6.7% out of the 8.7 million older people, living in England, require some care and support while living in their own home. 12% of that group had not received any local authority formal support service (Lloyd & Ross, 2014). Dorothy could be described as one of those who had previously “slipped through the net”, which may explain why she had no formal support prior the fall (Appendix A).
The “wicked” issue here, is a lack of information concerning Dorothy’s current situation and how recent events have raised the question of whether Dorothy is capable of managing self-care and whether services such as befriending, homecare and medical services could be put in place, to enable her to live independently. However, Dorothy herself has made it clear that she wants to return home without any support. Schon’s focus on reflection-in-action, could be informative here.
The process of achieving the best possible outcome for Dorothy involves an improved understanding of her situation, in conjunction with any possible safeguarding issues around her sudden deterioration. The social worker has a legal duty to visit Dorothy and to undertake an assessment. The assessment process is designed to identify needs and eligibility, and provide a foundation for Dorothy’s care and support (DoH, 2014; Walker, 2015). Throughout the assessment and eligibility process six themes need to be considered, including strengths-based approach, mental capacity, advocacy and participation support, impact on the family and carers, safeguarding and proportionate and appropriate professional involvement (SCIE, 2015). Assessment is “an on-going process in which the service user participates” (Coulshed & Orme, 2012, p. 22). Assessment informs the process of planning, intervention and reviews of Dorothy’s needs (Milner & O'Byrne, 2009). A narrative approach exchange model, which views Dorothy as an expert in her own situation is therefore the most appropriate model of assessment. This should aim to empower Dorothy and promote anti-discriminatory practice (Coulshed & Orme, 2012). The exchange model provides the person-centred approach or personalisation required throughout the assessment process (DoH, 2014). It further enables the social worker to build a relationship with Dorothy, while providing an opportunity for Dorothy to describe her own perspective and reframe her life experiences (Maclean & Harrison, 2015, p. 183). Reframing Dorothy’s life experiences will allow identification of her strengths and abilities. Her choices and control of the process are supported, reducing the risk of social exclusion (Parker & Bradley, 2014). The assessment process will consider a number of factors, including the Dorothy’s actual and expressed needs and how they impact on her wellbeing. For example, self-care ability, social networks and support, adequate housing, finance, care service, culture, risk, physical and mental needs (DoH, 2014). It is necessary however to consider how the narrative exchange model of assessment may be time-consuming, increasing stress on the social worker, especially when an interview evolves into a conversation. It is necessary for the social worker to consider using a combination of questioning and procedural models of assessment to ensure all relevant information is collected (Coulshed & Orme, 2012).
In terms of the different perspectives and needs of service users, carers and professionals involved, the White paper “Our Health, Our Care, Our Say” (2006) (DoH, 2006) and the National Service Framework for older people (2001) (DoH, 2001) promotes the Single Assessment Process (SAP). In conjunction with the benefit of a holistic needs assessment, the framework provides a set of standards and quality of care expectations for older people, for individuals with long term conditions, designed to minimise duplication of assessment (CPA, 2001; DoH, 2007). Information provided through holistic assessment could also help reduce the risk of Dorothy being readmitted to hospital, which is likely if she returns to a solitary home environment without a care package appropriate to support both Dorothy’s and her carer’s needs (Royal Voluntary Service, 2015).
With regard to the proportionate and appropriate professionals’ involvement in Dorothy’s care, the National Institute for Health and Care Excellence’s (NICE) (2015) provides guidance for “Transition between inpatient hospital settings and community of care home settings for adults with social care needs”. Focusing on person-centred care, effective communication, inter-agency and inter-professional collaboration, the guidelines emphasise the importance of safeguarding vulnerable adults and improving service user’s outcomes (NICE, 2015). In contrast to a medical model, which views Dorothy as a problem needing to be fixed, this approach to assessment can be viewed as a social model which provides an opportunity for empowerment (Parker & Bradley, 2014). Using the social model approach practitioners are encouraged to clearly understand an individual’s wellbeing within a holistic framework of social care, support needs and preferences, while treating individuals as “equal partners” with “dignity” and “respect” (NICE, 2015, p. 17). The aim of this person-centred approach is to help Dorothy regain or develop confidence and independence, minimise the possibility of oppressive practice by taking account of Dorothy’s personal perspective, as well as acknowledging any conflict that could arise as a result of the different values and ethics presented by other professionals or individuals, aiming to integrate professional values (Sanderson & Lewis, 2012). For example, “the ward sister stated Dorothy needed 24 hour care, while Dorothy was keen to go home” (appendix A). Critical reflection could encourage the social worker to draw on past experiences, while considering the different perspectives and feelings of Dorothy, professionals and other individuals or agencies who may become involved in Dorothy’s life. This may include carers and relatives (D’Cruz, Gillingham, & Melendez, 2007).
In order to understand Dorothy’s background, the social worker may compile a genogram to help obtain information about Dorothy’s social and family circumstances, including an understanding of the involvement of her family support circle (ADASS, 2015). Information provided in the case study does not identify whether Dorothy has a carer. If Dorothy has a carer, the Care Act 2014 gives local authorities a responsibility to assess their needs for support, including, financial, social, mental and physical needs. A combined assessment of both the carer’s and Dorothy’s needs would be undertaken, subject to obtaining their consent. In the absence of a carer, Dorothy may need to employ one, or appoint the local authority as her care manager, supporting her access to care services (DoH, 2014).
When managing uncertainty, such as potential impact of decisions and interventions, the uncertainty of Dorothy’s mental capacity which has been raised by professionals, critical reflection could help social worker to be “open-minded, take account of different perspectives, experiences and assumptions” (Adams, Dominelli, & Payne, 2009, p. 4). Information from medical staff regarded Dorothy as in need of significant support in self-care. This appears to be evidenced by the initial assessment from Dorothy’s previous social worker, describing how Dorothy appeared to be having difficulty in retaining information (Appendix A). This initial assessment information could inform whether a further assessment with regard to Dorothy’s mental capacity should be considered under the Mental Capacity Act (2005) (MAC) (The National Archives, 2005). A specific trained practitioner, such as an Appointed Mental Health Practitioner (AMP), would carry out such as assessment. The assessment needs to be underpinned by the five principles of the MAC (2005) and the nine protected characteristics of the Equality Act (2010) (The National Archives, 2010). If the assessment confirms Dorothy does lack capacity or has difficulty being involved in her assessment process, such as in reading and writing, an independent advocate should be provided to support her, “Care Act 2014”. The advocate could support her with communication and decision making, such as, informing her about available service options and ensuring decisions and interventions are based on Dorothy’s best interests. This will support the social worker in promoting Dorothy’s wellbeing and counter any negative effects of possible discrimination and marginalisation she may face (DoH, 2014; Mind, 2015; Thompson N. , 2012).
Potential safeguarding concerns, evident from the case study include Dorothy appearing unclear or unrealistic about her situation (Appendix A), together with her being female, aged 83, with possible social exclusion and limited communication skills. Dorothy could be a victim of domestic abuse (Action on Elder Abuse, n.d.; BBC, 2013; WHO, 2015), or suffering from acute diseases such as dementia (Age UK, 2015) or Parkinson’s (Age UK, n.d.). For example, trauma like domestic abuse and falls due to Parkinson’s disease or dementia could have affected Dorothy’s biological and social functioning. This could impact on Dorothy’s self-care or ability to retain information (Herman, 1994; SCIE, 2015). The Care Act 2014 defines adult safeguarding as “protecting adult’s rights to live in safety, free from abuse and neglect” (DoH, 2014, p. 230). The Act sets out a clear legal framework for local authorities, such as Safeguarding Adults Boards (SAB), health professionals and other agencies to ensure they work together to protect vulnerable adults, such as Dorothy (DoH, 2014; SCIE, 2014). The framework principles include empowering individuals in the decision making process, taking action to prevent harm, protecting those in greatest need, taking proportionate response to any risk presented, upholding partnership working, accountability and transparency within the assessment process (ADASS, 2015; SCIE, n.d.).
In order to find out if there is any specific action required to safeguard Dorothy, a risk assessment in a safe environment, using a standard tool, such as a risk identification checklist (RIC) of Domestic Abuse, Stalking and Honour Based Violence (DASH) could help both the social worker and Dorothy to better understand her situation and to build a trusting relationship. If, as a result of the risk assessment Dorothy is identified as high risk, she would be referred to the local Multi-Agency Risk Assessment Conference (MARAC). The MARAC is a forum for professionals and agencies to share relevant information, discuss options and provide a structure plan to safeguard the adult victim. A fortnightly meeting to review the service user and their carer’s needs should be provided in order to ensure adequate support. Professionals and agencies including local police, health professionals, housing department, voluntary sectors and independent domestic violence advisors should be invited to the MARAC (DoH, 2014; Salford City Council, 2015; Valios, 2015).
In Dorothy’s case, her social worker’s first task is to liaise with ward staffs and consultant responsible for Dorothy’s care, in order to find out whether Dorothy is medically fit to be discharged. Research has identified how falls and fall-related injuries are common and serious problem for older people. This could have impacted on Dorothy’s “confidence”, “independence” and “mortality” (NICE, 2013, p. 4). In addition, the social worker needs to investigate concerns about Dorothy’s cognitive impairment with the medical consultant, and request a mental capacity assessment for Dorothy as previously no formal assessment had been conducted in relation to her mental health and mental capacity (Mind, 2015). Moreover, the social worker needs to introduce herself to Dorothy, undertaking a full assessment. This full assessment aims to deconstruct any “wicked” unknown issues. This will involve exploring Dorothy’s perception of the risk versus benefit of her wish to be at home (Taylor, 2013), her feelings with regard to possible readmission to the hospital, why she does not want support in her home, information about her carer, family support circle and social network, together with an in-depth financial assessment to ensure Dorothy is receiving the appropriate benefits such as Attendance Allowance (AA) and Pension Credit (Davies, 2012). A referral to the occupational therapist for an assessment to ensure Dorothy’s safety within and outside her home, such as home hazards will be required. It is also essential to refer Dorothy to intermediate care, reablement and befriending services. Intermediate care and reablement services will provide a 6 weeks free of charge support to empower Dorothy to regain her independence. This might involve for example, having a support worker to help with cooking, shopping and self-care (Age UK, 2015). Befriending service is a service to help address loneliness among older people. Their service may involve a volunteer providing friendly conversation and companionship for Dorothy on a regular basis (Age UK, 2015). These support services could help minimise risks, promote wellbeing and enable Dorothy to live independently at home. They may also assist the social worker to carefully monitor the situation for any changes, such as any increase in Dorothy’s cognitive impairment (Davies, 2012).
After combining all the evidence from all the professionals, agencies who involved in Dorothy’s case and information gathering through assessing Dorothy, a further assessments of needs will be undertaken to ensure Dorothy and her carer support is appropriate and relevant to their needs (Davies, 2012). It is crucial to measure Dorothy’s needs eligibility of the local authority’s criteria and helping Dorothy, her family and carer to understand what support service is available and at what cost (McDonald, 1999; The National Archieves, 2014). In order to work with Dorothy in an anti-oppressive manner, safeguarding her from further harm, promoting her wellbeing, while enabling her living at home independently, it is fundamental to use a person-centred model in the development of her temporary and longer term support plan, according to the statutory guidance of the Care Act (2014) (TLAP, 2015). Therefore, Dorothy’s care and support package could be focuses on putting adequate services in place to support her and her carer to meet their needs. For example, support in self-care, domestic, eating, cooking, befriending and respite services. The decisions will involve Dorothy, her family and carer, all professionals and agencies who are involved in her case, such as physiotherapist, nurse, General Practice, occupational therapist, befriending and reablement service and previous social workers. Furthermore, Dorothy and her carer’s needs can fluctuate and impact on the best outcome they would like to achieve. Therefore, assessments should reflect more accurately on the comprehensive needs of the service user and their carer (SCIE, 2014).
Critical reflection enable social worker to identify whether the support package will adequately safeguard Dorothy and in living independently at home. Critical reflection is the social worker’s ability to discover learning through intervention and to have the ability to generalise and contextualise to different situation (Fook, Ryan, & Hawkins, 2000). Therefore, in order to achieve a positive outcome, collaboration and communication is compulsory between professionals, agencies and individuals within Dorothy’s life.
In this essay, critical reflection enable social workers to explore an event from within their own understanding to the meaning that service users attribute towards an event, rather than within the event itself (Schon, 1983). In Dorothy’s case, her social worker will be able to develop a suitable plan for intervention, by acknowledging the need to address underlying the personal and professional assumptions, as well as dominant social narratives, in order to shape individual’s holistic understanding and experience of a given incident (Thompson & Thompson, 2008). Reflection also support the social worker in discovering new information through both personal and professional experiences and research. This new information enable an individual to reconsider an event, and determining whether something could have been done differently or better (Gibbs, 1988). For example, through understanding the different perspectives in medical and social models, it helps minimise conflict and oppression. Through research study in domestic abuse, it enables the social worker to acknowledge the risk factors that could be affecting Dorothy.
Furthermore, reflection could support social workers to acknowledge that unequal power dynamics, concerns around oppression and issues with stigma are all societal problems that social workers need to engage with not just on a micro-level, but also a macro-level (Thompson N. , 2012). Revan’s critically reflective action learning suggests reflection becomes more collective and more public. Individuals are encouraged to share their different reflections, to explore them and to push them further (Pedler, Abbott, Brook, & Burgoyne, 2014, p. 5).
In conclusion, critical reflection is an ongoing process in social work practice. It allows individuals to develop their skills, review their professional decision-making and provide a venue for the surfacing of practice “wisdom and tacit knowledge” (Noble & Irwin, 2009, p. 357). The experience of applying models of reflection within the chosen case study, Dorothy enable the social worker to explore different interpretations with regard to safeguarding. It supports in developing engagement with theories and research knowledge, as well as collaborating with others services. However, there are skills and knowledge in relation to self-awareness and power dynamic that are need to be developed the future social work practice.