Leading change

The Senior Social Worker and Nursing Clinical Lead in the Staying Home Team, Stoke City Council and North Staffordshire Combined Healthcare NHS Trust (NSCHT) have with the full active involvement of the team redesigned and implemented a new ‘best interests’ decision-making process. This new process has led to improved outcomes, experiences and use of resources within the team, whilst also demonstrating leadership in change and commitment to high quality care provision.

Where to look

North Staffordshire Combined Healthcare NHS Trust (NSCHT) is a provider of mental health, social care and learning disability services in the West Midlands. The team at Marrow House Assessment and Therapy Unit provide dementia assessments in care homes and in the community to some of the most vulnerable adults locally. This includes providing access to specialist information, support and advice, specialist bed-based and community reablement/therapy services, short break services, and early and timely intervention to help reduce risk of crises.

The Mental Capacity Act (2005) empowers people to make decisions for themselves wherever possible, and protect people who lack capacity by providing a flexible framework that places individuals at the very heart of the decision-making process.

Someone may lack mental capacity due to having had a stroke or brain injury, having a  mental health problem, dementia, learning disability or acute confusion, drowsiness or unconsciousness because of an illness or the treatment for it. In these situations, there is a need to ensure individuals can participate as much as possible in any decisions made on their behalf, and that these decisions are made in their best interests. The Mental Capacity Act (2005) code of practice provides a clear ‘checklist’ for those trying to work out an individual’s best interests, including which steps need to be taken under the law to identify all the issues that would be most relevant to the individual who lacks capacity for each decision.

The Senior Social Worker and clinical lead identified that the quality of mental capacity and best interest assessments met the standard required under legislation, however there was unwarranted variation in how these assessments were conducted and the process wasn’t streamlined; there was room for improvement which would also align to proposed changes in the guidance soon. The Senior Social Worker and nursing clinical lead led a programme of work to redesign the procedure for ‘Best Interest support and planning for service users’, to ensure the needs of service users admitted to the service were identified and supported early in the assessment process.

What to change

A full review of the ‘best interests’ assessment process was reviewed by the multidisciplinary team with challenges and opportunities highlighted. The team also identified opportunities to develop the skill sets within the team through additional education and training to support changes in the assessment process.

The senior social worker and clinical nursing lead at NSCHT identified an increase in complexity of people referred into the Assessment and Therapy Unit which had begun to shift the ‘normal’ service provision to a more intensive 24-hour care and support service. As a result, unwarranted variation in practice regarding mental capacity assessments and best interest decisions including involvement of service users, families and carers was evident across the team.

A deep dive review of the team’s activity and performance over the preceding 6 months of practice revealed potential improvements in:

• Knowledge;
• Co-ordination of capacity assessments;
• Deprivation of Liberty Safeguards (DoLS);
• Best interest planning to include families and carers.

How to change

A comprehensive improvement programme was developed and agreed with the team, service leads and key stakeholders. The programme has been divided into specialities and individuals from within the team were nominated to lead each piece of work based on their knowledge, expertise and skill set. Peer reviews of the team’s best interest and mental capacity assessments were undertaken to support learning as well as ensuring each section of the improvement programme was robust.

Based on learning from the deep dive and peer reviews, a newly devised assessment process and assessment resources were developed and agreed. A best interest checklist and process for meetings was formulated, to support and guide team members through the process.

To ensure the new process and resources were embedded as routine practice, a training package was rolled out on both a formal and informal basis for all staff within the team to keep staff up-to-date with legislation and guidance.

Adding value

Better outcomes – The standard of assessments undertaken by the team since the changes has improved, with increased involvement of the service user, their families and carers. The assessment processes now comply fully with the legislation and embrace the person-centred ethos of The Mental Capacity Act (2005). Decisions are made in a person’s best interest and are more holistic and person centred which has led to better service user outcomes.

Better experience – Staff have welcomed the change and now report they understand better the process, pathway and implications of the decisions they make on behalf of service users. They report that service users, their families and carers are better supported. Staff also report a growth in staff confidence. They described a heightened and updated knowledge base of capacity, including the implication and effects the outcome of these assessments can have on the individual service user. Service users, their families and carers have also received the change well and report they feel more empowered and more informed of the best interest planning and decision making.

Better use of resources – As the assessment is more inclusive of people important to the service user, the need to re-evaluate the ‘best interest planning’ during the care pathway is significantly lowered, providing improved efficiency and time management across all services and team members. The process, now streamlined, has made engagement for service users less onerous which is an added benefit of the process improvements.

Challenges and lessons learnt for implementation

However good you think you are there is always room for improvement; the cycle of review and change needs to continue even when you think you’re at your optimum.

It’s important to keep service users at the centre of your improvement plans.

Be inclusive in the informal training and support all levels of staff to attend, to understand the process. This will involve tailoring your approach.

The non-registered members of the team have the most face to face contact therefore it is vital they are empowered and engaged in the changes to the system and processes. Non-registered staff can feedback the bigger picture that affects individuals and service users often favour voicing their wishes to staff on an informal basis rather than during formal assessment. This empowers both the staff and service users to have a strong, valued voice in care and treatment plans.

Find out more

For more information contact:

• Diane Evans-Nelmes, Clinical Lead Staying Home Team, North Staffordshire Combined Healthcare NHS Trust, diane.evans-nelmes@combined.nhs.uk