Tackling specific issues: safeguarding people experiencing homelessness

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Moderator: I'm Adie Cooper, I'm the Care and Health Improvement advisor who leads on safeguarding and also I'm chairing the session this morning. Please put your questions in the Q and A function that you've got this morning in the webinar and we'll come to that towards the end after our 3 speakers. This is the seventh of a series of 8 virtual webinars that build on work that we've undertaken previously regarding adult safeguarding and homelessness. (Moderator further describes the previous work that has been done and the reason for the webinars, 00.52-02.26) Today we are particularly addressing specific issues around working with safeguarding and people experiencing homelessness, but all of the sessions have had a common ground and common objectives. Those objectives are to share information, particularly regarding positive practice in this area of work, to provide an opportunity to understand how safeguarding people who have experienced homelessness has changed in the last year due to COVID. The intended outcome of this series of webinars is to produce a further briefing later this year that pulls together the further learning gained from having people come and speak through the webinars, and we'll be asking people to contribute. I'm very pleased to welcome today Mike Ward from Alcohol Change UK, Barney Wells from Enabling Assessment Services in London, and Aileen Edwards and Alison Comley from the Bristol Creative Solutions Board and Second Step. What we have in the programme is a series of 3 presentations, a break between the second and third presentations, and then a slot towards the end where we can pull together questions from the participants to address to the presenters.


The recording of this webinar will be available in a few days, and the slides will be available on the LGA website after this morning's session. Mike, I'm going to hand over to you and ask you to start on your presentation.


M: Thank you very much, let me just share the screen. I hope that people can see that now. Thank you. What I'm going to talk about for the next 25 minutes is a project that Michael Preston-Shoot and myself have been involved in over the last 12 months on essentially safeguarding vulnerable dependent drinkers. What we've been looking at is the development of a national briefing document about how to safeguard this very challenging group of clients, and what I'm going to talk about is the thinking behind that document, the stuff that led up to it, and also some of the content of that document. I think we need to start with real people in the real world, and probably the best example for our purposes of a real person is Angela Wrightson. This is a name that will mean something to some of you but not to others. This was Angela Wrightson, and even if you don't know the name probably many of you will have seen this picture on the main BBC evening news on at least 3 occasions between December 2014 when she was murdered and June 2017 when the safeguarding adult review into her death was published. You may remember that she was murdered by 2 teenage girls in her own home up in Hartlepool. She was a very vulnerable woman who was known in her local community as 'Alcoholic Angie', and she had a massive impact on local services. In just 3 years she had over 1,000 direct contacts with mental health, alcohol services, ambulance service, hospitals, 472 incidents reported to the police, which of itself is an astounding level of activity.


But probably the astounding things from the case are really (1) the lack of multi-agency working around her, and secondly from my point of view, the fact that despite her vulnerability, despite her chronic alcohol problems, the local alcohol services closed her case effectively because she wasn't motivated to change. And that notion around motivation to change is at the centre of what we're doing. And there has been a belief that clients who have got alcohol or indeed drug problems need to be motivated before we can do something, and our argument is that a motivation-focused approach effectively perpetuates the exclusion of some of the most socially excluded clients in our community. We need different thinking. These clients are a real challenge to many people. As part of the work that Michael and I did, we did a national survey. This had over 200 responses, and as you can see a third of the people in that survey were seeing over 20 or more clients in this change-resistant, dependent drinking client group in 6 months. Those people, a lot of them were probably specialist alcohol workers, but what's interesting is beneath that group you've got another third of workers who are seeing between 6-19 such clients in 6 months. They are the more generic workers who are being challenged by these clients. Now, at the bottom of our response is this document that what was Alcohol Concern, is now Alcohol Change UK, produced in 2015. This is the so-called Blue Light Project Manual. This sets out over 80 pages techniques, tools, approaches, pathways, for working with change-resistant drinkers. And it is freely available, it's on the Alcohol Change UK website if you'd like it.


And over the last 5-6 years we've rolled out this work across the country, and in 2019 we won a Guardian Public Service Award, a Royal Society of Public Health Award, and previously a Nursing Times Award for the work we've done on this. And probably most significantly the Blue Light Manual was mentioned as good practice in the Angela Wrightson Safeguarding Review to highlight it as one of the ways to work with her. And the manual does tell us what works with these complex, change-resistant, dependent drinkers. We know that assertive outreach is effective with these clients. We have a very good body of evidence that it is not only effective (TC 00:10:00) but now also we know that it is cost-effective. We have this big London study, ACTAD, by Professor Colin Drummond from the Maudsley, which has shown that £1 spent on assertive outreach with this client group can save £3.42 in public money. Outreach works. It will require time. It will require a consistent and persistent approach, but it does work. We also know that multi-agency client management works, and part of the rollout of our project and the thing for which we won awards is that by simply setting up multi-agency groups that meet regularly to manage the most complex dependent drinkers in the community you can have a positive impact on those clients and save public money. And I think if you want to know the best answer to this client group it does have to be assertive outreach guided by a multi-agency group which is the approach we're using in places like Northumberland, Sandwell, Surrey. There are things we can do, there are things that work, and there are things that we are showing that work.


However, at the end of that Blue Light pathway there are still going to be a significant group of clients who are still not changing, and whose vulnerability means that they require a much more structured framework to manage their behaviour. And the place that we see these clients most acutely is probably in the safeguarding adult reviews. In the last few months Michael and his colleague have published a huge review of SARs. We published this much smaller review of SARs back in 2019, and this looked at 41 safeguarding adult reviews published in 2017. This included Angela Wrightson. Of those 41 15 mentioned alcohol, and in 11 alcohol was a problem for the adult being safeguarded. And tragically in each case the serious incident that was being reviewed was the death of the adult themselves. And what that says is 25% of the SARs that we looked at contained alcohol. And what's interesting is that Michael Preston-Shoot's research last year came up with pretty much the same figure in terms of the role of alcohol in safeguarding adult reviews. I'm not sure that's what anyone ever expected in 2014 when the Care Act was put into place, but that is the reality. That people with chronic alcohol problems are placing a very significant impact on the safeguarding process. And what is most concerning is the response to those clients. And this is not something that was happening 2 or 3 years ago, this is a very current, very real issue that I'm hearing all the time. Workers pushing back at these clients, saying, 'They're choosing their lifestyle. This is a lifestyle choice, to live like this.' Or as one worker said to me, 'This man just likes living in his own urine and faeces.'


There are these attitudes to this client group. And I hope everyone on this call will appreciate that the situation is much more complex than that, and we need therefore a much better understanding of the legal structures that can support and manage these very challenging clients, which is the purpose of our briefing document. Now, if you're interested in legal powers I would suggest that you look at the Drug and Alcohol Treatment Act of 2007. This Act allows a social worker to detain a chronic dependent drinker or drug user against their will and take them to a special unit where they can be managed, detoxed, and a treatment programme started for 28 days, extendable by a further 2 compulsory periods of 28 days. Now, I don't know whether you think those kind of powers are a good idea or not. The thing you really need to know is that they only apply in New South Wales in Australia. They are not current British powers, some of you may feel sadly. But what they highlight is that other jurisdictions do have specific legal frameworks for this client group. And Australia is not alone in this. Sweden has very specific legal powers. I think it's 39 of the states in America have legal frameworks for this, as do New Zealand. And a lot of European mental health frameworks, for example France, are much more flexible and are able to incorporate this client group within their structures. We are left struggling to manage these clients with powers that don't really fit. Now, if you're interested in the Australian experience, and there is no reason why you should be but you may be, there is a really good YouTube presentation. There is a complex link there, that may come across in the slides to you, but if you want to see it just go onto YouTube and search the name Glenys Dore and you'll find the presentation.


And she talks about how it works in Australia. Under the Act someone who is severely dependent on alcohol or drugs, at risk of serious harm, likely to benefit from treatment but refuses, and where no less restrictive treatment is available can be detained under those powers. The typical client is not going to surprise you. It's a 59 year old bloke with a chronic alcohol problem who's constantly calling emergency services, constantly turning up at the emergency department, and living in squalor. That won't surprise you. What may surprise you is the effectiveness of these interventions. Of 40 detained alcohol patients at 6 months 10% had died, 25% had relapsed, but 60% were now abstinent or improved. If any alcohol service in England achieved those outcomes they would be very happy. And what it does show is that many of these complex dependent drinkers do need a more structured response to take hold of them, to stabilise them, and help them to move forward. And we, as I said, don't have those powers. What we are struggling to use is the Care Act, the Mental Capacity Act, and the Mental Health Act, none of which were drafted for this client group specifically and don't really fit. What I'm simply going to talk about is give you some headlines from our guidance document and what we have said about each of those 3 powers. In the guidance we also acknowledge the existence of other key powers that might be beneficial for this client group, ranging from the Human Rights Act to the Anti-Social Behaviour powers, the Alcohol Treatment Requirements, and indeed Environmental Health legislation, which I think is often too rarely used with these clients.


In terms of the Care Act I think it's sad that I have to say this, but I think one of the key messages that we need to get across is the Care Act applies to people with alcohol problems, because I do encounter people who do not seem to think it applies to that client group. But clearly it does, and dependent drinkers with care and support needs have a right to assessment under Section 9 of the Act just as anyone else does. More importantly, under Section 42 dependent drinkers with care and support needs who are vulnerable, abused, or self-neglecting require safeguarding by local authorities. And I think it is the introduction of self-neglect into this context which is so important because it has brought within the remit of the Care Act a large number of chronic dependent drinkers who are self-neglecting. And certainly, as I've already said, I'm seeing in the work that I do, but we're seeing it in safeguarding adult reviews, such as the Andrew review from Waltham Forest, that people are seeing self-neglect in drinkers as a lifestyle choice rather than as a safeguarding issue. And I hope that our guidance will push back against that. I'm going to spend slightly more time on the Mental Capacity Act because I think this is probably even more challenging than the Care Act. And certainly when we did the survey work for our guidance document, our briefing document, (TC 00:20:00) the thing that posed the greatest problems to professionals was the Mental Capacity Act. 61% of the people we surveyed said they had had problems with applying the Mental Capacity Act to chronic dependent drinkers. And I think there are people out there who are still asking, 'Does the Act apply to these people?' And clearly it does.


Part 1 of the test says that, 'A disturbance of the mind or brain can be due to the symptoms of alcohol or drug use,' so, they are coming within the remit. I think the bigger challenge is how we apply the second stage. There will be some people out there, because of their dependent drinking, who are unable to understand or retain information. Probably these are people with significant cognitive impairment as a result of their drinking. But I think the thing that applies more acutely and more relevantly to many of these clients, people like Angela Wrightson, is can they use or weigh information? Many dependent drinkers can tell you that alcohol is screwing up their life. They can remember that information. What they can't do is use that information to change their behaviour. And the Mental Capacity Act code of practice gives us a very interesting analogy. Sadly it is an analogy rather than an exact comment, but I think it must apply to this client group. What it says is, 'A person with anorexia may understand information about the consequences of not eating, but the compulsion not to eat might be too strong for them to ignore.' And I think you can see within that that you could apply that same principle to dependent drinkers or indeed dependent drug users. So, I think there are circumstances under which we can consider the Act as applying to this client group. And probably most notably we've got the London Borough of Croydon versus CD case where you've got a 65 year old chronic dependent drinker with diabetes, depression, epilepsy, who looks a lot like the guy in that Australian case. Frequent falling in his flat, non-compliant with medication, self-neglect, poor personal care, deteriorated home environment, frequently calling 999, attending A&E regularly.


And the judge in that case ruled that CD lacked capacity in relation to decisions concerning his care, and made orders about action to be taken in his best interests. I think the real challenge with mental capacity, and the one that when I talk about it people, sort of, are typing in to the chat function, 'Yes,' with 3 or 4 exclamation marks after it, because this is a very real problem, are clients who are being found, this is a real case that I've got in my head, a guy found in his bed, covered in urine and faeces. At that point he's regarded as lacking capacity, he's taken to hospital, he's detained under a DoLS, and he is detoxed. At that point, once he's been detoxed, his capacity is assessed again and he is now deemed to have capacity and he is sent home, and the cycle starts again. And this guy I'm thinking of had cycled through this 6 or 7 times in fairly short order. I've had contact with people who are talking about clients going through this kind of cycle far more times than that. And I think we do need to think about how the Act is applied in this context. And I certainly think the notion that Michael has put forward of the use of executive capacity, recognising that these clients may be able to take decisions but often can't execute decisions when they are back in their home circumstances, is a useful framework and is one that we talk about in the guidance document. But I think from an alcohol specialist point of view, I would highlight just 2 or 3, what for me are, in a sense, bleeding obvious things but I think which need to be said to workers. Alcohol misuse is a chronic, relapsing condition. The notion that someone at the point of detoxification is cured is a nonsense. And in particular, what we know is at the point of detox drinkers often go into what is called by AA the pink cloud.


Immediately after being detoxed they feel very high and very positive, and they're saying things like, 'Yes, I've got it cracked this time. I'm going to go home, I've got it sorted, everything's going to be okay.' But it's as unreal as anything else. But worker optimism buys into it. And the client goes home, and the cycle starts again. Now, in some ways that wouldn't matter. But it matters because of kindling, and kindling is a process by which each subsequent detoxification can make the next detoxification worse and can impose levels of physical damage on people. And multiple detoxification will ultimately increase physical damage to people and potentially give cognitive impairment to people, and in the context of the Mental Capacity Act you have to ask, is that in the client's best interest? So, we see the Act as applying to this client group but assessments of capacity should never be simple with these clients. They're going to need multi-agency discussion, they're going to need professional challenge, they need to be marathons not sprints. But I do think the compulsion associated with addiction can be argued to override someone's understanding of information about their drinking. I will very briefly just mention the Mental Health Act. The Mental Health Act does push back quite clearly at detaining someone under the Act because they are dependent on alcohol or drugs. And that's often taken as the final word on the Mental Health Act and substance misuse. I have no problem with the Act refusing to be used with people who are dependent, that's not a problem.


What we fail to recognise is that it is possible to detain someone under the Act if they are dependent and have disordered mental functioning due to their chronic drinking or drug use. And that does provide a framework in which we could use the Act. Using it's going to be difficult because of the lack of facilities, and it is going to be a last resort, but it is possible. I'll finish just with this quote. Glenys Dore, in her YouTube presentation, does talk about opposition to the use of legal frameworks with this client group, and saying you're denying people their human rights. And what she says is that what we're effectively doing if we follow that route is really allowing people to, 'Die with their rights on.' Some of these clients are so difficult to manage that we are going to need to deny their autonomy to stabilise them so that we can move them forward. And our guidance document I hope will help people to better manage these clients. Thank you.


Moderator: Can I hand over to you, Barney, to pick up and do the next session? And then we'll come to questions at the end, and just to reiterate slides will be made available on the LGA website as well as recording.


M: Good morning, thank you, everyone, for being here. My name is Barney Wells. I'm a mental health social worker by background, and I'm director of Enabling Assessment Service London. So, my goal of this session is to provide some background to attempts at delivering training and support to people who work with rough sleepers around the area of assessing mental capacity. I want to examine some case studies, and in part the case studies are there to illustrate some of the practice realities, but they're also case studies which I've used previously in training and I think I'm quite wanting to look at the usefulness of them in that context. I'm then wanting to describe some ongoing and recent challenges, and I have to say I see this session as very live to some discussions I've been having in recent weeks even, (TC 00:30:00) especially during that period of very cold weather we had recently. And then I'm very interested in feedback on best ways forward. I say I'm not going to offer conclusions, I probably will say some things but I'm really interested in other people's perspectives if there's any way of gathering that. This session isn't a briefing on the Mental Capacity Act, I'm going to assume a certain level of existing knowledge. It's an exploration of how the Mental Capacity Act assessment can be better incorporated into practice for people who are involved in a day to day way in working with rough sleepers. So, when I say background this is partly mine and partly of some projects I've been involved in, which I'm going to look at. So, as I said, I was previously an ASW and then an AMHP working in statutory specialist homeless mental health services in Camden and Islington. Around the same time that EASL started I developed some training for AMHPs around Mental Health Act assessments and rough sleepers, or the AMHP Role and Rough Sleepers was what I called it. That was in 2012.


That same year a Serious Case Review was published regarding a Mr A who died in Lambeth in very cold weather in 2010. There had been concerns about his mental capacity, in fact, he was declining any shelter. London Ambulance in fact were called out and carried out, used their screening tools, said they found him to be capacitous, but he died on the street and one of the recommendations of the Serious Case Review was to develop some tools and guidance around mental capacity and some other areas for outreach teams. And EASL, I sort of took on the delivering of that training at a later stage. Some of you may be familiar with this sort of page. This is Pathway, the homeless health charity who are hosting this guidance currently. It's also on the Homeless Link website and various other places, I think there's a link in the publication by the Local Government Association around safeguarding and homelessness. The guidance includes reference to other issues around Mental Health Act, hospital support, finding ways to help people who work with rough sleepers to support better assessments if someone's, for example, admitted into hospital. But I would say the key to it probably is this document, which is a mental capacity screening tool. It leads a worker through the questions they should be asking, both in considering the functional test of capacity for someone who there are concerns about their decision-making. It also prompts them to also consider many elements of the best interest checklist in terms of making sure information's delivered to people in different ways, etc. And this has been out there for a few years now.


There have been several different, the last edition was in 2013, and I would say that in practice I think it is a useful tool and probably has supported better, more effective consideration of capacity for people in all sorts of areas, but I suppose it is very much geared towards those scenarios were, for example, an outreach worker is concerned that someone who's declining shelter might lack capacity to make that decision. So, the development of this screening tool was initially hosted by South London and Maudsley, and was funded by Lambeth and the Greater London Authority, then it was hosted by Pathway and funded by the GLA with the project managed and training delivered by EASL. Thames Reach were particularly involved, actually, in developing the screening tool and on the steering group there, and Mungo's have also been involved in hosting subsequent training and paying for the publication of some of the documentation. So, the training which we delivered in relation to this project, we tried to reach all different groups over time. Much of it was to outreach workers but we also tried to familiarise different health workers, approved mental health practitioners, I did some specific workshops for people involved in hospital discharge, psychiatric liaison, and in some areas local authorities were keen and we were able to deliver workshops more orientated towards people like community safety and parks police. It was interesting, we didn't get much buy-in from ambulance service or police and that might be something we come back to. What I did find is when I delivered sessions in a particular local authority we would sometimes community safety officers, safer neighbourhood officers from the police attending and that was very helpful, but by and large they weren't wanting to invest time in it.


So, the steering group for this project was originally chaired by Elizabeth Clowes, who was the Lambeth commissioner at the time of the Serious Case Review. We've had no direct funding since 2018 but the resources are still available. As I said, the training wasn't just about Mental Capacity Act, it was also about the mental health act. It was also about the Mental Health Act. It was also around risk assessment, the outreach role, the wider context of decision-making within mental health services, and from 2016 the sessions I delivered tended to include testimony from someone with lived experience of street homelessness and being subject to interventions around mental health. I think the training was generally well-received in terms of feedback. More varied in terms of success reported by outreach workers in communicating concerns to other relevant agencies, mental health services, police, and ambulance, but sometimes it was successful. And I think some of those barriers Mike was just referring to are probably relevant here. I think inherently there are some real challenges for outreach workers. When is it appropriate for them to be completing mental capacity assessments themselves? When should they be providing the benefit of their knowledge of someone and their situation to others who might complete an assessment? I think outreach workers, I don't want to generalise but they're often a group of people with lots of quite specific skills, and actually having worked in this area for many, many years I've got a lot of respect for their assessment skills and their person-centred approaches, often.


But I think sometimes the authority they have when communicating their concerns to health professionals or local authority workers who have less experience of working with people with that background is difficult, so, I think it is a real challenge for them sometimes when they've got those concerns, and having them heard. More recently, the last couple of months, St Mungo's asked me to develop some more explicitly mental capacity and severe weather focused training for their outreach workers. What I'm going to do now is look at some case studies and scenarios drawn from these different trainings. My aim is to give a sense of the resources used as well as to consider how well they reflect the realities. I often start with this case study even though it's not someone who's currently rough sleeping, but I feel it's a good example for reasons I'll go into. So, Jane is a hostel resident where Brian works nights. Brian knows that Jane has a diagnosis of borderline personality disorder, and that she sometimes binge drinks alcohol. He's also aware of her history of taking intentional overdoses. At the start of his shift Brian is told by colleagues that Jane had difficult news earlier in the day and had come to the office and left her medication with staff as she felt unsafe. Several hours later Jane comes to the office, heavily intoxicated with alcohol and tearful. She demands the return of her medication, stating that she can't go on any longer and that life isn't worth living. Brian is concerned for her safety if she has access to her medication. He feels that her ability to make decisions about staying safe is impaired by her intoxication and her emotional state. He refuses to give her her medication and asks her to meet with his manager to discuss this further the next morning.


He explains his decision to her and justifies it by writing a progress note that explains his reasons referring to the relevant parts of the Mental Capacity Act, the 4 step capacity assessment, and the best interest checklist. And I suppose my reason for including this case study often is I think this is a very stark situation where someone in a position where they don't have very much authority necessarily in terms of qualification (TC 00:40:00) is needing to make a capacity assessment themselves and carry that through. And I think it's helpful to try and get people starting to incorporate thinking about mental capacity in their day to day work, to protect them and to protect the people they're working with. Now I'm getting on to one of the examples which we drew up for the more recent training, very much for outreach workers. It's cold and forecast to get worse. SWEP has been declared. You visit the sleep site of a rough sleeper. Their clothing and bedding appears wet, they are shivering. They appear distracted when you attempt to speak to them. You offer them a place in a shelter and they decline. You ask what their reasons are for declining and they refer to fears that if they go indoors they will be gassed by the secret services. Then I was asking through a poll, 'Are there grounds for you as an outreach worker to consider that this person might lack mental capacity to decide whether to accept shelter? Would you ask mental health services to attend and carry out a mental health assessment before you make a decision (inaudible 41.15) opinion about whether they lack capacity?' And again, I suppose it's trying to put outreach workers in a position where they are actively considering the criteria and applying that in situations which are actually going to entail an immediate act, potentially.


I always want to try and counterbalance a situation like that with this one. So, lots of similarities. It's cold and forecast to get worse. SWEP has been declared. You visit the sleep site of a rough sleeper. Their bedding is organised and protected, they have plenty of insulation, and they are dry. You offer them a place in a shelter and they decline. You ask what their reasons are for declining and they refer to wanting to keep hold of their site they've got, worrying that if they go into a shelter it will be cleared. They explain their immigration status means they won't be eligible for ongoing support with housing. They know about and use a local day centre. So, again, it's asking outreach workers not to start presuming and leaping to assumptions about capacity for anyone who's declining the offers they're being made, and to think about that in detail. In fact, in reference to this case I think if the weather was very extreme as some of those works were recently it would be worth them referencing the fact that they thought about capacity at the time but not necessarily to carry through an assessment. Again, it's May and the weather is mild. You visit the site of a rough sleeper, their clothes and bedding are dirty and disorganised, they appear distracted when you attempt to speak to them. You say that you may be able to help them access accommodation but they say they're not interested today. You ask what their reasons are for this and they refer to fears if they go indoors they will be gassed. So, here the question I'd be saying is, 'There are grounds to suspect that this person's capacity to make decisions about accommodation may be impaired. Would you (a) complete a mental capacity assessment then call an ambulance, stay talking to them, provide information about day services they can access and suggest that you can visit them again in coming days, or would you leave promptly and make a referral to mental health services?'


And I suppose the benefit of this scenario is trying again to get people to think about the whole best interest approach as well. There may be not the same need to make a decision now about this person in relation to where that person's mental impairment might be impairing their decision-making. There might be opportunities now to bring in other experts to help think about mental health issues, for example, but then there will also be opportunities to engage that person, give the information in different ways, and to work with them over time. In a way that might not be possible when the situation's more extreme. I suppose that brings me on to the other area of good practice here, and it is just endlessly not always wanting to see the Mental Capacity Act as a way of achieving solution, it's just something which should be incorporated into workers' day to day work with people whose decision-making may be impaired. So, this is another case example drawn from real life about a man in his 60s who slept rough in an area for many years, declining shelter even when it was cold, happily speaking to outreach workers who couldn't understand his decision-making. Local mental health services agreed to meet with him and did so on the street. The mental health team, in discussion with the outreach worker, considered his capacity in relation to decisions to remain street homeless, but they didn't establish evidence of significant mental impairment and they didn't feel he could be considered to lack capacity or to meet criteria for an admission under the Mental Health Act. He said he'd consider accepting accommodation if he felt his physical health declined. He was discharged by the mental health team but with advice that street services could re-refer.


Some months later George referenced some unusual ideas to the outreach workers about foreign powers influencing the unseasonable weather. Outreach re-referred him to mental health services and a CPN visited George on the street. He repeated the ideas but it was not felt to be a belief that was held with delusional intensity, and it was not clear that it was linked to the particular decision to decline accommodation given that he wasn't felt to be lacking capacity. The following winter George seemed less robust physically, concerns increased, he initially declined shelter but then did under his own steam attend housing and was happy for outreach and health services to provide evidence to a local authority around his entitlement and his vulnerabilities. So, again, this is not a situation where capacity led to some dramatic intervention but it is an example of good practice where consideration of capacity in an ongoing way becomes part of practice. This is another case study drawn from a real situation, slightly adjusted to reflect changing resources. So, it's November. Darren, in his late 40s, becomes sleeping rough in a very public way. Drinking alcohol chaotically, walking with a distinct limp and occasionally seeming to wince with pain. Offered a hostel place but declines it, his reasons are unclear. Outreach services also have concerns about his physical health and note that some of his statements seem paranoid. Following a referral to mental health services social worker agreed to attend with an outreach worker early in the morning. Darren was not visibly intoxicated, no sleeping bag, no socks. Outreach workers advised that he'd had both in previous days. Willing to engage in chat and observed social niceties but was guarded when asked about his reasons for declining accommodation.


Appeared distracted at times and some of his answers were non-sequiturs. He left the assessment and began drinking again. A week later a period of severe weather started and was forecast to continue. Darren continued to decline shelter. When outreach contact mental health team the original social worker is on leave and there's no willingness to explore bringing an appointment forward. The outreach worker makes a safeguarding referral to the local authority, stressing the immediacy of the risks because of the weather, the lack of information about Darren's health, and the possibility that his decision-making is impaired. This would be the moment for the outreach team to complete that mental capacity screening tool to help communicate their concerns. Multi-agency discussion including primary care and the mental health team follow, information is gathered from the local hospital about his physical health, it was established that he was known to homeless services in a neighbouring area. It was concluded that an assessment under the Mental Health Act was indicated. When this took place his presentation was similar to when seen by the social worker the previous week. The doctors and the (mw 48.38) did agree that the criteria for admission under Section 2 were met. In hospital it transpired that Darren had significant symptoms of psychosis, including distressing auditory hallucinations, and that his drinking was in part an attempt to block these out. Darren in fact did carry on to gain much more control over his life, he was discharged into his own accommodation in due course, remained engaged with mental health services for many years. Reignited contact with his family.


I mean, I'm hoping that those examples give a flavour, I think, of some of the complexity but I'm going to spell it out here a bit more. I think the challenges in practice is that inherent complexity related to the person's needs, but it's also about different agencies, different knowledge bases, different authorities and priorities between those agencies. There's an interface between different laws and the need to balance competing rights. The impact of limited entitlements on options that are open to some rough sleepers sometimes puts people in a really difficult situation, and certainly I've sometimes been involved in assessments where someone's ability to make decisions is impaired but also that's made much more complicated by the very (TC 00:50:00) poor choices that are available to them. I think there is a real danger sometimes with overenthusiasm about mental capacity as the framework, and it can be that services or workers start seeing everything through that focus, through that lens, and it's really important for workers to carry on incorporating other frameworks, and in face, in terms of the Mental Capacity Act, that's clearly more in line with the principles as well. I think there's a real challenge, often, about when does the decision need to be made and the risk assessment for that. Who is best placed to carry out that actual assessment? Is there time to bring in different services and professionals to support consideration of capacity, is there a role maybe for the Court of Protection? Sometimes an assessment may conclude that someone does lack capacity to make a decision but an intrusive intervention may not be in someone's best interest and justified, but there's still a need to keep that issue of capacity and best interest under review.


There are, of course, the issues which Mike was referring to earlier about executive capacity and the complexity of some of those assessments is going to be very difficult and likely involve multi-agency input. There are going to be differences between areas, resources, outreach, accommodation, mental health, and police. There are going to be different priorities, histories, and cultures. And in my experience there are differences between different areas in terms of how willing they are to intervene or not intervene. Sometimes that's justified if it's based on a proper consideration of all the information and risk, sometimes that can be a barrier to the information being properly considered. Sometimes there's an issue with the pressures on services to deliver in terms of KPIs, etc, and sometimes I've had many experiences where there's resistance, for example, from mental health services not accepting a referral because they believe that the homeless services are trying to clear the streets for reasons which are political and don't reflect people's autonomy. Sometimes that might be the case but I think sometimes that's a barrier, there's an assumption that's why those referrals are being made. I haven't got time to go into the examples I was intending to but I would draw people's attention to the recently published SAR of MS in Hackney. If there's time after this we could potentially reference some other local situations recently, especially where I feel outreach workers have made very good assessments about people's capacity, they're being very immediate risk, but there's a real barrier for emergency services to engage and understand how they've reached those conclusions.


In terms of recent positive developments I really strongly feel that the focus on safeguarding and homelessness over the last year has made a huge difference. EASL is currently commissioned by the GLA to work with some of the outreach workers which don't have specialist support, and it's very striking how often now the safeguarding framework can lead to proper, more joined-up working and decision-making where previously we were having to support outreach teams to knock on doors of people who were very resistant to doing that, but who were actually the people who should have been carrying out further assessments. There are more resources currently around mental health, which is fantastic, and I think there are probably a lot of people who are better off because of that. There is a danger that with more mental health specialism attached to outreach teams, if funding is withdrawn outreach workers may be deskilled compared to where they were. So, help to support better use of MCA. I think there's something about training, confidence, and authority of street outreach workers to complete mental capacity assessments. Finding ways in each locality to support them in communicating this to emergency services where the situation's are life and death. It would be great to have more training involvement of police and ambulance service in this area. When the concerns are more chronic, again, training, confidence, and authority of street outreach workers at least to contribute to better mental capacity assessments and best interest assessments. There are also issues around resources and structures to support planned multi-agency working. I also think there's something about the sector incorporating mental capacity more in their day to day practice, including when people are compliant.


I wonder how often an outreach worker persuades someone who's heavily intoxicated to go along with them into a shelter when actually that person may not be capacitous. Now, that act would be in their best interest but it would be a good thing in terms of incorporating this thinking into day to day practice as well as being properly MCA compliant for those sorts of actions to also reference mental capacity and how those decisions were reached. I'm going to stop sharing now. Just about on time. I swept through a few of the examples.


Moderator: Thank you so much, Barney. We've got a cluster of questions coming through the Q&A, thank you colleagues, keep them coming. We're going to take a 10 minute break and we'll come back for Alison and Aileen's presentation in 10 minutes, and then we'll bring the questions all together at the end. Stay logged in and we'll join you back again in 10 minutes. So, welcome back everyone, and thank you, Tara for posting the link to the MS safeguarding adult review report from Hackney to everyone that Barney mentioned. I'm going to hand over to Aileen and Alison to put up their slides, and to reiterate, the slides are available on the LGA website.


F: Hopefully you can see those slides, thank you, Adie, thank you very much. My name is Aileen Edwards, I'm the chief exec of Second Step, which is a mental health charity. Alison, do you want to introduce yourself?


F: Hello, I'm Alison Comley and I'm the independent chair of Bristol's Creative Solutions Board.


F: Thank you. Alison and I are going to co-deliver these slides. I'm going to do the first part and Alison's going to do the second part, and what we're going to be talking to you about this morning is about how agencies are coming together in Bristol to really improve services for, really, people who've got multiple disadvantage. And it picks up some of the themes that Mike and Barney identified, is agencies with differences, different cultures, different systems, and different understandings of key issues for very vulnerable people. So, I'll just say a little bit about Golden Key. I'm the chief exec of Second Step, we are the lead agency for a programme called Golden Key in Bristol. Golden Key is a partnership of 22 different organisations, statutory organisations, voluntary organisations, commissioners, and also we have a fantastic Independent Futures group of people with lived experience working together. We've been funded by the Lottery under their Fulfilling Lives programme, which is an 8 year programme which is due to finish next year in 2022, so, 7 years have flashed by. And the focus of Golden Key is on multiple disadvantage and lots of the individuals that Mike and Barney have talked about would fall into this group. So, it's people with homelessness, mental health, drug and alcohol, and offending backgrounds. Often the people who systems fail. And the focus of Golden Key is in 2 parts. There's a service delivery element, which we will talk about in a minute, which is around our service coordination function for people who basically are falling through the gaps, and also a big focus on system change. And that is really about taking learning from individuals to ensure that we change for more than just that one (TC 01:00:00) individual but we make really big service improvements for people.


So, I mentioned that one of the service delivery elements is the service coordinator team. They are people who engage with people who have multiple disadvantage and their role is to coordinate services and to ensure that we're finding new solutions for individuals. The Creative Solutions Board came together because there were issues that the service coordinator team couldn't solve on their own. They were seeing individuals, they were doing their best, they were making lots of good progress, but there were certain things that they couldn't do on their own. So, we talked to the strategic director in Bristol City council about setting up a creative solutions board, and we brought together some learning from the Plymouth Creative Solutions Board and what they were doing, and we have evolved their concept to the Bristol board. One of the things that the strategic director at the city council was saying, obviously, they had a huge interest in safeguarding because of the numbers of homeless deaths in the city, and they were keen that the Creative Solutions Board had a safeguarding focus. So what we did was that they identified a safeguarding lead, as the person that we would work together with to set up the Creative Solutions Board. Importantly, what we wanted to do was to really explore how we did change, in different ways, how we would not just be doing more of the same, but how did we come together in a different way between different agencies. so, what we wanted to do was focus on individual solutions, which we knew were hard to find, but also that we wanted to bring the learning up to system level so that it benefited more than just that individual. So, the Golden Key Partnership a couple of years ago, really embarked on setting up the Creating Solutions Board, and with sign-up from agencies. So, importantly the people who were involved in the agencies, and Alison will say more about this, were people with senior, budget-holding responsibilities, and, crucially, and Alison will say more about this, lived experience is really at the centre of the expertise we wanted in the room.


So, the purpose of the creative solutions board is two things. Ensuring that the person, the kind that we were discussing at the Creative Solutions Board, is at the centre, that's really important that it's really rooted in everyday experience, really coming together to find new solutions, so, that person being at the centre, and finding new creative solutions and different ways of planning and coming together. Importantly, we wanted to take a helicopter view, which is really important, about, what is really going on in the system that we are failing these individuals so much. Importantly, looking at things we're not doing collectively together, but also what could be done. What learning could we do as a whole system? Where is there change and flex that might come about that we can bring real change and better outcomes for all? I'm going to talk to you now about Peter, someone who has been discussed at the Creative Solutions Board. These will be issues and themes that will be familiar to all of you, I'm sure, and touches on the way that actually, the system really fails individuals. In the work of Garden Key and Creative Solutions Board, we use a formulation approach with input from psychologists to help us think about how people present, but also the patterns and trends in the way in which people are using services, and also the way in which services are responding to the individual. Here, you've got a cycle working with Peter which was a cycle that services and Peter went around many times. As I said, one of the striking things was the way that services engaged with Peter at crisis points, and so, Peter would often be in prison or in hospital, psychiatric hospital, for short periods of time, so his mental health would improve in either of those situations and he would come off drugs (inaudible 01:05:39-01:05:25) job, accommodation, but there was no multi-agency plan in place, and, as you can imagine, Peter would struggle in the accommodation and his mental health would deteriorate, and he would start to use drugs again as a way of managing the situation.


Then, he would get into a spiral with the accommodation provider struggling to support him, but the lack of mental health or drug and alcohol support around him meant that he would find it hard to engage with services, and he would lose his accommodation. Then, there would be some sort of incident, probably some sort of crime would be committed, so he would be back in prison, or that he would have a physical or mental health crisis and he would end up in hospital. Therefore, we were back in this cycle, and it was clear that that agency really only intervened with Peter at crisis points, so when, through accident and emergency, or picked up by the police, or some sort of incident. As soon as Peter started to improve, agencies would withdraw. This was the cycle that Peter was stuck in, and agencies were stuck in. So, I'm going to hand over to Alison now to talk about what we did, but, before we find out how we approached finding solutions for Peter, Alison is going to talk to you more about the Creative Solutions Board.


F: Thanks, Aline. So, how does the board work? Then, we will come back to talk about what we did in respect of Peter. Firstly, having the right experts in the room, and obviously the best expert that needs to get into the room is the person that we're talking about. The referral information that comes to the board really tries to capture the essence of that individual, and they are asked to contribute to that. The individual can't be referred to the board if they don't agree to it. So, there are issues around consent. We want people to be actively in the middle of the room. Our lived experience colleagues on the board are fantastic in terms of helping us to keep things grounded and real, and often intervening in the discussions in a really pertinent way to help us to get somewhere a little bit more creative. We've got the safeguarding lead, as Aline mentioned, Bristol was concerned about deaths amongst the homeless community, so it's really important that it's linked up with the safeguarding process. We've got strategic managers, who come with a mandate and an ability to change the service offer in the room. They don’t have to go back and ask, they can do it in the room. We have got commissioners as we start to look at what might work for the future, it's important to have commissioners in the room. We have practitioners, who come and present the case, who are often frustrated and exhausted, having gone around that loop, as Aline just described, a number of times. They bring some of the creative solutions.


As the Chair, I'm really keen that we've got an active board, that people come and contribute, and that obviously means recognising there are a lot of different power differentials in the room, and working quite hard to make that work so that everybody feels comfortable in terms of contributing. The way the board works is, the board papers come out describing the individual, the practitioners do a very short presentation, because we all know how we can love to get involved in the detail when sometimes that's not the most (TC 01:10:00) helpful thing to do. We then have a section together where we look at doing some creative planning for that individual and come up with an action plans. The second half of the meeting is, we think about the learning that we've used around that individual, and try to apply it to the system. In terms of the independent Chair, that's me, I'm very proud, and it's a real honour to be the Chair of that board. In setting up the Creative Solutions Board, it felt really important to have someone independent, so that the board wasn't owned by a specific organisation, and it was actually a partnership that was owned by everybody. Of course, as I'm not employed by any of the organisations, I can positively challenge, as do obviously other people in the room. It was felt that that was a really important premise on which to set the board up. We say we're creative, but it's a challenge, particularly in times of Covid, it's challenging being creative and we continue to try and do things in different ways.


Our first meeting, we sat around a huge great big table in the City Council, one of their big committee rooms, not massively creative. We now try and work in a much more informal way, because as soon as you sit behind a big table, it sounds a really small thing, but suddenly all our hierarchies become displayed, so it was really interesting trying to think about doing things in a different way. We've got a strong referral process. We want to make sure the right people get discussed at the board. We want the great multi-agency work that goes on in the city to carry on, and the board to only kick into action where those processes have ground to a bit of a halt, or we can't find a way through. We spent quite a long time getting the paperwork right, and that balance between knowing about the person, not getting lost in the detail, as Aline said, there's a psychological formulation which involves the team that are working with that person. I think that element of the multi-agency work before the client gets to the board actually starts to help develop some of those relationships, different perspectives, and we ask that team to think about some creative solutions. When we started up, we thought the board was going to provide the creative solutions. That didn't work very well, actually, it's the practitioners that know what the creative solutions are, and, what the board now does is take those solutions and look out how it might remove the blockages in order to make those creative solutions happens. We need to understand the system around the person, what are the barriers and the blocks, what stops the system from responding in a different way, and giving people time to reflect on that and an opportunity to impact on change.


I think, often, because people are working at a really high level, a real pace that people are working at, actually just taking some time to step back and think, I think, has been really helpful. There is a commitment to collaborate, there are some simple things that we're working on. Do we all use the same common language to describe things? The answer is, no we don't. So, we are currently doing a piece of working trying to define our terms and come to some agreements, so that we all understand what we mean when we use the term risk, when we use the term multiple disadvantage, what are we actually talking about? So, that's a piece of work that we are doing at the moment collaboratively. We focus on the learning from the individual to the system, and that's interesting doing that in the one meeting, and giving us the chance to say, well, we might have done something differently for this person, what would that mean if we wanted to do that for the whole system? What is the impact of that? My favourite word, tenacity. I think anyone who is working in the field of multiple disadvantage, being tenacious is one of the things you have to have, because you have to keep going, because things aren't going to change straight away, you have to keep going. That's just a picture of what I've just described, which will be helpful in your pack of who's sitting around the board. Moving onto what helped Peter, Peter ended up in a hospital setting, so we were able to organise an assessment of carer support while he was in the hospital.


We know that, in terms of best practice, that transition from hospital to community can be a time of risk, but also a time of opportunity, and by getting all of the right people around Peter at that time, that was really helpful in terms of his discharge back into the community. We identified a housing solution that bypassed hostels, one of the things that Peter couldn't cope with was group living, so we negotiated something different for him, and flexed a bit of the timescale to apply, and agree the accommodation. I think, one of the things that comes up a lot at the board, and it relates to one of the other speakers' comments about key performance indicators, in terms of trying to keep services filled, because we know there is a demand, sometimes we set unrealistic demands in terms of how quickly spaces need to be filled, when actually, a little bit more time would make sure the right person go the right service. We created a team around Peter, as I said, while he was still in hospital, the issue around the head injury hadn't really been addressed for Peter, so bringing together the social worker, head injury practitioner, drug and alcohol worker and the coordinator really started to look at Peter in a holistic way, and part of that was a commitment around organisations not to close the case. We know that social policy at the moment is, you get in, you do what you need to do, and you get out again. Actually, for some of the people we're talking about, that doesn't work.


You need to be working together as a team, and one of the things that we've developed in the Creative Solutions Board is this concept of an associate professional. So, someone being part of the team, who may not be working directly with the individual, but can help the team, may well become involved later, but becomes an associate professional, and that seems to be working well. We have managed to identify a mentor for the team, the Mental Health Trust took on this role to help support the team, and finally, in terms of flexible appointments in terms of the local drug and alcohol services, rather than saying you have to come on this day at this time, they were flexible about, you have to come in the morning, and again, that provided a much greater chance of Peter attending. That's just a very quick nutshell of what we did around Peter, but there is a big question of, so what for the system? So, we're looking at a small group of clients, we're trying to get something creative going and then look at what that means for the system. I think, when you start to talk about systems, that can feel really difficult to decide where to intervene. We're constantly reviewing and refining how we do the work, is there a better way? Trying to get that balance between the client and the system, and then using the system thinking to feed into what might be going on in the city about change. So, thinking about how services are commissioned, thinking about how service processes work, is there a different way of doing things? We're trying to measure our impact, the March meeting, we are going to be looking at all of the clients that we currently talked about, and there's not a huge number, but looking at those clients, looking at what our intervention did for that person.


Was it short-term intervention, and now things have gone back to how they were? What's happened in the system? One of the things that's become really evidenced through Covid is that the relationships that people have built through the Creative Solutions Board have stood them in good stead in managing the challenges of Covid. People know each other, they know who they are, they know how they think, they know how their organisation works, and that's been really helpful. We've provided a space for creative thought and challenge, and I do think that in the current climate, it is getting more and more difficult to create space for that. Sometimes, there is something more urgent that needs to be done by an organisation, so trying to get this as an important aspect of thinking through, and challenging what we do and how we do it, I hope has been very beneficial for the system, and for the individuals. Again, things are starting to develop from that, so, my team around me, which is developing in terms of trying to create that as a concept for that group of people where the normal way that things work doesn't work for them. So, having that team around them, having a team that will hold them, having a team that will continue to be there rather than having to go back around the circle and re-refer all the time to get specialist input, really trying to think about, how could we embed that across the city and across the way that people work. That's a gallop through what we do and how we do it, I hope people have found that useful, and obviously, I'm happy to pick up questions in the next section. Thank you. (TC 01:20:00)


F: Thank you very much, thank you to Mike, Barney, Alison and Aline for those presentations. We've got many interesting questions that have come through the Q&A, and I'm going to hand over to Michael to try and cluster those and direct them, in terms of who might respond. Michael, over to you then.


M: Thanks, Sadie, and thanks to Mike and Barney and Alison and Aline, a really interesting and useful morning. Thank you very much. There was a question in the Q&A about whether we had an examples of the Court of Protection having a positive response in relation to the issues that particularly Mike was focusing on. I will just highlight at this point that Laura Pritchard-Jones, who gave a presentation in an earlier webinar, her presentation does contain reference to Court of Protection judgements, and she subsequently provided an additional list of Court of Protection judgements involving alcohol dependents and Korsakoff Syndrome, and they should be on the LGA website for the relevant webinar, but I'll just highlight a couple here, as a kind of taster or starter for 10. So, she referenced a case known as Leicester City Council vs MPZ, and that's a 2019 case and she also referenced a slightly earlier case of DM vs York City Council, 2017. Both Court of Protection cases. If you can't find the list on the LGA website, I'm sure it's there, but just in case you can't, let me know and I'll put a different post up on the LGA website. Mike, a number of questions for you, one person was particularly interested to know how many participants there were in the survey that you referenced that you led on for the work that we’re doing jointly, and whether you've got any sense of who they were, what kind of job roles they were holding. Then, also, an interest in your evidence or links to research around the concept of kindling that you mentioned. Sorry for being a quasi-barrister and asking you more than one question at once, but I don't doubt your skill.


M: Well, I can answer both those questions, and I have put some answers into the Q&A for people, if you look at those questions, you can see it. I think that's most important if we deal with the second one first, because there is a question there about the evidence for kindling, and I've put in a link to a piece of research. It's a piece of American research, I think for the Institute of Mental Health in America, which is, even if you just read the first paragraph, it will summarise everything I said for you. The best way to do it is to google kindling, alcohol withdrawal, and you will come up with a lot of evidence for it, but I think the one I've put in is probably the best piece of evidence. In terms of the survey, we had roughly 200 respondents, the questions obviously oscillated slightly around that, I think one of the questions had slightly fewer respondents. They were across health, social care, alcohol, housing, all sorts of settings. I think in terms of alcohol and drug workers, we had something like 22, 23% in t hat survey were alcohol and drug workers. I think, as I said in the presentation, those were the ones who generated, we had 20 plus contacts with this kind of client group, but the rest of them were housing, adult social care, but also 999 services, emergency services, people like that. You could see that they were also experiencing a considerable burden from these clients.


M: Thanks Mike. People were also interested in the notion of executive capacity and whether we would say just a little more about executive capacity, so, I'm wondering whether, Mike you could kick of, and then Barney, whether you could offer any additional ideas about executive capacity and how to include that in the usual way, understanding, retaining, etcetera.


M: I am terrified about talking about executive capacity with you on the call Michael, you are the person who should really be answering this question because it is your expertise. As I see it, it is this notion which was summarise it think very well in the Angela Wrightson's safeguarding review, and I think that's one of the best summaries that I've read. I can't remembered who authored that, but it does talk about that difference between decisional capacity and executive capacity, which is a real issues for dependent drinkers, because dependent drinkers can often, for example, at 8 or 9 o'clock in the morning, tell you that they want their life to be different, they want this to happen, they are going to do that, they are going to do that, but at 4 o'clock in the afternoon, you know that none of those things will have happened because they will be drunk again. They have the ability to take a decision, but because of the compulsion associated with their drinking, they don't have the ability to execute that decision, and for me, that is a central concept. People have commented that it's not just relevant to drinkers and drug users, it is also obviously relevant to people with eating disorders, but even potentially hoarding and things like that and some other compulsive behaviours. That's my starter.


M: I will offer something after Barney. Barney, anything to add?


M: I would defer to both of you two, but there was a very useful article in community care in October, titled, 'When Mental Capacity Assessments Must Delve Beneath What People Say to What to What They Do', and I found that quite a digestible, readily shared article, insisting that these things need to be taken into account. Sometimes it's in relation to all sorts of issues about capacity, but especially executive capacity, it is about the importance of maybe unqualified housing, their knowledge of someone being incorporated properly into assessments, and not trying to get the most qualified person to meet someone for half an hour and then advise, does this person have the capacity or not. It's about incorporating other peoples' understanding.


M: Sorry, Barney, what you were saying was somewhat distorted. I could understand it, but we'll keep our fingers crossed when I come to ask the next question that's directed at you. Hopefully people caught it, particularly the reference to a recent community care article that talked about executive capacity. So, my contribution to executive capacity, it is the distinction between what people say and what people do. So, often a signpost to think about executive capacity will be repetitive patterns that people say one thing, but do nothing, or do the opposite. So, spotting repeating patterns, and then feeding back into conversation what you observe people doing or not doing, and then seeing whether they can use or weigh (ph 1:29:20) retain and understand what you might be feeding back, and a good example is Court of Protection judgement known as GW vs The Local Authority. It is, in fact, a case of a woman with Huntingdon's Career, where ultimately the Court of Protection, based on observations of her behaviour, ordered that she should remain in a nursing home, and indeed, be deprived of her liberty through the use of the relevant safeguards, because she could not keep herself safe (TC 01:30:00) in the community even though she was saying that she knew how to. Okay, so, something there on executive capacity. Turning for the moment to Alison and Aline, some interesting questions for you about your presentation, one person was interested to know whether you will be publishing your findings and your experiences in the work that you've done. Other people are interested in knowing how many people have been the subject of conversations in the board, to give an indication of the kind of scale of the issues that you're working with, and whether there are some commonalities across the cases that the board has discussed. then, also, some interest in how the post of Independent Chair is funded. Aline and Alison, I don't know which of you can address those observations, or indeed, whether both of you are going to.


F: Both of us are going to. I will address the first thing, which is about publishing. As part of Golden Key, we have the University of West of England, which is our evaluator for the whole programme, and it's just writing up a paper on the Creative Solutions Board, and, in fact, I've just got a draft this morning which I've got to review, which is done through interviews and with the members and thinking about system change, so that paper will be coming out in the next month or so I imagine, and will be on the Golden Key website, so we can do a link to that.


M: That's helpful.


F: Alison, do you want to talk about the number of clients?


F: You might want to come in as well Aline, but I think, in terms of clients that come to the board, that concept of the cyclical nature of what happens for individuals is really strong in terms of, there isn't a lack of professional involvement with these individuals. There is a lot of involvement, what sometimes doesn't work quite as well is the coordination of that response, and maybe the timeliness of that response, because as we know, if you're working with people with multiple disadvantage, your windows of opportunity might be few and far between, and if we can galvanise around those windows of opportunity the outcomes for that individual are obvious much better and greater. I think another thing I would pick out is that issue about organisations having been involved with someone, oh they don't engage, so we'll give up. I think one of the things about the board, when we started on the board, we heard that terminology quite a bit. I don’t think anybody uses that terminology now in terms of thinking, well, what is it about what our services offers that means this person doesn't want to engage, so, trying to tip that on its head. I think that is quite significant in terms of language changing, but organisations to trust each other to come in and do something, when we collectively feel it is the right time, I think it's quite important in terms of trying to get the best outcome for that individual. Accommodation in all of its shapes and forms is a problem in Bristol, so, the amount of accommodation available, at all different levels, is an issue that we're constantly trying to work on and work with, which will be the same for lots of other parts of the country, and trying to change how we might allocate that. Trying to think about working from a strengths perspective as well, trying hard to bring that in in terms of the person that we're talking about. We've not talked about lots of people, I think we've talked about 7, so we're looking at how we scale it but actually, I think we will get quickly, but because we're wanting to give it sufficient depth, and the work that goes into preparing the paperwork and the presentation to the board, there is a lot that goes into that, it doesn't just happen. We've got a pipeline of people. I mentioned earlier, that people need to consent, so sometimes that takes a bit of time to sort all of those things out. So, it's not massive, but what it is telling us is quite a lot about the system, and I think we will get to a point where we will be able to group issues together and maybe deal with them more systematically.


M: Do you come back to cases?


F: Yes, we do.


M: In a sense, it isn't a one-off?


F: No.


M: The board reviews the impact of its previous recommendations or decisions in relation to a particular case?


F: And, to see what happens, and sometimes, if nothing has happened, that tells us something about the system as well, so we try and then take that into the learning bit about, well, so why didn't that happen then, what is it about the system that was comfortable about that not happening.


M: Okay. There was some interest also, Aline and Alison, in your referral forms, particularly in the inclusion of the voice of the individual. The question was whether those referral forms are accessible, so that people who might be interested in trying out this approach somewhere else could see what you do?


F: Yes, I'm sure, if people contact myself or Alison, if you contact me, then I will send those on. We are in the process of setting up a similar board in South Gloucestershire, because they were interested in the way that were doing it as a neighbouring authority. Just to say, in terms of currently, Golden Key is funding Alison's role, the local authority picked that up. One of the other themes that Alison picked up on was around language, I remember there was one situation where we were talking about risk, where probation was saying this person is a low risk person, and the policeman in the room said, he's been arrested 35 times in the last 3 months for assault, that is not low risk, so it just really highlighted that we have such different understanding of risk, and that really hampers the way in which people work together.


M: Yes. Okay. Thank you. I'm going to try Barney again, Barney has turned his video off, so let's hope that the sound comes through better this time. Barney, there was interest in the mental capacity screening tools, and whether they are accessible for people to download and to use, and also, whether you've got any case examples of where Mental Capacity Act training had included a focus on homelessness or substance misuse, and the impact of that training.


M: Is my audio good enough for this to be worth doing?


M: No, unfortunately, your sound is not going to work, and I'm not sure what we can do to rectify that. Maybe if you could put in the chat for everybody whether there Mental Capacity Act screening tools are available for download online, and if you've got any examples of Mental Capacity Act training, whether you could put those links online as well?


M: I have put some on already, I will carry on, I'm presuming you still can't hear me, so I'll stop now.


M: Okay, thanks Barney, and sorry for the disruption to the sound quality. Mike, I don't know whether you've also got examples of training involving substance misuse, particularly alcohol misuse, and the Mental Capacity Act and the outcomes of that?


M: Yes, we run two major courses that I think relate to this. There is one which is a one-day Blue Light's project training course, which is on the general principles of working with change resistant drinkers, and looks basically at tools and techniques that we've set out in the Blue Light manual. (TC 01:40:00) So, it ranges across things like understanding barriers to change, it looks at the importance of nutrition with this client group, even things like smoking cessation have an impact of this client group, so there is a whole range of tools and techniques in that one-day course. We have also, as a result of the work that Michael and I have been doing, developed a half-day online workshop on safeguarding vulnerable dependent drinkers, which explores in more detail the material that I've been talking about today, and the material that is in the briefing document that Michael and I have developed. Can I also make a couple of points, Michael-


M: You might also want to reference when the briefing document that you've mentioned a few times is likely to be published on the alcoholchange.uk website?


M: I would love to reference that, but the problem is, I don’t know. It is available in a completed draft version, and if anyone emails me, you can get my email, I'm more than happy to send the draft version out to people as a PDF, it is complete, but there will be a prettier version which I'm optimistically going to be saying is going to be out in April, that's my dream. In some ways, it does relate to training, and I was particularly thinking about it when Alison was talking, I chair various multi-agency groups that manage chronic dependent drinkers, and one of the things that I think is notably lacking in the field is good guidance documents on how you chair and run one of these multi-agency groups, because all the focus on multi-agency groups is on setting up the group, and the structure of the group. The real trick to it is how you chair it, and how you make it work as a living group, and there is a real need for us to develop guidance on that for people up and down the country. I also think, because I'm writing a number of styles (ph 1:42:20) about this at moment, this whole issue of non-engaging clients, too often, local areas just simply don't have a policy on what you do about non-engaging clients, where is the policy on that? Where is the training and the technique surrounding working with non-engaging clients, because it is something which unites these clients.


M: Thanks Mike, I agree with both of those things, and, indeed, Angela and Aline may have a comment to make on that, and Angela and Aline, when you've made any comment on what Mike has just said about how you make boards meaningful living entities, there was a question in the chat too about pets, and whether your work as a board, particularly when you are sourcing accommodation for people, has had to focus on the issue of peoples' animal companions.


F: If we just talk about chairing, and the way we are trying to do it in the Creative Solutions Board, Alison will have a lot more to say on this than me, but actually, we did spend a lot of time thinking about how we create the right ethos for the board to be creative, and spent a lot of time actually building relationships, so, the focus was on building relationships between people on the board, and having a relational approach, that is absolutely key to the success. Actually, that has held us in good stead when we went into lockdown and the pandemic, I was amazed to hear so many people talk about how fantastic the Creative Solutions Board had been, because they had built those relationships. I think that's a really helpful question Mike, about how we build, and what is the way in which you create that creatively minded space, where people can be encouraged to do things differently.


F: I think that one of the things that I've done quite recently, because I think that quite often, people end up on groups or on boards representing their organisation, and then they think they will never get off it again. Sometimes, people don't want to do stuff like that, because they think they'll be trapped forever, so, what of the things we've done with this board is negotiated with people their commitment for 12 months, and then, 12 months later, we'll do that again, and that's been really helpful to have that one-to-one conversation with people about that. I think, also, that balance between, there are people on our board who are more interested in the client bit than they are in the system bit, and vice versa, so I suppose, what I've tried to do in the board is make sure people get a bit of everything, because actually, taking an individual and then trying to helicopter that view-up in the system is an interesting way to view things, and I hope, I'm not really the best person to answer this, but I hope I try and create an atmosphere where people feel they can trust each other to take a few risks, and in my experience of partnership work, I have had a local authority career in various guises, is that actually, there are sometimes, if you can get a partnership working really well, it's what I like to term, you can get some organisational naughtiness going in a good way. There are things sometimes you can do in a partnership remit that you might not be able to do in your own organisation, so I'm very pro trying to do that, and trying to get people to think in a different way. We also have some fun doing that as well, so I think humour is quite important. People are dealing with some really difficult situations, and one of the by-products of the board, which I hadn't anticipated, is the practitioners that came and present give really positive feedback, in the sense that the board have made them feel energised again, because they were working with people, difficult circumstances, not getting a lot back, and actually having a senior group of managers listen, ask questions and take their solutions, they found quite energising. That wasn't something I'd thought about before.


M: I love the phrase positive organisational naughtiness, I might reference that in the briefing that I have to write after the webinars. Could you touch briefly on pets, Adie has reminded me that there was a Tower Hamlets saga where the fact that a person who was homeless had to give up her pet, I think it was a Ms C, but it's certainly on the Tower Hamlets Safeguarding Adult Board website, where that was quite a feature of a case. I don’t know whether the issue of pets has cropped up on the board that you chair?


F: No, it hasn't but I would say that in homelessness provision in Bristol, people have worked really hard to make sure that there is provision for people with pets. It is a significant issue for people in terms of obviously wanting their pets with them, but there is provision for some accommodation.


M: Okay, thank you both. Adie, I think we've gone through the questions as best we can in the time available, I think we've covered most things.


F: Yes, thank you very much Michael. We'll just wrap up for the last couple of minutes with a couple of slides on where we are in terms of the CHIP programme, Michael, if you could put those up.


M: Yes.


F: Thank you.


M: Do you want me to talk to them?


F: Yes, very briefly, a couple of minutes.


M: So, as Adie said, we've run 7 so far, of the 8 webinars, the last one is next Monday afternoon, and, in fact, key in that session will be contributions from Experts by Experience, including from Independent Futures, which Aline and Alison mentioned as part of the work that they're involved with in Bristol, so there will be a contribution from Independent Futures' group of Experts by Experience there, as well as an Expert by Experience from Birmingham, and then, Adie and I will bring the webinar to a close. It is also possible that there will be a contribution on emergency duty teams and their roles in adult safeguarding and homelessness. So, that will probably be added also to the agenda. A reminder that I am tasked to write a follow-up briefing after the 8 webinars, so if any of you have today examples of positive practice, (TC 01:50:00) either in relation to direct work or the team around the person or organisational support for the team, or even organisational naughtiness, to pick up Alison's theme, I would be really happy to hear from you, and that's my email address. Then there are other resources on the local government association website, associated with adult safeguarding. The first ever national analysis of safeguarding review in England is there, data about the impact of the pandemic on adult safeguarding work that Adie has led on is also there. There is work Adie, Jane Lawson and others have been involved in around safeguarding concerns and Section 42 of the Care Act, that is also on the LGA website. ADAS is running some seminars, some webinars, on the EU settlement scheme, and one of those in particular on March 11th is for organisation supporting people experiencing homelessness, so there is that link also, and that's it I think.


F: Thank you very much Michael, so sorry, I'm afraid that's all we've got time for this morning. Thank you to everybody who put questions in the Q&A, and colleagues who answered. Thank you all for joining us, I hope you found it useful. The presentations will be available on the LGA events page, as will be recordings of this webinar, alongside the previous webinars. There is going to be a short survey being sent out to colleagues who've dialled in. Please complete it, because this has been a trial in terms of testing out how to disseminate information and provide information for people, so we're really pleased, and welcome any responses in the format of these webinars, and what you think of them, so please respond to the survey. Thank you to colleagues in CHIP and RGA for supporting the webinars and making it happen, thank you Michael for developing this programme, and thank you everybody and stay safe, I hope to see you next week at the final webinar. Take care everyone, goodbye.