This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the first three descriptors in the Behaviour domain, to help you assess your or your relative’s “level of need” in this important domain.

Catch up on parts one to fourteen below!

Get Help Breaking Down The Decision Support Tool: An Overview

Get Help Breaking Down the Decision Support Tool: Breathing Part 1

Get Help Breaking Down the Decision Support Tool: Breathing Part 2

Get Help Breaking Down the Decision Support Tool: Nutrition Part 1

Get Help Breaking Down the Decision Support Tool: Nutrition Part 2

Get Help Breaking Down the Decision Support Tool: Continence

Get Help Breaking Down the Decision Support Tool: Skin (including tissue viability), Part 1

Get Help Breaking Down the Decision Support Tool: Skin (including tissue viability), Part 2

Get Help Breaking Down the Decision Support Tool: Mobility, Part 1

Get Help Breaking Down the Decision Support Tool: Mobility, Part 2

Get Help Breaking Down the Decision Support Tool: Communication

Get Help Breaking Down the Decision Support Tool: Psychological & Emotional Needs

Get Help Breaking Down the Decision Support Tool: Cognition, Part 1

Get Help Breaking Down the Decision Support Tool: Cognition, Part 2

Following the 2018 revisions of the DST, Behaviour moved from domain number one to domain number nine. It now follows Cognition and precedes Drug Therapies & Medications, highlighting the common interaction between these three domains.

The assessed levels of need in the Behaviour domain range from ‘No Needs’ to ‘Priority’ needs, one of only four domains that include all six possible levels of need. In any domain with a possible ‘Priority’ level of need, there is potential for an immediate risk to life, should needs not be met or be met improperly. The ‘Priority’ level of need is sufficient to evidence eligibility for CHC funding, regardless of any other level of need and without examination of the four Key Characteristics. Needs in the Behaviour domain are important because of their significant impact on the safety of the individual and others, and the delivery of necessary care. This interrelation should always be carefully considered in the analysis of the four Key Characteristics.

The following clinical factors are relevant to the assessment of needs in this domain:

• Does the person present with ‘challenging behaviours’ – restlessness, agitation, wandering, attempts to abscond, verbal and/or physical aggression, sexual disinhibition, resistance to necessary care, destruction of property.
• Do the ‘challenging behaviours’ pose a risk to the individual, their peers and/or their carers?
• Do the behaviours respond to reassurance, distraction or leave-and-return?
• Is necessary care able to be delivered as planned? If not, what is the impact on the individual?
• Is the person able to understand the risks posed by their behaviours?
• Are they able to retain that information? For how long?
• Is there involvement by the Mental Health Team?
• Are any medications prescribed to manage behaviours? Are these prescribed routinely, or as required?
• Are the prescribed medications effective in reducing or eliminating the identified behaviours?
• Are any specialist techniques required (e.g., restraint, MAPA holds)
• Is the person able to live in the community/non-specialised environment?
• Has the person been subject to Section under the Mental Health Act due to their behaviours?

The DST provides the following advice to those assessing needs in the Behaviour domain:

Human behaviour is complex, hard to categorise, and may be difficult to manage. Challenging behaviour may be caused by a wide range of factors including extreme frustration associated with communication difficulties or fluctuations in mental state.

Challenging behaviour in this domain includes but is not limited to:

• aggression, violence or passive non-aggressive behaviour
• severe disinhibition
• intractable noisiness or restlessness
• resistance to necessary care and treatment (but not including situations where an individual makes a capacitated choice not to accept a particular form of care or treatment offered.)
• severe fluctuations in mental state
• inappropriate interference with others
• identified high risk of suicide

Describe the actual needs of the individual, including any episodic needs. Provide the evidence that informs the decision overleaf on which level is appropriate, such as the times and situations when the behaviour to likely to be performed across a range of typical daily routines and the frequency, duration and impact of the behaviour.

Now that we’ve outlined the type of things the Multi-Disciplinary Team (MDT) will be considering in this domain, let’s take a look at the descriptors for the first three levels of need. For each level of need, we provide a case study to give you a better understanding of how the descriptors might be applied at your or your relative’s assessment.

NO NEEDS

No evidence of ‘challenging’ behaviour.

Key Factors No evidence of any challenging behaviours Compliant with necessary care No risk to self or others

CASE STUDY – NO NEEDS

Mrs. X is fully compliant with all aspects of her care. She does not present with any restlessness, agitation or aggression.

Mrs. X presents with ‘NO NEEDS as she displays no evidence of ‘challenging behaviour’.

LOW

Some incidents of ‘challenging’ behaviour. A risk assessment indicates that the behaviour does not pose a risk to self, others or property or create a barrier to intervention. The individual is compliant with all aspects of their care.

Key Factors Challenging behaviours which do not pose a risk to self or others Compliant with necessary care

CASE STUDY – LOW

Mr. X can be verbally aggressive if male carers attempt to assist with personal care and/or hygiene. Mr. X occasionally defecates inappropriately on the bathroom and bedroom floor; care staff explained this was because he can’t get to the toilet in time when he has loose stools.

Mr. X has never been physically aggressive towards staff or residents. When approached in the correct manner, he is fully compliant with all aspects of his care. There have been 2 occasions where he has been verbally abusive to night staff when they entered his room to check on him.

Mr. X presents with a ‘LOW’ level of need as he presents with some incidents of ‘challenging’ behaviour. A risk assessment indicates that the behaviour does not pose a risk to self, others or property or create a barrier to intervention. He is compliant with all aspects of his care.

MODERATE

‘Challenging’ behaviour that follows a predictable pattern. The risk assessment indicates a pattern of behaviour that can be managed by skilled carers or care workers who are able to maintain a level of behaviour that does not pose a risk to self, others or property. The individual is nearly always compliant with care.

Key Factors Challenging behaviour which follows a predictable risk Skill is required to manage the behaviour With such skilled management, the behaviours do not pose a risk to self and/or others Compliant with necessary care most of the time

CASE STUDY – MODERATE

Mrs. X has a cognitive impairment due to her dementia diagnosis. She can at times be non-compliant with care and her family report that the approach to delivering care is important in gaining her compliance and co-operation. There have been occasions when Mrs. X has declined care by the care staff and her family report that if approached in a different way, she will be compliant; for example, she may refuse her eyedrops but if you reassure and tell her the doctor has prescribed them, she is then happy to have them.

Mrs X’s family report that she does not like to be rushed and if she feels she is, she is likely to be non-compliant and refuse the intervention. On occasions when she does refuse interventions, staff leave her and return later to try again, which is usually effective.

There have been no incidents of physical aggression. Mrs. X can become verbally agitated at times and can tell staff to go away or get out but there is no evidence of escalation of any behaviours.

Mrs. X presents with a ‘MODERATE’ level of need as she presents with ‘Challenging’ behaviour that follows a predictable pattern. The risk assessment indicates a pattern of behaviour that can be managed by skilled carers or care workers who are able to maintain a level of behaviour that does not pose a risk to self, others or property. The individual is nearly always compliant with care.

We hope this has helped you to understand the first three descriptors in the Behaviour domain.  Don’t miss the next part of this series, Behaviour Part 2, coming very soon!

If you need help assessing your relative’s level of need in any domain on the DST, don’t hesitate to contact one of our specialist Advice Lines to discuss your case today. If you need expert advocacy support with any stage of your assessment or appeal, visit our 1-2-1 support page.

Don’t forget to take a look at our informative guide book How to Get the NHS to Pay for Care which is available as an email PDF or in paperback.

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