Adults with learning disabilities who are vulnerable need support to ensure that they are not denied the right or opportunity to make their own decision and give their own consent (Peate & Fearns, 2006). According to Hayes, (1993) states that, adults with learning disabilities who may have had no choice but to accept the labels ‘dingbat’ or ‘airhead’ to cover the confusion, memory lapses, misread or misunderstood directions, or the dozens of other mean tricks that adult has played on through the years.’
People who have much less the ability and capacity to understand new or complex information, either less able learn new skills also has a little ability to dealing independently like-the ability to social work weakness and the requirement that of the beginning before the age of puberty have a lasting effect on development (Scottish Executive,2010).
Adults with learning disabilities comprise of a highly vulnerable part of the society, who have limited access to health care facilities /services offered to them. According to Kerr et al., (1996a) he states that, learning disabilities suffer form a similar range of morbidity as the general population, but some conditions are seen with greater frequency within certain syndrome. They are often faced with obstacles and challenges while coping with grave situations such as loss and bereavement of loved ones, personal illness, death etc (Elliott, 1995).They are known to have been ignored persistently in terms of providing services in the need of personal illness, death, and other challenging life situations, thus increasing their vulnerability all the more (Elliott, 1995).
Vulnerability & Risk:
‘A vulnerable adult is a person who is eighteen years of age or older who is, or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or herself, or protect him or herself against significant harm or exploitation.’
-‘No Secrets’ March 2000, p 45.
Every human being becomes vulnerable during their lifetime for many of reasons they all respond differently to events that happen to them because of who they are and the lack of support that they have around them (Jacki, 2001). The term ‘vulnerable adult(s)’ is now use more widely in the social care field than it ever was, but it may be open to interpretation and being vulnerable means different things to different people (Jacki,2001).
People with learning disabilities are one of the most vulnerable groups in the society (Department of Health 2001). Learning disabilities may be more at risk not only because their own difficulties in understanding or communication but also because of the way they receive services and the fact that they may be actively targeted or taken advantages (Jean and Anthea, 1997). The broad definition of ‘vulnerable adults’ is a person:
‘who is or may be in need of community care services by reason of mental or disability, age or illness; and who is or may be unable to take care of themselves, or unable to protect him against significant harm, risk or exploitation’ (DOH 2000, s.2.3).
Among the most vulnerable members of society they can’t speak up for themselves. For example, if consequences are limited when an adult with learning disabilities abuses another person, the victim may be left with the idea that such behaviour is normal and acceptable, and that services will provide little protection and that their complaints will not be heard. It may also increase their vulnerability to further abuse because abuse can become normalised and more likely to be the victim of abuse physically (McCarthy and Thompson, 1996).
The Oxford Dictionary define ‘risk’ as meaning a hazard, a dangerous, exposure to mischance or peril, as verb it also similar which means ”hazard, to danger, to expose to the chance of injury or loss”( Parsloe, 2005). Risk is closely linked to dangerousness, resulting in harm which seems to be agreed means harm to self or others and extend of harm which constitutes a risk in various situations especially adult with learning disabilities.
‘If you don’t know for sure what will happen, but you know the odds that’s risk, and if you don’t even know the odds, that’s uncertainty’ (Knight, 1921, p.25). Royal Society (1983) states that, risk assessment which axiom as the probability that a particular adverse event occurs and social services has been concerned predominate with risk assessment to prevent harm. They may also suffer further if they have to deal with seeing their perpetrator on a regular basis, and may be subject to further assaults in retaliation of their initial complaint. In addition to the risks to existing victims, poor responses may result in increasing numbers of people being abused.
Definition of ‘vulnerable adult’ in section 80(6) Care Standard Act 2000 states that-
(a) ”an adult to whom nursing and accommodation or personal care are provided in care whom” (b) ” in adult to whom personal care is provided in their under arrangements made by a domiciliary care agency’ own home (Peate & Fearns, 2006). Adults with learning disabilities, and those people who have a less capacity like who have mental illness, old and frail, need protection from potentially abusive situation over which they might have little control (Department of Health, 2000). Learning disability Adolescents obliviously it is not always acted in ways that serve their own best interests, even as defined by them (Fischhoff et al., 2000). Sometimes their perception of their own risks, even of survival to adulthood, is larger than the reality; in other cases, they underestimate the risks of particular actions or behaviours since adult’s abuse and risk has gain higher profile. According to Kemshall and Pritchard (2001) states that, there has been much debate about a welfare model or a criminal justice model should be adopted. After the recent death Steven Hoskin 22 year’s young man who has been dead by numbers people. Adult’s vulnerable protection systems are likely to come under close scrutiny (Jacki, 2001).
It is possible, indeed likely, that some adolescents engage in risky behaviours because of a perception of invulnerability-the current conventional wisdom of adults’ views of adolescent behaviour. Others, however, take risks because they feel vulnerable to a point approaching hopelessness (Fischhoff et al., 2000). In either case, these perceptions can prompt adults to make poor decisions that can put them at risk and leave them vulnerable to physical or psychological harm that may have a negative impact on their long-term health and viability.
The concept of learning disability Brumback (2004), people who have development disorder in their language, speech, reading and associated communication skills needed for social interaction also who have sensory handicaps such as blindness or deafness and generalized mental retardation. According to Robert (2009) Learning disability is a neurodevelopment disorder affecting a specific cognitive skill that occurs in the presence of intact skills in most others realms and specific impairments are presumed to be due to dysfunction of the brain and to have been present since birth. And learning disability substantially limits functioning in one or more aspect of person’s life (Mapou, 2004).
According to Mencap (2010) reports that, in the UK there are 1.5 million people with a learning disability. Most are treated as ‘different’ and don’t have the same control over their own lives as the rest of our society. Over the past century and a half there have been huge changes in the in the labelling of those people presently categorize as having learning disabilities. In social policy terms, they have been variously labelled as ‘vagabonds’, ‘idiots’, ‘mentally handicapped’, ‘learning disabled’, and ‘people with learning difficulties among others names (Gordon,2005).
Above the definition indicates that, Learning Disabilities is thÐµ terminology used to label people that function at an intellectual level that is significantly lower than the average people in society (David and Hinor,2003). Different periods in history have meant different things, depending on the social and economic circumstances of the time, and of course on how long people with learning disabilities lived (Brian, 2006).
Risk Assessment Decision Making Process / Practice Tools:
Increasingly responding to the risks of others, preventing risks to vulnerable adults or running risks to themselves is all in day’s work for the busy practitioners and manager in the field of social care (Brearley, 1982). Every day a lot of risk situation changes rapidly and what applied yesterday but may not today. Those service users who are identified as “at risk” would be provided highly effective instruction to reduce their risk in the identified area (e.g., language, reading, numeracy/ math, behaviour) (Brown, 2003). David Carson (1988b) points to about risk ‘ Risks should be taken to achieve specific goals in the light of possible harms occurring’ and ‘Taking risks involves deciding that the potential benefits of a proposed act out weight the potential drawback’ (p.248).
Hence risk always should be taking whether or not to act to achieve beneficial results in an awareness of potential harm. To minimize risk and make it useful and meaningful, may risk situations need to be reassessed regularly perhaps daily basis according service users daily need. People with learning disabilities are subject to risk all time due to their vulnerability they sometimes abused by those who have control over them or by those who realize that they are vulnerable because of their disabilities they often find it very much more difficult to assess risk the way most of social carer and services do (Vaughn and Fuchs, 2003).
While most of carer don don’t asses risk very efficiently they generally make some attempt to do so. It’s not easy at all to do risk assessment as it is a complex task and most of the time carer or support worker they do adequately but not very thoroughly (Carol, 2002). In spite of some difficulties, there is an increasing awareness that people with learning disabilities can make choices, moreover they want to do so. Nevertheless it’s often failed to consider is that, the amount of risk that these choices carry and most of us have grown up accustomed to risk-taking. Many problems about assessing risk that different services user may perceive the different risk. What is acceptable to one person may not be acceptable to another. Main objective of the risk assessment when it’s possible may sometimes affect decision making in number of different ways (Heilbrun, K.et.al (1999). It is true many adults with learning disabilities who have always facing risk in their everyday life. Significantly about choice decision sometimes it’s difficult for adult as well carer to make right choice how could be at risk.
The difficulty for people with learning disabilities is that carers often do feel often they are expected to make these choices for them. The law of negligence can appear to inhibit decision making ‘personal freedom and choice sit uncomfortably next to the concepts of duty of care and professional liability’ (Fuchs, 2003). People with learning disabilities may not have done perhaps carers need to be encouraged to help their service users how to make choices with and appreciation of the risk involved. This is more challenging task than just encouraging choice alone it seems that not only should people with learning be allowed to make choices and take risk ‘they should actively be encourage to do’ (Kemshall & Pritchard, 1996).
Multidisciplinary Risk Assessment:
There are a range of sources where information can be gained for a through risk assessment which include the prospective resident, their relatives or practitioners involve with the person and any written reports; which may be historic or recent (Alaszewski and Manthorpe, 2002). The problem with the right to make choices is that it assumes that adult with learning disabilities are able to make choice about risk in the same way every one does (Heilbrun, K.et.al.1999). It acknowledge that adult with learning disabilities do have real difficulties with many cognitive takes. Most have problems in assessing risk effectively because of the complexity of doing so it is likely that people with learning disabilities will find the particular difficult. An endeavour to make balance the protection of vulnerable adults, as standard in the ‘No Secrets’ guidance ( DoH, 2000) where different policies that encourage and aid to take more control to service users in their lives which also including to take opportunities and manage risks. In 2007, Department of Health established risk assessment and management regulation and various assessment tools for help practitioners and professional to work predominately in the field of social care. According to Jones, 1998 states that, the assessment of ability to consent and the ability to make real choice, especially in relation to understanding the likely consequences of the choices or decision made.
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It could be helpful when any risk assessment plan to do like-if carer support worker want to take any decision about the service users or any person , is the person are aware about that decision been mad or going take ? Are they communicating their choice decision making? Giving more choice people with learning disabilities especially about taking risk, it’s mean that carer have to be alert to the extent to which the service users are able realistically to assess the level of risks involved (Sellars, 2003). Many adult with learning disabled the most successful way to avoid and minimize risk to avoid further problem is by effective management. When the person concerned may have been living in a setting where the opportunities for such behaviour have been very limited or absent, carers and professionals are sometimes tempted to assume that because the recent past has been incident-free the problem has disappeared (Carol, 2003)
Risk assessment is about predicting the future and the likelihood of particular events occurring; these will be both wanted and unwanted events (Pritchard, 2004). “Risk assessment is merely the description of good methodical practice to risky situations” (Jones, 1998 p.5). In leave to address matters of importance for instance dangers, hazards, and known triggers and how best to keep away from them is a risk assessment. Confirm that they are recognizable with the exacting risks that you have put measures in place to reduce, or eliminate them and that you could face with the person in your care. A multifaceted and time consuming task and a continuous process is Assessment (Pritchard, 1997).
Assessment of risk for adult with learning disabilities which should be evolutionary in nature constantly informed and shaped by changes of circumstances upon service users needs (Brown, 2003). The practice of risk assessment and management is the process of data collection, recording, interpretation, communication and implementation of risk reduction plan (Maden, 1996). For the risk of learning disability, clinical model of risk assessment have become the norm. There are two kinds of risk that are relevant to work people with learning disabilities, risk of unnecessary exposure to undesirable events or experience, and risk of negative consequences when possible benefits and desirable experiences are perused ( William, 2006).
Above this it is clear that a strategy of prevention should implement, and management is required so that risk and benefit are balanced. In social care and health care there are broadly two main context of risk which are not provided and everyday risk in their life and learning disability have a history of formally documented offence (Thompson, 2000).
So far it has been established that different service users have different risk upon their physical and mental health which is major issue for people with learning disabilities and there are large number of people with learning disabilities who suffer from variety of physical and mental health condition (Heilbrun, K.et.al. 1999). However, the true extent of the problem cannot be known, due to difficulties in assessment, and it is estimated that the actual number is high due to the service users being unable to sufficiently communicate their social life. It follow that the more severe the communication problems, sometime its difficult service user are gain true assessment (Priest & Gibbs2004).
In order to fully appreciate the process of risk assessment, here identify the one of particular service users and consider the kind of life they lead at present. Service users who is Mr ‘M’ 22 years old young male with complex physical learning disabilities who has Cerebral palsy affecting all four limbs, epilepsy, severe learning difficulties and Migraine which affects him seizure pattern. Who lives in a residential care home with four others service user’s people with learning disability. However this service user also have gastro feed which need to use for his water and medication as he can’t drink and always need someone to assist his food. Deliberate self-harm is relatively common when he feels unhappy and anxiety his verbal language is very limited he can communicate within short sentences and can answer ‘yes/no’. Mr ‘M’ always need to use wheel chair for maintains his everyday life.
Assessment of risk
“The plan should note risk – low, medium or high – as well as the impact of the child or young person on others.” (“Guidance on the Child or Young Person’s Plan”, Scottish Executive. 2007, page 13). Risk assessment is useless unless the results are shared with everyone who is involved in the care of ht client (Sellars, 2003 p.154). There are several risk exist her for this service users as he has Cerebral palsy which is a general term used by doctors to refer to a set of neurological conditions that affect a people movement and co-ordination. Neurological conditions affect the brain and nervous system. Epilepsy is common, he needs to regular medicine and to control this and possibly refer to regular doctor visit due to he has migraine problem as well as. He also has choking difficulties while he eats his meal. Risk can fall of wheel chair if it does not fasten. At risk of being hurt when moved. And at risk of falling off ramp when loading in to resident vehicle while he travelling.
Risk to carer/staff:
This service user often to risk carer or staff, some risk that he could become aggressive if he is feel hungry or any physical illness. Infrequently he can become aggressive or even violent during the illness so that this behaviour needs to be monitored.
Frequency of risk:
This service user sometimes settled and had good responded well to medication. It is likely he is vulnerable and sometime faced with stress in his life due his migraine problem. And he has Percutaneous Endoscopic Gastrostomy (PEG) and need to see doctor every four months.
Level of Risk:
The level of risk is very high this residential care home has own risk assessment plan. For minimize the risk as vulnerable adult trust has their own policy according to service users need. For health and safety and others physical risks as well as there are recognized health risk associated with the carer and service users. Taking risks daily on occasion, and thus the level of risk that he will come to harm which is quite high.
Manual handling risk: To minimize risk during changing of position in bed/on floor, slide sheet to be used and make sure service user is positioned correctly and two trained staff to assist him all times. Staff to use high adjustments on equipment where needed like Hoist. To transfer from bed to chair, chair to bed and chair to chair the level of risk also high staff always hoisted for all transfer using allocated sling. Staff to use height adjustment equipment where available during Changing Bench/ shower/ bath level of risk also high. Due to his physical ability while he travels in transport he need his wheel chair and have to make sure four point clamps to be use while on the vehicle and addition seat belt to minimize risk during his journey.
The immediate outcome is that health needs are constantly monitored by his parents and his career. He has cerebrally palsy which affecting his limbs and also had severe learning disability and epilepsy which is controlled using prescribed medicine that administrated by his concern of his resident/trust. He also sometimes suffers from migraine and takes medication for his migraines appears to be controlled at the present time. He always uses wheel chair for mobility. Seizure and migraines are prone to increase when become too warm and carers are aware of this which is monitor by closely.
From the above analysis it is clear that this service user is a high risk client. However, the key to understanding the level of risk is the acceptance that his behaviour could be change which depends on his medication and close support from his parents/ career and doctor. And it is important in the first instance try keep staff safe and would be wise to ensure that staff work always in pairs, and that vulnerable are not left alone unattended. While assessed others should not be put at risk and violence can’t be ignored (Casella’s, 2003). Sometimes it would be wise to monitor behaviour it may be possible to discover patterns his behaviour like- When he became agitated is there any time or reason? How about his voice does he react different tones of voice? Why he wants to hit staff is there any communication gape? Are some time or someday difficult? Does he feel uncomfortable or need personal support? Or are there any physical problems which make him unhappy and annoyed?
For behaviour assessment by psychologist or doctors recommended, in order to see if any patterns emerge this may allow the behaviour plan to be managed within the existing home. However sometime service users simply exploiting inexperience staff to his advantage, then it may be necessary to move him to another place ensuring that he is supported by staff with experience who knows him well. Thus a review of medication and careful monitoring to ensure that he takes it may improve the situation which he has epilepsy and others physical illness. And staff should be aware environment they are in and hazard that may be present. While proper risk-assessment procedures may be lengthy and complex quality of life for a person with learning disabilities is likely to depend upon them (Kemshall and Pritchard 1996).
Risks change constantly and people grow, change, and develop. It is important to review risk assessment regularly, and aim always to increase choice and freedom for the people with learning disability (Sellars, 2003 p.155). People with learning disabilities are beginning to reclaim the lives they lost in the institutions, having choices, jobs, sex lives and even becoming parents – unthinkable until even quite recently. Slowly, perhaps far too slowly, the rest of the community is beginning to realize that the majority of people with learning disabilities are not so different from everyone else, and need the same things in their lives that all of us do: ‘work, leisure, partners, and a sense of being part of a social group’ (Heillbrun, K. Et al 1999).
They want to feel useful and valued, as we all do. Life is full of risks. We all take risks all the time, and the more familiar they are the less we tend to recognize the real level of risk involved. It actually takes the greatest risk in our lives every time that we step into a car, but few of us really consider that risk seriously (Daniel, 2003). This is the other side of the coin; we are inclined to believe that ‘it won’t happen’, even when the objective statistics suggest otherwise the difficulty that now exists for people with learning disabilities, especially those with greater disability, and those who care for and support them, is that the law specifies that many such people are vulnerable, and not able to make this choice for themselves (Daniel, 2003).
The onus of assessing risk and making the decision therefore often rests with carers. Because it is such a difficult decision to make for someone else, carers often take the simple way out, and avoid letting situations arise where learning-disabled people in their care have the opportunity to develop sexual relationships: if a person cannot make an ‘informed choice’ then perhaps it is easier not to offer them that choice (Lindsay 2004). This is the current dilemma for those who work in community care situations. According to David J. Thompson,(2000) the issue of sexual relationships is perhaps the most difficult and complex, but this problem of balancing risk and choice is a constant one for carers and professionals, in relation to many aspects of everyday life. In the background is the ogre of the law (and/or local management), ready to jump on the unwary, should they get it wrong. No wonder, perhaps that many are cautious about enabling such choices to be made.
Get higher in the information of vulnerable adults referred to them for the reason that they are at risk of physical and sexual mistreatment, in addition to financial fraud, a study has found in Social services departments have seen (Simon, 1997. So where adult with learning disabilities have more complex problems, such as behaviour problem, mental illness, or others any physical or mental disorder they will need additional care and support to cope with their everyday lives (Hawks, 1998). Sometimes these problems impose additional risks, and these do need to taken into account when assessing and managing risks for each person/adult.