Chapter 55 – Deborah Brady and Fiona Brannelly (D3SOP15)
Domain 3 Standard of Proficiency 15
Be able to identify and document the unmet needs of individual service users and demonstrate an ability to select the appropriate escalation route working with colleagues and the service user to resolve the gap in care.
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KEY TERMS Unmet needs Communication and needs Documenting needs Escalation routes for addressing unmet needs Complaints procedures |
Social care is … advocating for the rights of people to have the life according to their will and preference by being innovative and creative in eliminating barriers. |
Unmet Needs
Unmet needs occur when supports and services are unavailable or inadequate to meet a service user’s will and preference, irrespective of the service. This chapter is written from our many years’ experience as social care workers in disability services. People with disabilities are at a greater risk of their rights and needs not being identified and addressed. These unmet needs can relate to issues such as inadequate access to food sources, exposure and lack of protection from abuse and neglect, inadequate access to housing and respite, and limited family and social relationships, to name a few. In some situations, service users have the skills and abilities necessary to identify and communicate their will and preferences with their family or social care worker (SCW). For a service to meet the needs of the service user they need to gain in-depth information of ‘what is important to the person and what is important for the person’, which is usually contained in their personal plan (HSE 2018: 13).
Personal Plan Diagram (A National Framework for Person-Centred Planning in Services for Persons with a Disability 2018: 13)
This approach puts what matters most to the service-user at the centre of the service in relation to the quality of care and support they access and what needs to happen to ensure they have the life they want. As an SCW you may be appointed as a key worker with responsibility for ensuring that these plans are updated and maintained to reflect the needs of the person you are supporting. These plans should be reviewed regularly and updated to highlight the changing needs of the person. This is done by the SCW, with the service user, their staff team and family/carers to ensure that the service they are receiving meets their current needs. These plans address not only the care and support the person requires but also their will and preference, hopes and dreams.
In the past we have seen many cases and reports of abuse in care such as the Áras Attracta Swinford Review Group 2016 report, which provides evidence of the negative impact of what can happen when the needs of people with disabilities are not addressed and how it can impact on the culture of an organisation. People with disabilities want nothing more than to have a say in their own lives and to gain access to the supports they need to be included in their communities to live an ordinary life (HSE 2018). For years people with disabilities were, based on their cognitive impairment, denied their legal capacity to make their own decisions. This had detrimental effects (Davidson et al. 2018), making them very vulnerable to exploitation and abuse as they were deemed incapable of expressing their wishes or lacking capacity to make their own decisions (Killeen 2016). Decisions were made by professionals and families in their ‘best interest’, not taking into account their will and preference (Carolan 2018).
Examples of this range from lack of the service user’s consent in relation to medical treatments, the services they received, and where or with whom they lived. To ensure a quality service that is meeting the individual’s needs, personal plans are developed with that individual, their families and/or carers which contain valuable information about the individual to ensure that they will receive the service they want. If these plans consistently highlight needs that are not being met, there are different avenues you can take to rectify this. We have used fictional case studies in this chapter to illustrate how we identify and document unmet needs within our sector.
Case Study 1
Identifying Unmet Needs
Social care worker John has been Mary’s key worker for the past three years. Mary has a hearing impairment and is non-verbal with a moderate intellectual disability. She uses a hearing aid and a picture exchange communication system (PECS) to communicate.
One day Mary came into her day service from her home and didn’t follow her usual routine. It is important to note that when someone cannot communicate verbally, staff awareness of the individual’s body language and routines are heightened, as changes in these can be an indication that something is not okay. Mary had a cup of tea but then went up to the physiotherapy bed and lay down. Mary is very inquisitive and likes to be in the company of staff members, so for her to do this is out of character to those who know her well. There was a locum staff working that morning and a permanent staff member who was with another service user. John was at a meeting and afterwards came into the kitchen, where staff drew his attention to Mary. They told him that she may have had a late night and was tired. However, John, who knows Mary very well, became very concerned. He went up to the physiotherapy area and asked Mary if she was okay. When he looked at her he knew she was seriously ill. John quickly informed staff of his concerns and made the decision that he needed to get Mary to hospital and there wasn’t time to wait for an ambulance. He instructed staff to get Mary’s hospital passport and list of medications while he organised transport. John brought Mary to the hospital and even though Mary could not communicate her illness and appeared well to the nurse, John advocated for her to be seen straight away – sometimes service users like Mary do not present symptoms of illness in the same way as the general population.
Mary was diagnosed with sepsis from an untreated urinary tract infection and ended up spending two weeks in hospital. On discharge, a care plan was drawn up for Mary by her service team that included regular urine tests and a referral to urology. A historical search of Marys medical files showed a history of UTIs which was not noted in her recent medical notes, so this was added to her current care plans. Additionally, her communication passport was updated to acknowledge the importance of knowing Mary’s routine and body language.
To be able to identify an unmet need for service users who cannot communicate verbally, you need to have a good knowledge of the person’s will and preference, which is reflected in their normal routines and behaviour. The ability to identify an unmet need early and act on it quickly is an important part of the role of a social care worker.
- On reflection, what are the key issues you identified in this case study and how would you as a SCW address them?
- What strategies and documentation would you have in place to prevent this situation from reoccurring?
Communication and Needs
Needs can be communicated through verbal language, objects of reference, picture exchange communication (PEC) or other communication devices or aids. Consequently, it is vital that family and SCWs have received the necessary training in communication tools and assistive technology. However, in the disability field, we frequently support people with limited communication abilities that can lead to difficulty in identifying and addressing a person’s unmet needs. Therefore, in such circumstances it important that staff are familiar and have a relationship with the people they are supporting. It is also essential to have the necessary training and skills to enable SCWs to decipher the subtle cues (body language, facial expressions, different vocal tones) that service users use to communicate. It is sometimes through these subtle communication cues that we as SCWs can identify and understand a person’s will and preference and thus identify their unmet needs.
Case Study 2
Staff were working with Ann for a number of years. Ann was non-verbal and although social care staff, along with the speech and language team, trialled several communication methods including objects of reference and PECS (through verbal communication and record keeping), Ann would not engage with the process. Consequently, staff would have to rely on their knowledge of Ann and her body language and facial expressions as cues. Several staff recorded that there were several incidents when Ann would stand while on transport. This was a new occurrence, so staff called a meeting as it was a health and safety issue.
TASK 1
What are the key issues you identify in this case study and how would you as an SCW address them?
After the meeting it was decided that we would seek the support of the behaviour specialist. We investigated any changes on the bus: Had the other people on the bus recently changed from where they would usually sit? Was there conflict between service users? Did this happen all the time or only when certain people were on the bus? We also investigated if there was anything from a medical perspective that we needed to address. The staff team are aware that all behaviour is communication, and medical issues/pain can present in many forms in the disability service. After routine blood tests and a scan, it was determined that Ann had gallstones. The appropriate medication was administered, and she were placed on a waiting list for surgery. Since the administration of pain medication, there have been no additional recorded incidents of Ann standing while on transport.
Documenting Needs
To ensure that a person’s unmet needs are addressed, it is vital that SCWs, staff teams and family establish a clear and open communication process. This communication process is supported through the use of written reports and care plans. As part of our duty of care, we are legally obliged to keep written records and these records must be safely stored in line with legislation. Report writing and record keeping are two important elements of the SCW’s professional role in line with current best practice and legislative requirements. It enables SCWs and their co-workers to provide safe and effective services and a continuum of care, while ensuring accountability. In order to ensure that our reports are written to a professional standard there are a few key points you should note.
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How to Write an Effective Report |
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Report writing must: |
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Be understandable, clear and concise. |
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Use objective and neutral language. Reports should not include emotive language or abbreviations. |
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Be completed in a timely manner. |
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The Benefits of Quality Report Writing |
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Report writing allows us as SCWs to provide chronological facts based on practice evidence which support and inform our provision of care and promotes accountability |
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Reports provide effective communication between staff and the multi-disciplinary team. |
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They ensure continuity of care and assist in the detection of risk/complications. |
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They facilitate collaboration between service user and professionals (Parr 2013). |
In line with ‘a person-centred approach’ to service delivery, written records are maintained which contributes to a quality continuum of care for service-users and families. These records are important for the service user and their family and, under the Freedom of Information Act 2014, can be accessed by them. Records can be maintained in a variety of formats, e.g., written notes, emails and documents on iPads, etc. As SCWs it is important that we safeguard the service users’ personal information. The European Union General Data Protection Regulation (GDPR) and the Irish Data Protection Act 2018 provide the framework for record management. One key principle of record keeping is knowing what information to keep, why we require this information, how it may be used, where it came from, how long it should it be kept for and where it should be filed/stored. As SCWs we have a legal obligation to store this information securely. Record keeping is central to accountability, provides the basis for interventions, a context and reasons for decisions made and allows practices to be monitored.
Overall, records should provide clear evidence of the care and support that the service user receives and requires. They should also include their will and preference, their hopes and dreams, changes identified, and that the information is shared with the appropriate individuals. This has clear benefits for early detection and can address potential unmet needs for the person, which in turn may prevent behaviours of challenge or highlight the lack of resources such as speech and language therapy or physiotherapy.
Escalation Routes for Addressing Unmet Needs
When an unmet need has been identified by an SCW from the documentation (such as individual notes, team meeting minutes, monthly progress updates, personal plans, etc.) there are different ways to address the issue. The SCW brings this information to the attention of their social care leader (SCL) individually or at a team meeting where each individual’s progress is discussed. Team meetings should happen regularly, and at these meetings information is shared and concerns are highlighted on each person in the service, to ensure that they are supported by each member of the team.
Taking on board the nature of the unmet need, the SCL will then identify the most appropriate escalation route to address these concerns. This can mean a referral to a member of the multi- disciplinary team (MDT) or, if the individual is already receiving input from a variety of professionals, an MDT review can be called. The MDT will include a number of professionals such as psychologist, behaviour support specialist, occupational therapist, social worker, speech and language therapist and physiotherapist who work together to assess, plan and provide support to the service user and their staff team. SCWs are an integral part of the MDT as they work directly with the service user and can advocate, on behalf of the service user, for unmet needs to be addressed. At an MDT review, a SCW can highlight their concerns, with the support of the SCL. Additionally, if the unmet need is a restriction to the service user’s rights, there will need to be a referral to the human rights committee or social worker in the organisation or externally through an independent advocate from the National Advocacy Service (https://advocacy.ie). Alternatively, the SCL/SCW can support the service user to go directly to their area manager to highlight the unmet need, especially if there is a gap in resources to support the person. A huge part of an SCW’s role is to promote self-advocacy and empower the person to communicate their own unmet needs. Advocacy can be provided through different forums; individually, or part as a group in the person’s day or residential centre, which then can feed into a larger advocacy group where senior management will meet with the group regularly throughout the year. Access to self-advocacy and advocacy supports in general is very important for service users. Taking into account everyone’s input, the manager will then seek resources through completing a business plan for the HSE to attain additional funds to meet those needs. (If there isn’t currently an advocacy group in your service, you can contact the National Advocacy Service.)
Complaint Procedures
If the unmet need is not rectified at a local level, the person can be supported by the SCW to make a complaint. These complaints can be heard and addressed either internally or externally. Most services have an accessible complaints form which can be completed by the person themselves or with support from their family or SCW and forwarded to the local manager and/or complaints officer. Every service should have a complaints procedure in place and SCWs need to be familiar with the correct procedures and policies in their service. These complaints have to be addressed in a timely manner. However, if you are still not happy or if your service does not have an accessible complaints route, then there are different avenues to report their concern such as the HSE’s ‘Your service your say’ complaints process (https://www2.hse.ie/services/hse-complaints-and-feedback/your-service-your- say.html). Or there is also the confidential recipient Leigh Gath, who deals with concerns of abuse, negligence, mistreatment and poor care practices (https://www2.hse.ie/services/hse-complaints-and- feedback/report-a-concern-about-a-vulnerable-adult-in-care-to-the-confidential-recipient.html).
It is important to remember that the service user’s quality of life should not be based on the resources of the service. As an employee of a service, you have many routes to go through to highlight an unmet need (e.g. local or senior management, MDT, advocacy, etc.). However, if you have exhausted all available avenues, there are alternative options outside the service to support people with a disability, such as an independent advocate. Just remember that if the person is not at the centre of the service, they will continue to live a life of someone else’s choosing through the lens of ‘best interests’ until systems are put in place to support and protect their expression of will and preference and their rights (Croucher 2016). As an SCW, you are in an influential position to empower the person you are supporting to advocate for the life they want.
Tips for Practice Educators
An important requirement to assist the student in achieving this proficiency lies within the practice educator’s ability to assess at what stage of professional development the student is currently practising.
For this reason, it is important that educators are knowledgeable and have an understanding of the ‘student development model’. One familiar model is the Kolb reflective cycle (see diagram below). Other well-known models are Artur Chickering’s seven vectors of identity development and William Perry’s theory of intellectual development.
One useful tool that practice educators can use in assessing the student’s stage of professional development is regular support and supervision. When the student’s stage of development has been established, the student and practice educator can set learning goals to help them achieve this proficiency. There are several key steps in doing this.
First, throughout the practice placements and on-site learning, students should be exposed to the various ways in which service-users communicate. As mentioned, communication routes can include direct verbal communication, use of PECs, objects of references, Lámh, etc. Each service user may have their own unique way of communicating and it is important that students are exposed to these and have training in communication and different types of assistive technology if required. Training of record keeping and GDPR would also be very beneficial.
Second, students should be encouraged and given opportunities to link in with the staff team to discuss the experiences of staff and how they identified and addressed service users’ unmet needs through past experiences. Students could also read the service user’s personal profile to observe the recording of unmet needs and how this was rectified; however, this will depend on the organisational policies relating to GDPR and consent given by the service user.
Third, the practice educator and student could use a supervision session to discuss a hypothetical unmet need. During this session the student and educator could discuss what tools were used to identify the unmet need, how it would be recorded, the escalation routes used to address the unmet need and what organisational policies and process they should follow. It would also be useful to discuss and explore what national and international legislative laws within which we are bound to practice as SCWs, for example the Assisted Decision-Making Act 2015 and the UN Convention on the Rights of Persons with Disabilities (CRPD).
Finally, the student should be encouraged and given the opportunity to participate in an active case where the staff team are currently working together in supporting a service user to identify and address an unmet need. This is important to enable and enhance the professional growth of the student. The student should be encouraged to participate and offer solutions. Students, where possible, should attend team meetings and MDTs and have sufficient access to the necessary paperwork. The practice educator should encourage the student, along with the staff team, to discuss how the unmet need was addressed, acknowledge the positives and discuss any learning or further training that may be required to ensure future unmet needs can be appropriately and timely addressed.
Suggested Reading:
HSE, New Directions – Day Services for Adults with Disabilities: https://www.hse.ie/eng/services/ list/4/disability/newdirections/newdirections.html.
HIQA, National Standards for Residential Services for Children and Adults with Disabilities: https://www.hiqa.ie/sites/default/files/2017-02/Standards-Disabilities-Children-Adults.pdf.
Assisted Decision Making (Capacity) Act (ADMA) 2015: https://www.hse.ie/eng/about/who/ qid/other-quality-improvement-programmes/assisteddecisionmaking/assisted-decision- making.html.
HSE, Time to Move on from Congregated Settings: https://www.hse.ie/eng/services/list/4/ disability/congregatedsettings/.
Department of Health, Value for Money and Policy Review of Disability Services: https://www.gov.ie/en/publication/ed3564-value-for-money-and-policy-review-of-disability- services-in-ireland/?referrer=/wp-content/uploads/.
HSE, National Consent Policy – Quality Improvement Progammes: https://www.hse.ie/eng/ about/who/qid/other-quality-improvement-programmes/consent/.
United Nations Convention on the Rights of Persons with Disabilities (UNCRPD): https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons- with-disabilities.html.
HSE, A National Framework for Person-centred Planning in Services for Persons with a Disability: https://www.hse.ie/eng/services/list/4/disability/newdirections/framework-person-centred- planning-services-for-persons-with-a-disability.pdf.
National Resource Center for Supported Decision-making (USA): http://www.supporteddecisionmaking.org/.
References
Áras Attracta Swinford Review Group (2016) What Matters Most: Report of the Áras Attracta Swinford Review Group. HSE. Available at <https://www.hse.ie/eng/services/publications/ disability/aasrgwhatmattersmost.pdf> [accessed 11 September 2020].
Carolan, M. (2018) ‘Ward of court system does not protect vulnerable adults – HSE’, Irish Times, 16 January.
Croucher, R.F. (2016) ‘Modelling Supported Decision-making in Commonwealth Laws’, ARLC 2014 Report, Making It Work, AGAC 2016 National Conference, Sydney, 18 October 2016.
Davidson, G., Edge, R., Falls, D., Keenan, F., Kelly, B., Mc Laughlin, A., Montgomery, L., Mulvenna, C., Norris, B., Owens, A., Shea Irvine, R. and Webb, P. (2018) Supported Decision-making: Experiences, Approaches and Preferences. Belfast: Praxis Care, Mencap and Queen’s University Belfast.
HSE (Health Service Executive) (2018) A National Framework for Person-Centred Planning in Services for Persons with a Disability. Available at <https://www.hse.ie/eng/services/list/4/disability/newdirections/ framework-person-centred-planning-services-for-persons-with-a-disability.pdf> [accessed 5 March 2020].
Keeling, Chapman, Williams, Keeling, June, Chapman, Hazel M., and Williams, Julie. How to Write Well: A Guide for Health and Social Care Students. Maidenhead, Berkshire: Open UP, 2013. Web.
Killeen, J. (2016) ‘Supported decision-making: Learning from Australia’, Winston Churchill Memorial Trust. Available at <https://www.wcmt.org.uk/sites/default/files/report-documents/Killeen%20J%20 Report%202016%20Final.pdf> [accessed 20 November 2018].
Parr, T. (2013) ‘Record Keeping’ in A. Worsley, T. Mann, A. Olsen and E. Mason-Whitehead, Key Concepts in Social Work Practice. London: Sage.
