1. Introduction

The Bedford Borough Adult Learning Disability Team is an integrated team of social workers, learning disability nurses, community team assistants and administrative staff who provide support to adults with learning disabilities and their carers in Bedford Borough.

The hours of the Service are Monday to Thursday 8.45 – 5.20pm; Friday 08.45 – 4.20pm. The out of hours function will be supported by the Emergency duty Team.

The Team provides a specialist service to adults who are 18 years old and over, who have a recognised learning disability and the individual and / or their carer meets the national agreed eligibility criteria for care and support needs under the Care Act 2014.

The Team focuses throughout on what people can do, with support where necessary, rather than on what they cannot do. The service operated by the Team is based on the principles of valuing people now:

  • legal and civil rights;
  • independence;
  • choice;
  • inclusion.

The Team provides person centred services that offer continuity and consistency, whilst promoting the profile of people with learning disabilities in a positive and sensitive manner.

It offers a single point of contact through the duty desk to provide information and support for the following:

  • safeguarding: the team is responsible for safeguarding vulnerable adults and promoting a safer community (see also Adult Safeguarding);
  • specialist health care needs – assessing and monitoring complex health needs inclusive of the following;
    • epilepsy;
    • mental health / dual diagnosis;
    • complex physical needs;
    • challenging behaviour;
    • autism;
    • dementia;
    • end of life care and support (see End of Life Care).

Also social care needs such as:

The Team will facilitate assessment and intervention in a meaningful and person centred way in order that the individual gains optimum control in managing their life:

  • to ensure their views are listened too and are treated with respect and dignity;
  • to be able to make informed choices, including those, which may carry a risk and to be supported to make those choices where necessary;
  • to learn more about the world and to have the opportunity to try out new skills;
  • to be accepted as a valued part of the local community.

2. Referral

Contact can be made to the Adult Learning Disability Team by any means and by anybody. The Team needs to ensure that there is consent from the individual that they are happy for the referral to be made.

Information will be requested on the presenting need and the reason and outcome expected from a referral to the Team. It will process the referral and it will be progressed to formal assessment under the Care Act 2014. The assessment will be completed with the individual to establish eligibility for learning disability services.

The timescales for completion are within 28 days, however there maybe circumstances that will require a prompt response to urgent need.

A practitioner in the team will be allocated to complete the assessment with the individual, and will also ensure that if there is a carer identified through this process, a formal carers’ assessment will also be offered and completed.

3. Assessment

The purpose of the assessment is to identify and evaluate the individuals presenting need/s and how this impacts on the ability for the individual to live full and independent lives.

Information from the assessment should be used to inform decisions on eligibility and services offered to the individual and / or their carer.

The individual is central to the process and the depth and breadth of the assessment should be proportionate to their presenting needs, problems and circumstances.

The assessment should be holistic and person centred, and will include and overview of the person’s aspirations as well as health and social care needs.

Specific risk assessments will also be completed to reflect complex / high risk needs that the individual may present with (see Risk Assessments).

Adherence to the principles of the Mental Capacity Act 2005 must be followed, to empower people to make decisions for themselves wherever possible, and protect people who lack capacity by placing individuals at the very heart of the decision making process. This should ensure they participate as much as possible in any decisions made on their behalf, and that these are made in their best interests.

Assessment should be conducted in an open and transparent way in order that the individual can sufficiently:

  • get a better understanding of their situation;
  • identify options that are available for managing their own lives;
  • identify outcomes required from any support that is provided;
  • understand the basis on which decisions are made.

If, at the conclusion of the assessment, it is identified that the presenting need of the individual is not eligible for care and support from the service, full feedback will be provided along with signposting and advice for next steps in sourcing alternative support networks.

4. Personal Support Plan

A personal support plan will be facilitated by the Team to reflect and capture accurately the support needs identified through the assessment process, how services will be personalised and delivered to the individual. This may, for example, be a direct payment for an individual to manage their own care and support needs, through an agreed and assessed number of hours funded and provided through a direct payment to the individual.

A personal support plan will change and adapt to the needs of the individual as the Team recognises an individual’s needs are not static and can change at any time. Therefore all personal plans are subject to regular review, which is a statutory requirement of the Council.

4.1 Review

Team practitioners will review individual personal support plans to ensure that the service is providing the appropriate level of support as per the assessed need, and that it is fulfilling the expectation of the individual.

The process will evaluate the effectiveness and the quality of the support provided but also to make any necessary adjustments to ensure the plan is person centred and accurately reflects the need and how it will be met.

The review will also ensure the key responsibilities identified in the personal support plan are being fulfilled by those providing support.

Reviews for new services will occur within four weeks, then eight weeks and then after a 12 week period the review will occur once a year, when it is established that the support is appropriate and the need is stable.

With each review that is completed, an updated personal support plan will be completed and shared with the individual and others with key responsibilities in meeting the need identified through the assessment process.

Other services that the Team may offer include:

  • advice and guidance;
  • support with safeguarding of vulnerable adults issues;
  • health promotion;
  • support in accessing mainstream services;
  • signposting onto other agencies;
  • working with other agencies;
  • transition (preparing for adulthood) into adult services.

5. Partner Teams and Agencies

The Adult Learning Disability Team works with other teams and agencies to provide care and support to individuals. These include:

  • other health and social service professionals, for example clinical services, psychology, occupational therapists;
  • housing;
  • education, schools and colleges and SEND teams;
  • mental health services;
  • Clinical Commissioning Groups (CCGs), GPs, district nurses;
  • police;
  • Department for Work and Pensions, employment agencies and volunteers;
  • advocacy services;
  • registered care providers;
  • day service providers;
  • supported living providers;
  • leisure service provider;
  • voluntary organisations.

6. Financial Assessment

The Adult Learning Disability Team does not take account of a person’s financial circumstances in assessing their needs. However, the Council is required to undertake financial assessment to determine the amount the service user would be required to pay towards the cost of meeting their needs.

Every person’s eligibility statement must be assessed individually on the basis of their personal assessment.

See also Charging and Financial Assessment.