1. Bristol Community Learning Difficulties Service
Directed Enhanced Service Training

2. Introductions We are…………… And you are? We would like to know:-
Your name
Your role within the practice and
Your experience of working with people with a learning difficulty or disability

3. Training Session Content
Rationale for the DES
Definitions and identifying a Learning Difficulty
Eligibility
Common Health Problems
Communication
Consent
Disability Rights Act
Preparation for Health Check
Discussion

4. Rationale for the DES
People with a Learning Disability have poorer health than the rest of the population and are more likely to die at a younger age.
“Healthcare for All” (the Jonathan Michael Report 2008) made 10 key recommendations. The D.E.S. addresses all of these. (and specifically recommendation 8)

5. Learning Difficulty or Disability?
People with a learning difficulty living in Bristol have said they prefer the term “Difficulty”.
However, many professionals and government organisations e.g. Department of Health, World Health Organisation etc. use the term “Learning Disability”.
In this presentation the two terms mean exactly the same.
You might want to point out how in health terms the word “learning difficulty” is quite unhelpful as it causes considerable confusion (EG people with educational needs or dyslexia etc). However, we are requested to use this term.

6. What is a Learning Disability?
A significantly reduced ability to understand new or complex information, to learning new skills (impaired intellectual functioning)
With a reduced ability to cope independently (impairment of adaptive/social functioning)
Which started before adulthood,
With a lasting effect on development.
(Valuing People, 2001, DOH - pg 14 – 1.5)

7. How to identify if a person may have a Learning Difficulty
Explore their Communication skills and Understanding.
Ask about their Daily Living Skills and what they do during the day.
Discuss their History (esp. Schooling)
Question what, if any, Services they use.
Identify what type of accommodation they live in (e.g. supported living)
Relevant Medical Conditions
See our website
There is a fuller explanation of the 6 key questions on our website

8. CLDT Eligibility Criteria
To establish definitively whether a person has a Learning Disability (and thus eligible for LD specialist services) the CLDT use all or some of the following tools:-
ISACA (Initial Screening Assessment Checklist for Adults)
Psychology Assessments
Occupational Therapy assessments
Speech & Language assessments
Please make the point that establishing eligibility for LD services can only be done by us.

9. Common Health Problems
Respiratory Disease
Coronary Heart Disease
Sensory Impairments
Cancer
Epilepsy
Helicobacter pylori
Dysphagia
Weight (under or over)
Mobility
Skin Disorders
Dental Problems
Infections
Mental Health

10. Conditions also associated with LD
Cerebral Palsy
Downs Syndrome
Prader-Willi Syndrome
Fragile X
Tubular Sclerosis
Phenylketonuria (PKU)
GORD (Gastro-oesophageal reflux disease)
Autism
Epilepsy
Presence of these conditions does not mean the person has LD only that they might.

11. Dementia
The incidence of dementia is much higher in people with Downs Syndrome than within the general population.
Down’s Syndrome incidence rises with increasing age and rates vary:
2% years
55% years
Average onset 54th year
(Prasher 1995)

12. What are Community Learning Difficulty Teams – the CLDT?
The CLDT is a group of professional staff from Bristol Primary Care Trust’s provider function “Bristol Community Health” (BCH) who provide assessment, support, advice and therapeutic interventions to people who have learning difficulties.
We are co-located with Bristol’s City Council’s, Health and Social Care, Learning Difficulty Teams.

13. Composition of the CLDT
Community Nurses
Psychologists
Speech & Language Therapists
Occupational Therapists
Physiotherapists
Arts Therapists
Dieticians
Administration & Team support
Bristol Intensive Response Team (BIRT)
Social Workers
Psychiatrists
Forensic Team

14. CLDT linked services:-
Health Trainers
Health Facilitator
Co Trainer
Hospital Liaison Nurses
Transition Services
Courts & Prison LD Nurses

15. Contact Details for the CLDT
Bristol North Team (Brentry)
Bristol Central Team (Stapleton)
Bristol South Team (Withywood)
Bristol Intensive Response Team via the above teams
Open referral system and a referral form is on our Website:-

16. Associated LD Services
Mental Health : Lansdowne Assessment and Treatment unit (Part of AWP)
Placement Crisis: Concorde Lodge (Bristol City Council)
Residential & Domiciliary Care providers e.g. Brandon, Aspects & Milestones, Freeways, Mencap etc.

17. What are CM7s ?
They are a comprehensive HEALTH NEEDS ASSESSMENT which when combined with an Assessment of Need will be used to inform the package of care commissioned.
They can affect where someone lives, what support they have and their package of care.

18. Communication
All people with a learning disability have communication problems. It is probably the most significant barrier to services that they have.
Many service users are highly adept at concealing their communication and understanding problems
Please don’t assume that if a person is agreeing with you they know what you are talking about!

19. Top Tips for Communication(1)
Speak directly to the person with learning difficulties
Take your time – extra time may be needed
Get advice from the carers regarding how to communicate with a person
Arrange to have a quiet environment with not too many distractions
Get the persons attention e.g. use their name / make eye contact
Use everyday words e.g. heart rather than cardiac

20. Top Tips for Communication (2)
Use short sentences covering one topic.
Try to avoid questions/statements that the person can simply agree with (as sometimes people will give the answer they think you want.)
Use clear direct questions e.g. Does this hurt?
Use pictures or objects and gestures to back up what you are saying
Some procedures can be demonstrated on the carer first e.g. taking blood pressure, using a stethoscope
Clarify whether the person has understood by asking them feed back what you have said so as to test their understanding.
Some people may not remember information about their medication/treatment. Simple written information that they can look at or share with carers may help this.

21. Communication Exercise
Using the resources supplied ……

22. Consent :The FACTS (1)
No-one can give consent on behalf of another adult
It must be assumed that a person can give consent i.e. that they can make their own decisions unless proven otherwise
It is the responsibility of the treatment provider to make a decision about the person’s capacity to consent to treatment
It is a criminal offence to treat a person who has capacity and has not consented

23. Consent :The FACTS (2)
Everything possible must be done to help someone make their own decision
If it is decided that someone is unable to make a particular decision, it does not stop that person making other decisions
Decisions can legally be made for someone thought to lack capacity by: -
Those involved in the care and treatment of the person (within the framework of a best interests multi disciplinary meeting)
a court
a deputy appointed by the court
someone chosen by the person to make decisions for them (lasting Power of Attorney)

24. 5 Key Principles of Consent
Adults are assumed to have the capacity unless proved otherwise
A person must be given all available support before it is concluded that they cannot make decisions for themselves
Individuals retain the right to make unwise decisions
Anything done for someone without capacity must be in their best interests
Anything done for someone without capacity should restrict their rights and basic freedoms as little as possible.

25. Disability Discrimination Act 1995
It is a legal requirement not to treat people with a disability less favourably
It is a legal requirement to make “reasonable adjustments”
To ensure equality may mean treating some people differently
“Reasonable adjustments” are often about practices and procedures rather than physical access

26. Preparation for a Health Check
Accessible appointment Letter
Health Check Questionnaire (HCQ) sent out
Pre appointment phone call? Remind to bring HCQ
Carers support required?
Allocate one hour per patient.
Plan how and by whom check will be done
At the end of the health check the last page of the HCQ needs to be complete and agreed with the Service user.
Advise CLDT of DNA’s on second failure.

27. Health Action Plans This was an initiative started in 2001.
Some service users may already have a H.A.P which they may bring to their Health Check Appointment
When the health check is completed the last page of the HCQ needs to be completed, agreed with the Service user and actioned.
This document can then work as their revised Health Action Plan

28. What next for the CLDT? To maintain close links with yourselves
To explore appointing CLDT primary care liaison workers (similar to the hospital liaison nurses)
To help you keep your register up to date
To continue to develop services together that are accessible, effective and improve the health of people with a learning disability

29. The End
Any Questions?