the moves of several service users, we came across some issues in implementation:

1. We need commitment from other professionals to develop their competencies to carry out the basic screen effectively, but we did not always get managerial sign-up to allow individuals to follow this process through appropriately. Meetings with managers of other services could be useful to discuss the time demands. 2. As speech and language therapists we are clear that communication starts at the beginning of the process, but often referrals were only made once properties had been found and decisions confirmed. At times we suggested delaying the process to allow the individual service user time to gain more experience and understand the options available to them. Obviously this did not always make us popular! A longer term solution would be to express openly with all other stakeholders when the optimum time for referral to our service would be. 3. We found a large part of our time was spent informing others about the Mental Capacity Act and their roles in relation to it. Often family members are not familiar with the intricacies of the Act and on frequent occasions have thought that, regardless of the assessment findings, they would have the final say. It is vital in the current climate that speech and language therapists are knowledgeable regarding the Mental Capacity Act and the role of communication. An internet search will highlight training courses available to

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011

CAPACITY / IN BRIEF
you locally, and most areas have a policy to support implementation of the Act. Notwithstanding these difficulties, having a process to follow around change of accommodation has been useful for consistency and to clarify expectations. Most importantly we have had some good feedback from service users about how the process ensures that they are in control of where and how they want to live. Whilst this is a small step towards implementing government directives (DH, 2009), we would like to continue to develop this work and encourage SLTP others to do so too. Karen Bamford and Rachael Kasch are speech and language therapists working for Birmingham Community Health Care. For further information or to find out more about the resources they have developed, email slt@bhamcommunity.nhs.uk and see www.speechmag.com/Members/Extras. References Department of Health (2009) Valuing People Now. Available at: http://www.dh.gov.uk/ en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_093377 (Accessed: 12/01/11). Mathieson, A. (2004) Valuing People: more evolution than revolution, Learning Disability in Practice 7(2), pp.8-9. McConkey, R. (2007) Variations in the social inclusion of people with intellectual disabilities in supported living schemes and residential settings, Journal of Intellectual Disability Research 51(3), pp.207-217. Mental Capacity Act (2005) Available at: http://www.legislation.gov.uk/ukpga/2005/9/ contents (Accessed: 12/01/11). Venditozzi, M. (2009) How I help people move on (2): Talking flats, Speech & Language Therapy in Practice Autumn, pp.26-28. Resources Picture Communication Symbols, www. mayer-johnson.com Talking Mats, www.talkingmats.com Widgit symbols, www.widgit.com/symbols/

One lucky contributor in each issue receives 50 in vouchers from Speechmark (www.speechmark.net), which publishes a wide range of practical resources for health and education professionals.

In Brief...

supported by

Talking Mats and dementia

Joan Murphy and Tracey Oliver on the use of Talking Mats in managing daily living discussions for families affected by dementia.

REFLECTIONS DO I APPRECIATE THE WIDER BENEFITS WHEN PEOPLE ARE HAPPY WHERE THEY LIVE? DO I DEVELOP PROCESSES TO PROVIDE CONSISTENCY AND CLARIFY EXPECTATIONS? DO I GIVE SUFFICIENT SUPPORT SO OTHER PROFESSIONALS CAN FULFIL THEIR ROLES?
To comment on the impact this article has had on you, see guidance for Speech & Language Therapy in Practices Critical Friends at www. speechmag.com/About/Friends.

ecent guidance from the government recommends that people with dementia should have more involvement in decisions about their care options. Government policy also states that people with dementia and their carers should influence how government strategies and targets are implemented. Most families try hard to include their relative who has dementia in discussions around their care, but this is often difficult due to the communication and cognitive problems associated with the illness. This latest research, funded by the Joseph Rowntree Foundation and carried out by the Talking Mats team at the University of Stirling, has implications for the improvement and delivery of services. It could also be a significant help for people with dementia and their families The project explored if people with dementia, living at home, and their family carers can use Talking Mats together, to discuss how they are managing daily living activities. Eighteen couples (a person with dementia and a family carer) were involved and were asked to discuss the following topics using Talking Mats and come to agreement together: 1. Personal care (washing, dressing) 2. Getting Around (walking, using the stairs) 3. Housework (cooking, making the bed) 4. Activities (watching TV, listening to music). Following analysis of video data the results showed that both the people with dementia and the family carers felt more involved in discussions about how they were managing their daily living when using Talking Mats, compared to simply having a conversation. They also felt more satisfied with the outcome of those discussions. Two of the key outcomes were: 1. People with dementia reported that Talking Mats helped them to clarify their thoughts, express them to their family carers, and reach a decision in these discussions. One person said: It is so difficult to tell [my wife] what I think when I cant remember the words, the pictures could help me a lot. 2. Although people with dementia and their family carers both felt more involved in discussions when using Talking Mats, the increased feeling of involvement was significantly higher for the family carers,

who repeatedly reported feeling listened to by the person with dementia and felt that their loved one could actually see their point of view. One carer said: It never seems like he is listening to me. With this I can make him sit down and look at symbols and get him to understand what I am trying to say. The study concluded that Talking Mats helped improve communication between people with dementia and their family carers, and this hopefully could lead to improved relationships. Joan Murphy and Tracey Oliver are researchers at the Talking Mats Research & Development Centre, University of Stirling. Resources a copy of the findings and the full report on the project can be found at http:// www.jrf.org.uk/publications/talkingmats-decision-making further information about Talking Mats resources and training is at www. talkingmats.com

Phonology by numbers
Maggie Robinson suggests a simple, easy-toprepare game for working on phonology. Aim To practise using a phoneme in words or sentences. Materials You need approximately 10 picture cards which illustrate items with the target phoneme in target position in their names (15 is the maximum I would suggest). Number the pictures from 1-10, on the front. Method Spread the cards out face down. Take turns to turn over a card and either say the word, or say the word in a sentence. The numbers on the front of the cards have to be placed in order. The player who turns over number 1 can leave it face uppermost on the table. Any other number must be placed back face down. Once number 1 is face uppermost, the player who turns over number 2 can leave that face uppermost, beside the number 1. The game continues until all the pictures are in a line face uppermost. Maggie Robinson is an advanced practitioner speech and language therapist in Skelmersdale, email Margaret.Robinson@centrallancashire.nhs.uk.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011

Reprinted from www.speechmag.com

Ref. Bamford, K. & Kasch, R. (2011) Relocation, relocation, Speech & Language Therapy in Practice Spring, pp.4-6. This is Karen and Rachaels process map for change of accommodation.

Reprinted from www.speechmag.com

Assess the need for house move and the clients understanding around change of accommodation See flowchart 2

FLOWCHART 1

What type of accommodation is sought based on clients needs and preference?

Other accommodation Identified as appropriate

Supported Living Identified as appropriate

Provide accessible What is tenancy? information (available in PCS, Widget & photo)

Consultation with SLT (if needed)

Screen for Capacity around tenancy (see Basic Tenancy Screen)

Referral to SLT Capacity Decision made and documentation complete

Court of Protection

Tenancy to go ahead in appropriate format to be developed for individual Revisit What is Tenancy over months prior to move

Practical ways of supporting move See sheet 4

Reprinted from www.speechmag.com

Ref. Bamford, K. & Kasch, R. (2011) Relocation, relocation, Speech & Language Therapy in Practice Spring, pp.4-6. This is Karen and Rachaels flowchart for establishing an individuals understanding around change of accommodation.

Reprinted Flowchart 2

from www.speechmag.com

ASSESSMENT OF UNDERSTANDING AROUND CHANGE OF ACCOMMODATION IDENTIFICATION What is it like where you live now? (see sheet 4)

WEIGHING UP INFORMATION a. What is good/bad about where you live now? b. What do you want your new home to be like? (see sheet 5)

Is this the same as where you live now?

NO

YES

Do you need to gain more experience of the options available to you?

NO

YES

Can you stay in your current accommodation?

NO

YES

Identify type of accommodation sought (see flowchart 1)

3. GAIN MORE EXPERIENCE (see section 6)