Care & Support Services - Achieving Best Practice

Assessment

Assessment

Before an individual is identified as needing specialist care and support, they must undergo a series of assessments.

These assessments may not diagnose a learning disability, but they do decide whether the individual will receive social care.

This section explains the types of assessment an individual may undergo, including:                         - Official process or corporate screening procedures
- Clinical assessments
- Behavioural assessments
- Holistic assessments
- Person Centred Planning (PCP)
- Comprehensive assessments and care plans

Assessment is generally a means of making a judgement. Usually this judgement is informed by a professional understanding of a situation, alongside individual needs and circumstances. The term 'assessment' in social care needs to be considered in context. What is the purpose of such an assessment? What does the assessment hope to achieve? What is the problem it is hoping to solve?

A range of assessments can take place in the social care field, some of which are applicable to determine a learning disability. The differing assessment processes include:

• comprehensive assessment
• community care assessment
• multidisciplinary assessment
• needs assessment
• social functioning assessment
• psychiatric assessment
• risk assessment
• performance assessment
• health and safety assessment
• behavioural assessment
• intellectual assessment (to name just a few!)

Not all assessments are 'clinical tools'. Some assessments are related to 'official process' or 'corporate screening procedures'. Authorities or bodies can use this form of assessment as a 'gate-keeping' feature to rationalise access to their social resources. Dependent upon the nature and degree of the presented difficulty, the individual will either pass or fail in securing a service or a resource.

Such 'in-house' assessments are allegedly designed to ensure local resources are given to those who need them the most. Often these assessments can be set at different levels from one authority to another and may change year by year as resources and budgets are set.

For the most part, this topic area will focus on the more individual (as opposed to corporate driven) clinical assessments such as intellectual assessment and social assessment. These processes will then be measured with current initiatives surrounding Person Centred Planning (PCP), with the more corporate process of Comprehensive Assessment discussed at the end.

Ironically, intellectual assessment was the backbone of psychometric evaluation of care for people with learning disabilities. Tests first began to emerge at the beginning of the twentieth century and escalated during the First World War and years that followed. These tests have been subject to much controversy over the years. The merits and demerits of various tests have been argued about and abuses in their application have also been claimed. Some tests were said to be biased towards verbal skills, whilst others failed to recognise cultural diffrences. There have also been claims that too much importance was given to a single snap-shot measurement (such as I.Q.), against a more longitudinal perspective of a person's ability and why it may be impaired in the first place.

Psychological measurement of our inaccessible mental processes is dependent upon our outward expression of behaviour. We either have to observe spontaneous reactions to events, listen to the accounts people give of their experiences or behaviour, or set up a false scenario to 'test' an attribute or process.

People being 'tested' on various elements will generate a score which can be judged against an overall average and also an average for their age. These scores can subsequently be expressed as quotients, e.g. Intelligence Quotient (I.Q.), Mental Age, Developmental Age etc.

These 'norms-referenced' intelligence tests were originally developed to try and identify children who had an intellectual disability so they could receive appropriate help. To that end, they still have an important part to play in the process of diagnosis. However, a diagnosis of intellectual disability would not be made on the basis of an I.Q. score alone, but would include other information regarding a person's developmental history and social adaptation. A specific learning difficulty (like dyslexia or a language disorder) may suggest an individual has an intellectual disability, until specialised testing reveals a normal intelligence is present.

Intelligence testing, having once contributed towards a diagnosis of intellectual disability, is not necessarily considered so helpful in predicting future progress. The test will not offer anything regarding personality traits. There can also be considerable differences in social skills and competencies amongst those with equivalent I.Q. scores.

Clinically the use of intellectual assessment can still be important for some things. As a basis for establishing an educational need for example. It can also be relevant when considering issues surrounding the Mental Health Act 1983 and how it might apply to a person with learning disability. The legal system is particularly mindful to now address the intellectual ability of people who might be considered as 'vulnerable' when facing investigation or being charged with criminal offences.

There are a whole battery of tests which can be applied to try and determine an individual's intelligence and it is beyond our scope to debate them here. However, among the most commonly used is the Wechsler Intelligence Scale. There are scales for children (abbreviated often as WISC-R) and for adults (WAIS-R) (the R in the abbreviation refers to a 'revision').

Social assessment was developed to compensate for the deficiencies of I.Q. testing, which was failing as an overall measurement of the functional ability of those considered to have an intellectual disability. The concepts of social assessment grew out of the theories of social competence and adaptive behaviour. Adaptive behaviour was considered to be 'the effectiveness with which the individual copes with the nature and social demands of their environment' (Heber R. 1961).

These approaches focus on the assessment of a person's current abilities, as they become more noticable in particular social situations. Assumptions are then made that certain abilities could be generalised or 'adapted' to other social settings.

Adaptive behaviour became a measurement of ability for people with a learning disability and was especially common in the 1970/80s and American psychology. Examples of adaptive behaviour measures consist of tools such as Adaptive Behaviour Scale, Vineland Social Maturity Scale and Hampshire Assessment for Living with Others (HALO).

Similar forms of social assessment can look at what are called 'criterion-referenced behaviours'. This is where an individual is assessed for the achievement of certain 'crucial' skills for whatever is being taught or facilitated. In this case, people are not readily compared to each other (as in norms testing), but to a standard regarding various skills or activity. You are either capable (i.e. meet the standard or criteria) or not. The assessment can provide a focus for curricula, what needs to be taught and in what sequence. This type of assessment supported some Individual Programme Planning (IPP) approaches in years gone by.

I.Q. and adaptive behaviour measurement are considered as 'restricted' tests. This means that they can only be administered by people who have the appropriate training and know how to deliver them and interpret the results.

Whilst adaptive behaviour and criteria-referenced behaviour are still measured with various tests, this approach is less generalised, and perhaps now, has a more clinical and research focus. These assessments are now being replaced in the mainstream by the more participative approaches of 'Person Centred Planning' (PCP) where an individual's own personal plans and aspirations for the future are voiced. We still need to help individuals learn different skills and adapt their behaviour to new social settings, but this is undertaken more in a context of their chosen life plan and ambitions. If someone does not have the requisite key skills to follow their plans, then the object is to determine the level of support they require to follow the same course.

Behavioural assessment is another generic term which can apply to any holistic and functional assessment of a person. It is often undertaken when there are issues surrounding challenging behaviour, although not necessarily so. The assessment will usually be based upon an accurate and detailed analysis of a person's current and past life experiences. It will include their abilities and needs, plus their aspirations for their future.

Holistic assessment can be undertaken in many different ways, sometimes using an assessment tool or questionnaire to help collect information. A provider of a service or consultant may have their own preferred tool, but they will essentially gather similar information.

Assessments may have alternative approaches, for example, assessment formats for people who have multiple disability are likely to employ different approaches and collect slightly different information from those for people who have a mild learning disability.

The content of a behaviour assessment is likely to include information from the following areas:
- Previous life history
- What is currently happening in a person's life (e.g. current events, general quality of life)
- Their environment (e.g. living environment, day service or daytime activities, routines)
- General health (e.g. current and past illness, medication, evidence of any pain or sight and hearing deficiencies)
- Mental health (e.g. any symptoms of depression, anxiety, mental illness)
- Communication (e.g. how a person communicates, any speech problems)
- Noting a person's important relationships, friendships and family
- Leisure pursuits
- Comments regarding their abilities and skills
- A record of any identified need
- The views of any advocate supporting the individual
- Future wishes and aspiration of the individual

'Person Centred Planning' (PCP) is a way of supporting and working with people who have a learning disability. It helps to work out what the individual wants from life and how best to achieve it, the kind of support a person will need and how it would be best given. Such ways of working should ultimately lead to greater social inclusion.

What is fundamentally different between this and other mainstream assessment processes, is that the 'focus of control' is placed close to, or firmly with, the person with the learning disability and not an organisation or individual professional. In essence, it is not 'administered' or 'done to' a person but is an action plan for the future. PCP puts the person at the centre of the process. It uses a combination of techniques to focus on the person's aspirations and future wishes in their desire to drive the goals and plans for assistance and support.

There are various styles of a PCP process, such as Essential Lifestyle Planning, PATH, MAPS and Personal Futures Planning, but all are underpinned by similar values:

• Everyone has the right to plan their own lives
• A person has the right to be at the centre of any planning that is made on their behalf
• Everyone has the right to be part of their community
• A person has the right to live in the manner they feel is right for them, to have the necessary support to allow them to do this in a way that they wish it to be delivered

Such approaches do not rule out the use of any formal assessment undertaken by the likes of occupational therapists, psychologists, physiotherapists etc. What is important is that their assessments and recommendations are focussed on what support an individual may need to facilitate their personal plans.

PCP is the process put forward by the government in their strategy document 'Valuing People - A New Strategy for Learning Disability for the 21st Century', which addresses the long term needs and support of people who have a learning disability. The equivalent Scottish Executive document entitled 'The Same As You?' also recommends a similar process in the form of a 'Personal Life Plan'.

Comprehensive Assessment is a formal procedure which is undertaken under the terms of The NHS and Community Care Act 1990.

Each local authority has a duty to assess people who appear to need community care services. They also have to publish the eligibility criteria an individual will need to meet, to secure such community care services.

A number of differing levels of assessments can be undertaken. Comprehensive Assessment relates to someone who has multiple and severe needs, which are likely to need to be met by a number of agencies.

Comprehensive Assessment is usually undertaken by a Care Manager who, in most cases, is a social worker. They will, along with their own assessment, collate and consider information from other key professionals and they may also undertake a 'Carer's Assessment' as provided under the Carer's (Recognition and Services) Act 1995, to take a carer's needs into consideration.

Comprehensive Assessment may differ in format depending on the local authority, but each should collect the same essential information. From the assessment, a Care Plan (sometimes referred to as a Care Package) will be developed detailing services to be provided and any financial charges to the user.

The implementation, management, review and updating of the Care Plan (or Package) is a process known as 'Care Management' and this is looked after by the Care Manager.

A Care Plan provided under this act is not the same thing as a Person Centred Plan (PCP) - this is a separate enabling process in its own right. The compiling of a PCP, however, may be a specific service recommended in a person's Care Plan as one of their needs.

The Care Plan, which is written down, assumes the level of a quasi-legal document detailing the service you should expect to receive from your local authority. It will provide the basis on which any future complaint or appeal should be levelled.