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 Fifteen below!
Last week we looked at the first three descriptors in the Behaviour domain – ‘No Needs’, ‘Low’ and ‘Moderate’ needs. This week we’ll examine the descriptors for ‘High’, ‘Severe’ and ‘Priority’ needs in this important domain.
The following clinical factors are relevant to the assessment of ‘High’, ‘Severe’ or ‘Priority’ needs in this domain:
- What is the degree of risk posed by the behaviours and/or non-compliance?
- Is there a risk of serious illness, injury and/or death?
- Has anyone been injured? Did they require hospital treatment?
- How many staff are required to deliver care safely?
- What management techniques are employed and do these require specialist training (e.g., MAPA, as required sedation, restraint)?
- Are the management techniques effective in reducing the risks?
- Is the person independently mobile?
- Do they require 1:1 supervision (i.e., a dedicated staff member)? For how many hours a day?
- Is there ongoing oversight from the mental health team?
- Does the person require a specialized environment (e.g., EMI nursing, NHS facility, male only unit)?
- Is the person subject to Section under the Mental Health Act?
- Has the Safeguarding Team been involved?
- Have the police been involved?
*REMEMBER – Much of the assessment of needs in this domain relates to the degree of risk to the individual, their peers and/or those caring for them. Non-compliance with necessary care will pose a lesser or greater risk, depending on the assessed needs in other domains. For example, non-compliance with pressure area care would pose a far greater risk to a person with an existing pressure injury than a person whose skin is intact.
Now 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 ‘High, ‘Severe’ and ‘Priority’ 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.
|‘Challenging’ behaviour of type and/or frequency that poses a predictable risk to self, others or property. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.
Challenging behaviour which poses a predictable risk
May include some incidents of physical aggression
Skilled staff are able to mitigate risks through planned care
May be non-compliant with care interventions, but skilled staff are able to deliver necessary care safely
May require PRN (as required) sedation
Management techniques are effective in maintaining a safe level of behaviour
CASE STUDY – HIGH
Mrs. X is non-complaint with catheter care, personal cares and may be resistant towards some staff. Staff report that the ‘leave and return’ approach is employed with good effect. Mrs. X is reported to be restless and wander most of the day; she is at a high risk of falls.
Staff report that Mrs. X is frequently resistant to care and can be challenging to manage; she requires a skilled approach, which is usually effective.
Mrs. X thinks the lounge is her lounge at home and may become argumentative when other residents are in there. However, staff report she is easily diverted and not usually problematic to manage.
Mrs. X’s behaviours are a risk factor for falls; however, there is no further allusion to this in the mobility care plans. The care plan confirms Mrs. X has difficulty following instructions and can be non-compliant with care interventions. She can be quite sharp with staff when she doesn’t get the answers she is looking for. Staff report that she responds best in a quiet and calm environment.
Mrs. X is very reluctant at times to have a wash and can get quite angry with staff; if this occurs, the care plan outlines that it is best to leave her a little while and try again.
Mrs. X requires lots of prompts and reassurance to agree to necessary care interventions, some of which are critical (e.g., compliance with medication and catheterisation). While staff can predict when Mrs. X is most likely to present with challenging behaviour, it is still difficult to manage without the sensitive approach from familiar carers.
Mrs. X presents with a ‘HIGH’ level of need as she displays ‘challenging’ behaviour of type and/or frequency that poses a predictable risk to self, others or property. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions’.
|‘Challenging’ behaviour of severity and/or frequency that poses a significant risk to self, others or property. The risk assessment identifies that the behaviour(s) require(s) a prompt and skilled response that might be outside the range of planned interventions.
Challenging behaviour which poses a significant risk
Risk is not always predictable
Prompt and skilled response required from staff
Staff require specialist training to manage the risks – e.g., MAPA
May require 1:1 care
May require 3+ staff to carry out interventions safely
Management techniques are usually effective in maintaining a safe level of behaviour but the risk cannot be completely mitigated
CASE STUDY – SEVERE
Mr. X presents with unpredictable challenging behaviour and is physically aggressive. He can display self-injurious behaviour by banging his head against the walls and can present as sexually disinhibited; he will also urinate in communal areas. He can cause property damage by punching and kicking windows and is at risk of falls due to his wandering/restless behaviour.
Mr. X’s wife reported that he was very aggressive to her whilst he was living at home, causing bruising, and necessitating a safeguarding referral and strategy meeting.
A Mental Heath Act assessment was undertaken in June/July due to his mental health/behavioural presentation which ultimately led to the breakdown in his home placement. The first care home placement served notice after three months, as it was unable to manage his behavioural needs, and his wife recalls that it took a long time to find an alternative placement.
The home manager reports that commencement of antipsychotic medication appears to have had a positive effect on Mr. X’s behavioural presentation, and that he appears much more settled since his admission to the home, which is registered to provide EMI nursing care. However, staff report that he ‘still has his moments’.
The behaviour support plan states that Mr. X can become verbally and physically aggressive, particularly during personal cares. He requires 1:1 supervision 24hrs a day. Antecedents to challenging behaviour include, others invading his personal space and being unable to communicate effectively.
Mr. X will become restless and pace up and down. He can become both verbally and physically aggressive towards staff during personal cares by swearing and hitting out. Strategies include, using reassurance and a calm approach. Mr. X needs basic step-by-step instructions on all care actions; he needs time and space to calm down. He sometimes responds to distraction, e.g., putting on the TV, offering him a drink or taking him to a quiet room.
Mr. X continues to require 24-hour 1:1 support and, occasionally, up to 3:1 support during personal cares to which he is resistive to on a daily basis. MAPA hold techniques have been used to escort Mr X away from other residents when he becomes agitated; this requires specialist training.
Mr. X presents with a ‘SEVERE’ level of need as he displays ‘challenging’ behaviour of severity and/or frequency that poses a significant risk to self, others or property. The risk assessment identifies that the behaviour(s) require(s) a prompt and skilled response that might be outside the range of planned interventions.
|‘Challenging’ behaviour of a severity and/or frequency and/or unpredictability that presents an immediate and serious risk to self, others or property. The risks are so serious that they require access to an immediate and skilled response at all times for safe care.
Challenging behaviours which pose an immediate and serious risk
Risk is grievous/life threatening
History of serious assault or self-harm
Requires a specialized environment (e.g., NHS facility/specialist behavioural unit)
Requires a minimum of 1:1 care 24-hours a day, may require 24-hour 2:1 or 3:1
3:1, 4:1, or more, care may be required for certain tasks or activities, or at times of escalation which occur unpredictably at any time of the day/night
Staff require specialist training to manage the risks – e.g., MAPA, restraint
High levels of restraint required, including mechanical restraint (e.g., belts)
Legal framework in place around use of restraint (DoLS/CoPDoL)
Frequent, intensive input from Mental Health Team
Complex medication regime, under direction of Consultant Psychiatrist
Regular use of PRN anxiolytics or ongoing review of psychotropic medication – these may be used off license, over British National Formulary (BNF) limits or under titration
The risks remain extremely high, despite skilled management techniques
CASE STUDY – PRIORITY
We have no case study for a priority level of need in this domain, as it is exceedingly rare. The risks associated with this level of need are so high, the individual would usually require detention in a secure facility, meaning their care would already be NHS-funded. We would not expect to see a person discharged into the community if they were still presenting with a Priority level of need.
The vast majority of people presenting with behaviours at this level will be having some sort of mental health or behavioural crisis, meaning it would not be appropriate to assess their eligibility for CHC funding (because this can only be considered once the person is at their clinical optimum). We would expect to see such an individual treated in an NHS facility, and for there to be a considerable improvement in their behaviour before any consideration for CHC funding is undertaken.
We hope this has helped you to understand the last three descriptors in the Behaviour domain. Don’t miss the next part of this series, Drug Therapies & Medications: Symptom Control, 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.
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