How do you help those who cannot consent to their care arrangements to be as happy as possible? The answer of course lies in robust care plans, which are written by care staff who have a deep understanding of the nuances and complexities of the Mental Capacity Act and the Deprivation of Liberty Safeguards (DoLS).
Having a thorough knowledge of both ensures that a person lacking capacity who may or may not be subject to DoLS is always at the centre of every decision made. But, providing person centred care, which puts service users under DoLS supervision at the heart of the decision-making process, is rarely straightforward. Why? Well, those subject to DoLS are often unable to communicate their wants and needs effectively.
Ensuring that service users are the happiest that they can be, while protecting them from harm, is a delicate balance. It requires all parties to possess a broad understanding of the purpose, scope and limits of DoLS.
Sadly, some care professionals, local authorities and families don’t understand DoLS. And who can blame them? The language is full of jargon and hard to understand. It has led to some care services, who have misunderstood the legislation, to issue blanket supervision orders, which in some cases have led to service users being deprived of their liberty.
Following Baroness Hale’s Supreme Court judgment, which recognised that a person, who was happy in a care setting, may still be being deprived of their liberty, if they were unable ever to leave the service that was supporting them, DoLS will be replaced by the Liberty Protection Safeguards or LPS for short. However, the intention of the new legislation, which many insiders believe faces further delays, remains exactly the same according to Rachel Griffiths MBE, a mental capacity and human rights specialist. Ms. Griffiths, who consults for Quality Compliance Systems (QCS), the leading provider of content, guidance and standards for the social care sector, says, “DoLS and the new LPS legislative framework effectively do the same thing. But due to the impenetrable language used, DoLS has gained a bad reputation. In summary, people misunderstand the legislation and tend to ignore the ‘s’ in DoLS. ‘Safeguards’, however, is actually the most important word.”
Ms. Griffiths explains that a DoLS authorisation “accepts that a person’s care plan is restrictive”, but says that “once there is recognition that it is restrictive, the authorisation does not mean that the person is curtailed from doing things they enjoy”. Ms. Griffiths says, “it just means that staff are protected from liability when they do deprive a person of their liberty. This is because the care plan has been assessed by experts to see if it’s the least restrictive possible that will keep that person safe. Through DoLS, therefore, service users are actually having their right to liberty spot-lit.”
You can always improve a person’s little freedoms even if you cannot improve the big ones
It is this enlightened understanding of the legislation that is often the key to ensuring that a person is happy. Frontline carers, who truly understand DoLS, for example, recognise that while people under a DoLS authorisation might lack capacity to make major decisions, they can – almost always – make the smaller ones. “It is empowering people to do so” says Ms. Griffiths, “that can have an extremely positive effect on wellbeing.”
She explains, “Those protected by DoLS may not be able to manage the big decisions such as negotiating a busy road, managing their money or their medication, but they may well be able to decide what they want to eat, want to wear, or what music they wish to listen to. When I was MCA Lead for the CQC, I remember visiting a care home and I was delighted to see that that the service users, most of whom were in their eighties, were listening to the music of their era. You could instantly see the positive effect that the Rolling Stones, the Beetles and the Kinks had on mood.”
Always seek the views of loved ones
Often, when a person is unable to consent to their care arrangements, it is exceptionally challenging for busy care service staff to find out what makes them tick. But the Mental Capacity Act’s best interests test implores frontline staff to always align care with what makes a person happy.
On this note, Ms. Griffiths says that it is “vitally important that staff make the effort to reach out to friends and relatives”, as finding out about their quirks and their past can radically improve wellbeing”.
Ms. Griffiths notes, “The information imparted by family and friends can be gold dust. It can really transform a person’s wellbeing. If, for example, it transpires that a service user spent his or her life on a farm, then they can factor time spent in the garden or walking in nearby fields into a care plan. That also gives the person the opportunity to share their life history with the care team and fellow service users, which is incredibly rewarding for everyone.”
It began with an old photo
Sometimes, however, a person has no family. When this happens, the onus is very much on the care team to proactively build up a detailed picture of the service user’s personal history.
Ms. Griffiths says, “I was once visiting a home when I observed a junior staff member talking to an elderly gentleman. He had been extremely depressed and withdrawn because nobody has asked him about his interests, his family and his life experiences. She saw a black and white photo on his bedside table of him in army uniform. She asked him about it and the gentleman told her he had fought in the Second World War. She immediately contacted the British Legion, who visited him. His mood vastly improved all because a frontline worker took a person-centred approach.”
Understand that physical and mental health are often related
As a person subject to DoLS may not be able to communicate their wishes, if a person is unhappy, or displays challenging behaviour, it may not be due to depression or sadness, but simply because they are in pain. While community dentistry has got much better, it is not uncommon for someone in a residential care home to suffer from toothache. If a person living with advanced dementia or perhaps with a severe learning disability cannot communicate that they are in pain, care workers must closely observe them in an attempt to establish what is bothering them.
Ms. Griffiths remarks, “When a dentist does need to be called, and the service users is frightened to see them, then care workers should try to establish strategies to make the visit less stressful. For those service users, who don’t like to have their teeth cleaned, again, seeking tips from relatives is key. In an attempt to reduce decay, carers who have listened to relatives have made small changes – such as introduce a mild flavoured toothpaste – or swap their standard toothbrush for an electric one. In doing so, they have discovered that these tiny tweaks have had an incredible impact on wellbeing.
Perhaps this best demonstrates that people with lived experience of the MCA do not always find the same things important as professionals do. However, carers should bear in mind that the person’s voice is crucial. Listening to what they have to say is what counts. After all it is their life, not ours.”
The article was first published in the The Carer – Issue 74