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We reported yesterday on calls to enhance guidance and training for professionals on best interests decision making under the Mental Capacity Act, but I thought it would be worth trying to pull out some of the key lessons from the study in question.

About the research

The research seems pretty solid and is based on an online survey, and telephone and face-to-face interviews with social care, health and legal professionals about best interests decisions they have taken under the Act.
It comes courtesy of charity the Mental Health Foundation, which has done a lot of work on how professionals can apply the Act (for example), and two of the country's major research centres into the two key client groups involved, the Norah Fry learning disability centre at Bristol University and the Bradford Dementia Group.

Though its focus was on best interests decisions, many of the most interesting findings relate to assessments of capacity. (Do see our guide on conducting a capacity assessment, which is based on work by the Mental Health Foundation).

Lack of understanding of MCA

A major finding was that the principles of the Mental Capacity Act were not being adhered to in a significant minority of cases. While people should be presumed to possess capacity, not assumed to lack it on the basis of disability, diagnosis or age, and have the right to make unwise decisions, about one-quarter of best interests decisions followed apparently flawed assessments of capacity related to perceived unwise decisions or to someone's disability, age or diagnosis. Though this finding was based on an online survey - and so may not reflect the complexity of cases - these issues remained when researchers probed deeper through interviews.

Impairments dominating assessments

Researchers found in some cases conclusions were drawn about a person's lack of capacity because of their inability to communicate verbally or respond to the presence of other people.
"In all these cases, it seemed that the impairment did dominate, and that practitioners had some difficulty in adhering to the principle of presumption of capacity," said the report.

Lack of capacity based on lack of 'insight'

An assessment that someone lacked capacity was in some cases based on the finding that they lacked 'insight' into their care needs, particularly in relation to people with dementia. So, for instance, if professionals believed that a person would be better off in a care home and the person disagreed, this apparent lack of insight translated into an assessment of incapacity to decide. But the research points out that 'insight' is not a word mentioned in the Mental Capacity Act code of practice and that lack of insight in this sense does not equate to a lack of capacity. In one striking passage, it says: "Whether a person with dementia accepted a particular course of action recommended by professionals (frequently admission to a care home) influenced whether an assessment of capacity was initially undertaken and, in turn, if a finding of capacity was made."

Making best interests decisions

Some interesting findings on this:

• Best interests decisions in social care were most frequently carried out through a series of multi-disciplinary team meetings. Typical features of successful practice were good chairing and organisational skills, clarity in defining the decision to be made, and an overriding concern for engaging the client at the centre of the process.
• Social care decisions more often related to safeguarding and changes of accommodation, rather than care reviews, direct payments or care planning.
  
• Though best-interests decision makers should consider the person's expressed wishes, feelings and values, the researchers only found a few cases where these had been influential in the decision.
• Outcomes for people were not just based on their best interests but on resources and available services. As a result, for instance, temporary admissions to care homes for people with dementia were often made permanent.

Recommendations

The research makes a number of significant recommendations. Here are a few key ones:-

• Revising the MCA code of practice to clarify the distinction between a lack of capacity, on the one hand, and unwise decisions and lack of 'insight' on the other.
• The code should include case examples that reflect the complexity of the cases experienced by practitioners, as well as examples of successful good practice.
• Pro formas for conducting mental capacity assessments and best interests decisions should also be added to the code.
• Providers should carry out regular audits of compliance with the MCA by staff.
• Care homes should hold weekly reviews of assessments of capacity and best interests decisions.

Hopefully this research should provide a springboard for practice, guidance and training improvements in relation to the MCA. Do have a read.

Deprivation of Liberty Safeguards (Dols) watchers (you know who you are) will be well aware that the number of applications for the safeguards from has been well below expected levels, with large variations between areas.

The implications are that people are being deprived of their liberty in care homes or hospitals without the protection that the Dols bring, and that this problem is particularly acute in certain areas. So how do you turn this situation around?

I was chatting to Dols expert Toby Williamson, of the Mental Health Foundation, the other day, who has a suggestion: the creation of an audit tool for care homes and hospitals to use to test whether residents or patients are being deprived of their liberty.

This would be tested on a sample of people in each area, ideally, so that local authorities and primary care trusts - who assess Dols applications - can gain an understanding of the extent to which people in their area are not being protected by the safeguards.

They can then work with care homes and hospitals to raise awareness of when they need to apply for a safeguard and provide training for staff where necessary.

It would all be done confidentially and without prejudice, so that care homes and hospitals wouldn't feel that this was a stick to beat them with.

It sounds a good plan but Williamson stresses that we need someone to design and implement such a tool. The Mental Health Foundation was considering it but could not source funding to do so.

He suggests that it is not a job for the Department of Health as this could appear heavy-handed. So do we have any other candidates? Maybe it's something for council or NHS bodies - the Association of Directors of Adult Social Services and the NHS Confederation, notably - to do in tandem with care provider organisations such as the English Community Care Association.

With Mum In Mind is one of a suite of films launched today by The Mental Health Foundation aimed at raising awareness about dementia and the use of self-directed support in helping people with dementia, their families, carers and social care professionals.

The 10-minute film tells the story of Terry, and how self-directed support has helped her mother get the right care to enjoy a more independent life in the comfort of her own home.

The films are part of a range of resources launched in response to the findings of Dementia Choices.

This two-year project found that people with dementia, their carers and social care workers are in need of more practical information about how self-directed support (including direct payments and personal budgets) can help improve their care.

Other films include "With John in mind", which is a 30-minute film telling Mary's emotional journey from the moment her husband John was diagnosed with dementia as well as a series of short films answering specific questions about self-directed support.

The Mental Health Foundation has also today issued a policy briefing for selected MPs and decision-makers on ways in which the Department of Health, the Care Quality Commission (CQC), and local health and social care providers can do more to increase the uptake of self-directed support.

The briefing recommends greater promotion of self-directed support amongst people with dementia, their families and carers, and health and social care, and new duties for the CQC to ensure this is being done effectively.

This comes following concerns that choice and control was not being extended to service users with dementia.

A national challenge called Living well with dementia has been launched today offering five teams a share of £360,000 to develop new design-led ideas for products and services to make the lives of those with dementia and their carers simpler, better and more enjoyable.

Launched by The Design Council and the Department of Health, the aim is to recruit teams with a variety of expertise, including designers, social entrepreneurs, businesses, service providers, support groups or individuals who may already have good ideas.

Details can be found on The Design Council's social network or on its website.

The closing date for entries is 30 September with final teams to be announced on 14 November.

I've just read through the judge's sentencing remarks in the case of a boy and his mother who have been convicted of conspiracy to murder their grandfather/father, who has dementia, and am speechless with shock. The motive was to secure inheritance money to help them both deal with money troubles. What is perhaps most shocking is that the woman convicted was her father's carer (and was apparently well thought of by the local Alzheimer's Society). Here are Mr Justice Foskett's comments.

A survey aimed at groups, advocates, supporting staff and carers who have direct engagement with people with dementia has been launched today.

The aim is to find out about how their dementia initiatives work, how people with dementia are currently engaged in influencing the issues that affect their lives, and explore the approaches and structures through which they can most effectively do so into the future.

It is part of a project led by the Mental Health Foundation and also involves the community interest company, Innovations in Dementia, the Alzheimer's Society, and the Joseph Rowntree Foundation.  

Did you know that this week is National Allotment Week? No, neither did I.

But residents of the Clara Court care home in Maidenhead do and they will be celebrating a bumper crop this week after they turned their balconies over to growing veg.

Leigh Reid, manager at the home, said: "The residents are having a wonderful time. The gardening not only keeps them fit and active but also stimulates their minds and encourages them to reminisce. This works particularly well as we are a specialist dementia home."

In a time of cuts it could save a few quid on sprouts too.