Adults with Incapacity - delayed discharge: good practice guidance September 2023

3. Good practice examples

“We have appointed a specific MHO to chair all of our AWI meetings.”

A lack of experience of AWI legislation and process by the chair of AWI case discussions was causing a delay to the process. Since making this change the HSCP have improved their performance in relation to the time taken to convene and hear AWI case discussions with a subsequent effect of reducing delays overall.

“We have integrated a social worker and MHOs into two hospital teams across the East and West of our area. We also have social work assistants in these teams.”

The HSCP was having difficulty in co-ordinating what was happening in the ward setting with that of the need to have community supports in place. By introducing MHOs to the hospital teams AWI issues were picked up and progressed quickly. The social work assistants are making a change in the way that they are focussing on the discharge planning for those able to be discharged with appropriate care needs in place. By integrating MHOs and social work assistants into the hospital teams we were advised that the communication across the multi-disciplinary team had greatly improved. Also, discharges were managed more closely to the point that delays were reducing.

“We have implemented a tracking system for all AWI delayed discharges, and we meet each morning to monitor the progress of these cases.”

This HSCP told us that they needed to implement a more robust process to keep an overview of their delays. By implementing a tracker system across the service, which is reviewed daily, the management team advised that they are now able to see every delayed discharge and the cause of the delay. This has helped them ensure the process is moved on at pace for the person awaiting discharge and that they are not being held in hospital due to a procedural issue.

“We have a prioritisation framework in place and guidance that all MHO’s work with. We also have a group of six sessional MHOs in the team working specifically on delayed discharge.”

This HSCP advised that they wanted to refocus their MHO team given underlying pressures of work and a lack of MHOs within the service. By recruiting sessional MHOs with a specific focus on delayed discharge where AWI was a feature they could quickly improve on the time for assessment and care management, given this was their sole priority. They advised that this has been helpful in reducing delays and also ensuring support to existing MHOs who are carrying other areas of legislative work.

“We have created a new Integrated Discharge Planning Hub made up of social workers, homecare, and admin staff. Staff from the hub update on AWI/DD daily. The hub has been in place since Christmas and has reduced the length of hospital stays for patients. Our MHOs manage the people on our discharge planning tracker.”

This HSCP advised that they had made the decision to completely review the way the MHO team and hospital discharge team were working, to precisely target delays where AWI was a factor. By implementing a specific hub approach, staffed by multi agency professionals, they are having daily and at times twice daily review discussions as a productive way of ensuring that hospital stays (where appropriate) are managed robustly, and that the person is discharged as a priority. The Head of Service advised that this thorough approach meant they were seeing the benefits of the work and were almost at a point where they may be able to prevent unnecessary admissions by implementing more robust community supports.

“We have refocussed to give staff the confidence to use supported decision making to enable the adult to make their own decision about moving rather than going direct to a guardianship order”

The HSCP refocussed on using supported decision making rather than going directly to a guardianship order and have reduced their AWI delayed discharges by 10 from the previous year. Previously if someone had been treated using authority from section47 of the Adults with Incapacity (Scotland)I Act 2000, then they were automatically considered to be lacking capacity and referred for a guardianship order. Now, they use the MWC tools for supported decision making, have ensured the least restrictive option has been used in each case and that the individual has a voice.

There has since been a drop in referrals for guardianship. The idea is that they don’t automatically go to a solicitor and apply for guardianship but speak to social work colleagues first to see if another option is possible.

This HSCP carried out an audit of AWI hospital delays. They scrutinised each individual to see if they could use supported decision making or advocacy and to see if pursuing a guardianship order was most appropriate. They had discussions with families. The topic of early interventions was discussed, for example, where people had delirium they sit with the patient for one or two weeks to give it an opportunity to resolve itself. Guardianship wasn’t always necessary. This was joint work between health colleagues on the ward and social workers.

They are educating health colleagues in AWI and the guardianship process. They are encouraging their teams to have professional curiosity and to have confidence to provide support for decision making to avoid the guardianship route. They have now pushed for a greater sense of trust in professional judgement. For example, they are encouraging social workers to put in the person’s notes that the person has ‘insight’ or ‘they may lack capacity in certain areas’ however, they have an understanding of what moving to a care home means, using MWC tool for support for decision making. They have looked for signs of the person’s own voice by trawling case notes to see if the adult had noted any preferences at any point.

“We have a framework of supervision of private guardianship applications”

The HSCP has a tight framework of supervision of private guardianship applications to ensure that the family and their solicitor move the application along in good time. They discuss progress with the family along the way. At week 3 – social work checks in with family. At weeks 4/5 – a private solicitor should be identified. At week 6 – if a private solicitor is not identified a meeting is held with the family to discuss barriers. At week 8 – if no progress they have a candid discussion with the family on the appropriateness of them as guardians. Social work could take over at this point if no progress has been made. They have only had to do this once.