ADULT LEARNING DISABILITY

PHYSIOTHERAPY SERVICE GUIDELINES

Date: November 2013

Version Number: 3

Author: Lisa Crooks

Review Date: November 2017

If you would like this document in an alternative language or format, please contact Corporate Services on 01595 743069.

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Contents

Contents .......................................................................................................... 2

Introduction ..................................................................................................... 3

Types of Service User Seen ............................................................................ 4

Totally Dependent Individuals ......................................................................... 4

Wheelchair Users with some Functional Ability ............................................... 7

Service Users who are Independently Mobile (with/out Walking aid) ............. 10

Individuals who access Acute or Musculoskeletal (MSK) Physiotherapy

Services ........................................................................................................ 12

References .................................................................................................... 14

Acknowledgments ......................................................................................... 14

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Introduction Historically, Adults with a Learning Disability (ALD) in Shetland were encompassed within the existing mainstream Physiotherapy Service. In accordance with Quality Improvement Scotland (QIS) (2006, 2009) and NHS Shetland Local Report (2009) it is Best Practice to have a service with differing criteria and resources required to meet the specific needs of this group of individuals within the Community. The Specialist ALD Physiotherapist’s Role is primarily to assess an individual upon referral and to agree appropriate Physiotherapeutic Intervention with that Individual/Carer. Individuals with a wide spectrum of ability can also present to the Acute, Musculoskeletal (MSK) or Complex Conditions Physiotherapy Team (CCT). They would be assessed and managed by which ever service was the most appropriate. The Specialist ALD Physiotherapist would liaise/act as a resource with the corresponding Physiotherapist and there would be a handover to the ALD Service as required. A Review of the existing ALD Service, including an Audit in association with the Clinical Governance Team, was undertaken in 2011. The action points raised have formed the basis for the development of these Physiotherapy Service Standards which have been devised for Parents, Health Professionals & Senior Social Care Workers/Managers.

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Types of Service User Seen

Totally Dependent Individuals Any person ages 19 or over with a learning disability who

is totally dependent on others for daily living skills – has complex physical needs and is wheelchair dependent

presents Carers with moving & handling challenges. Intervention Physiotherapy Assessment – to list the physical challenges and how these might be addressed Onward Referral – to other members of the Multidisciplinary Team (MDT) as appropriate. Development of Physiotherapy Management plan including – Provision & demonstration of written Physical Management Programme developed with the Carer outlining: *24 hour postural management plan

*Alternative positioning options

*Therapeutic moving & handling advice

*Activity & exercise programmes &

recommendations. The programme will be demonstrated to the Carer & others as indicated/required. This would take place in the individual’s home/place of work, if they do not attend a day care centre as the Carer would be the regular contact. The Physiotherapist will support the Carer until they are confident in carrying out the recommendations.

Outcomes The level of ability & disability are identified & recorded. A problem/plan list is drawn up with agreed, identified goals. Potential interventions and monitoring processes are discussed and agreed with Carer. Unmet needs which may be addressed by other team members are identified and a referral made with appropriate consent. The Physiotherapist provides recommendations regarding the individual’s postural management and how the Carer can be enabled to help the individual increase movement opportunities. Advice will be given on exercise & activities to maintain/slow deterioration in skills & function. A Therapist checklist is available for completion as required (see Appendix 4). The Carer is advised to incorporate the movement & positioning advice into the individual’s daily activities. The physiotherapy Programme will include regular changes of the individual’s position & incorporating passive /active/assisted movement into activities of daily living (ADL). Further demonstration /support may be required -including for new staff.

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The Carer will be advised that if there is any doubt whilst carrying out recommendations he/she should discontinue and seek further advice. The most efficient & safe method of handling will be recommended to minimise risk of injury to both the Carer and the individual. This could include assessment for specialist equipment. Wheelchair/Specialist Seating Assessment The Physiotherapist will attend for joint assessment with the Bio-engineer/OT and any follow-up appointments, where appropriate. Specialised Equipment Assessment The Physiotherapist advises on the acquisition & suitability of specialist equipment. The Physiotherapist will demonstrate use of the equipment when delivered and ensure Carer is competent in its use. Physiotherapy Interventions *Hydrotherapy/Swimming

Individual is either passively moved or actively assisted to move by Carer. *Respiratory Assessment

The Physiotherapist will assess and record respiratory functions of the individual & advise Carers on positioning & activities, clearance of secretions and importance of maintaining good respiratory function.

Carers are empowered to contact the Physiotherapist should there be any concerns/change. Recommendations are assessed in conjunction with ROSPA guidelines. Other MDT members will be included as appropriate. The Physiotherapist will advise on reasons for review or reassessment of prescription and follow up as required. The Carer is informed which specialist equipment will assist in the therapeutic management of the individual. The Carer is able to use the equipment effectively and will contact the Physiotherapist if there is any fault/damage/failure. Further demonstration can be requested if necessary. Health promoting activities which compliment the individual’s overall physical management programme. Regular movement opportunity. The aim is to slow down the inevitable long-term effects caused by an individual’s lack of ability to move & overcome the effects of gravity. The individual/Carer will understand the importance of activity & positional changes for good respiratory care.

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*Annual Review

The Physiotherapist’s recommendations are reviewed at least annually & any changes to the written programme made at this time. The Physiotherapist considers whether there is a need for ongoing Physiotherapy input/any change required. If it is agreed that it is not necessary to retain the individual on the Physiotherapy Caseload, the Carer is advised that the individual will be discharged and a summary of intervention sent with re-referral criteria. If unable to attend the annual review a progress report of intervention is forwarded to the Care management meeting. Review/input as determined by adapted Nottingham Rehab Management tool

Carers are aware of potential indications for earlier review and know how to request this. Any necessary changes are documented with the Carer’s input. Further demonstrations arranged if necessary The Carer understands the indications for potential re-referral to the service and who to contact should the need arise. A report of intervention over the previous year is given. Outcome to indicate amount of input required.

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Wheelchair Users with some Functional Ability

Any person aged 19 and over with a Learning Disability who is a wheelchair user:

With some functional ability

Has limited mobility (e.g. uses a walking aid) Is seeking to maintain mobility and functional independence.

Intervention Physiotherapy Assessment to assess level of ability& limiting factors. Appropriate intervention to improve/maintain mobility & functional independence will be agreed. Assessment takes place in most appropriate environment for the individual and may need to include e.g. stairs/outdoors/work environment. Relevant Physiotherapeutic Equipment will be provided and demonstrated to Carer as required, once assessed & dependent on appropriate funding. Onward referral – to other MDT members as appropriate Development of Physiotherapy Management Plan – *Exercises will usually be of a functional nature e.g. encouraging the individual to stand, transfer & walk. *Where specific exercises are appropriate, picture form individual programmes are the preferred format. *Carer will help facilitate Physiotherapy Intervention

Outcomes The Individual/Carer is advised of how much mobility/function might be encouraged/maintained. The individual is supplied with the most appropriate equipment. Carers are competent in its use. Any unmet need which may be addressed by another team member will be identified and a referral made. Having been given a suitable Physiotherapy programme the Individual will be reviewed by the Physiotherapist or Carer as appropriate.

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Wheelchair/Specialist Seating Assessment The Physiotherapist will attend for joint assessment with the Bio-engineer/OT and any follow-up appointments, where appropriate. Specialised Equipment Assessment The Physiotherapist advises on the acquisition & suitability of any required equipment. The Physiotherapist will demonstrate use of the equipment when delivered and ensure Carer is competent in its use. Physiotherapy Interventions

*Hydrotherapy/Swimming

Individual is either passively moved or actively assisted to move by Carer. *Respiratory Assessment

The Physiotherapist will assess and record respiratory functions of the individual & advise Carers on positioning & activities, clearance of secretions and importance of maintaining good respiratory function.

The Physiotherapist will advise on reasons for review or reassessment of prescription and follow up as required liaising with local OT/wheelchair technician. The Carer is informed which equipment will assist in the therapeutic management of the individual. The Carer is able to use the equipment effectively and will contact the Physiotherapist if there is any fault/damage/failure. Further demonstration can be requested if necessary. Regular movement opportunity. The aim is to slow down the inevitable long-term effects caused by an individual’s lack of ability to move & overcome the effects of gravity. The individual/Carer will understand the importance of activity & positional changes for good respiratory care.

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*Annual Review

The Physiotherapist’s recommendations are reviewed at least annually & any changes to the written programme made at this time. The Physiotherapist considers whether there is a need for ongoing Physiotherapy input/any change required. If it is agreed that it is not necessary to retain the individual on the Physiotherapy Caseload, the Carer is advised that the individual will be discharged and a summary of intervention sent with re-referral criteria. If unable to attend the annual review a progress report of intervention is forwarded to the Care management meeting. Review/input as determined by adapted Nottingham Rehab Management tool

Carers are aware of potential indications for earlier review and know how to request this. Any necessary changes are documented with the Carer’s input. The Physiotherapy requirements are discussed with the Care Team. Further demonstrations arranged if necessary The Carer understands the indications for potential re-referral to the service and who to contact should the need arise. A report of intervention over the previous year is given. Outcome to indicate amount of input required

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Service Users who are Independently Mobile (with/out Walking aid) Any individual aged 19 or over with a Learning Disability who is able to walk but:

Is prone to falls Has balance/co-ordination problems

Is at risk of “going off his/her feet” Presents Carer with moving & handling challenges.

Intervention Physiotherapy Assessment – *Environment *Physical Capabilities *need for provision of Equipment which may include a wheelchair referral. Physiotherapy Interventions *Hydrotherapy/Swimming

Individual is either passively moved or actively assisted to move by Carer. *Respiratory Assessment

The Physiotherapist will assess and record respiratory functions of the individual & advise Carers on positioning & activities, clearance of secretions and importance of maintaining good respiratory function.

*Annual Review

The Physiotherapist’s recommendations are reviewed at least annually & any changes to the written programme made at this time. The Physiotherapist considers whether there is a need for ongoing Physiotherapy input/any change required.

Outcome Predisposing cause is identified & addressed by the Physiotherapist Regular movement opportunity. The aim is to slow down the inevitable long-term effects caused by an individual’s lack of ability to move & overcome the effects of gravity. The individual/Carer will understand the importance of activity & positional changes for good respiratory care.

Carers are aware of potential indications for earlier review and know how to request this. Any necessary changes are documented with the Carer’s input. The Physiotherapy requirements are discussed with the Care Team. Further demonstrations arranged if necessary .

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If it is agreed that it is not necessary to retain the individual on the Physiotherapy Caseload, the Carer is advised that the individual will be discharged and a summary of intervention sent with re-referral criteria. If unable to attend the annual review a progress report of intervention is forwarded to the Care management meeting.

Review/input as determined by adapted Nottingham Rehab Management tool

The Carer understands the indications for potential re-referral to the service and who to contact should the need arise A report of intervention over the previous year is given.

Outcome to indicate amount of input required

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Individuals who access Acute or Musculoskeletal (MSK) Physiotherapy Services *Any individual aged 19 or over with a Learning Disability who presents with an acute episode requiring admission. *Any individual aged 19 or over with a Learning Disability who requires Specialist Musculoskeletal (MSK) assessment/treatment. •Individual will be living/working in the wider community and self managing in all aspects of self care/work. •Individual will be able to attend without carer/chaperone and will not be at risk/vulnerable in attending Physiotherapy Department independently. •Individual will understand basic written/spoken instructions/communication. •Individual will have the Capacity to Consent to Intervention. This will all be at the discretion of the Physiotherapists/Individual/Carer involved. Intervention Physiotherapy Assessment & Intervention – as required to meet needs of Individual Current Specialist ALD Physiotherapist’s Case Load will be accessible via online data base and current Case Files in Office.

Outcome Basic Respiratory/Mobility Information Sheet in front of Individual’s notes to facilitate Physiotherapy management in case of admission The Acute/MSK Physiotherapist will assess and manage the Individual’s Physiotherapy Intervention as appropriate. A joint assessment/intervention may be indicated. The Specialist ALD Physiotherapist will liaise with other members of the Physiotherapy Team and progress the Individual’s Physiotherapy as required to ensure optimum rehabilitation. Working with other MDT members to ensure optimum delivery of Service for the Individual.

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Education of Care Providers Intervention Training for Carers as required to update in any changes/refresher of existing management plan Training for new Staff as requested

Outcome Carer will be aware of main purposes of Physical Management Interventions for Individuals with complex needs The Carer will be aware of the value of specific Physiotherapy Interventions and their role in supporting the Individual to access & participate in movement opportunities.

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References NHS QIS – Best Practice Statement – February 2006, “Promoting access to healthcare for people with a learning disability- a guide for frontline staff” NSS QIS – Local Report- April 2009, “Healthcare Services for People with Learning Disabilities” NHS QIS – National Overview Report – December 2009- Quality Indicators “Promoting Inclusion and Wellbeing” and “Meeting General Healthcare Needs” Stewart et al, “Residential carers’ knowledge and attitudes towards physiotherapy interventions for adults with learning disabilities”, British Journal of Learning Disabilities, Vol37, issue3, pages 232-238, Sept2009. Adults with Incapacity (Scotland) Act 2000 A guide for Physiotherapy Staff CSP May 2006

Acknowledgments Fiona Smith – Physiotherapy Manager Jane Shephard – NHS Grampian Learning Disabilities Service Annette Baines – Administration manager Nottingham Demand Management Tool – adapted with kind permission by- Ian Johns, Paediatric Physiotherapy Manager, Broxtowehucknall County Health Partnership

NHS SHETLAND DOCUMENT DEVELOPMENT COVERSHEET*

Name of document Adult Learning Disability Physiotherapy Service Guidelines

Registration Reference Number CSGUI016 New Review

Author Lisa Crooks

Executive Lead Fiona Smith

Proposed groups to present document to:

Physiotherapy Department GPs and Consultants

Area Advisory Committee for AHPs Sample group of 5 Parents

Andrea Holmes Eric Gray Centre

DATE VERSION GROUP REASON OUTCOME

22/04/2013 1 Area Advisory Committee for AHPs PO PRO

18/07/2013 1 Physiotherapy Staff PO PRO

31/07/2013 1 Andrea Holmes, LD Nurse PO MR

16/12/2013 1 GPs PO PRO

16/12/2013 1 Eric Gray Centre C/S MR/PRO

15/10/2014 2 Core Clinical Governance Group FI/Approval MR

09/12/2014 3 Changes made based on CCGG suggestions – no need to resubmit

- Approved

Examples of reasons for presenting to the group

Examples of outcomes following meeting

Professional input required re: content (PI) Significant changes to content required – refer to

Executive Lead for guidance (SC)

Professional opinion on content (PO) To amend content & re-submit to group (AC&R)

General comments/suggestions (C/S) For minor revisions (e.g. format/layout) – no need

to re-submit to group (MR)

For information only (FIO) Recommend proceeding to next stage (PRO)

DATE CHANGES MADE TO DOCUMENT

22/04/2013 Positive comments received. Suggestion of sending to the Manual Handling Committee, however as it will be mostly SIC staff involved in manual handling that wouldn't be necessary.

18/07/2013 Feedback from the Physiotherapy staff meeting was positive - no changes suggested.

31/07/2013 Andrea Holmes queried about the need to include reference to 'Consent' and the document was updated accordingly.

16/12/2013 Theresa Slater suggested including the Therapist Checklist once agreed. This document will be updated when the final checklist has been approved.

16/12/2013 Sent out to GPs and Consultants. GPs were happy with the document, no feedback from the Consultants.

16/12/2013 Sent out to 5 sets of parents – no feedback received.

17/03/2014 Addition of the approved Therapist Checklist as Appendix 4 of the document and a sentence referring to it on page 4 (version 2).

15/10/2014

Tabled at the new Core Clinical Governance Group for information/approval – some minor changes were suggested including: extend the review date by one year, remove Lisa’s name and use her job title, add carers details and preferred method of contact, add existing level of mobility on referral form.

04/12/2014 Changes discussed with Lisa Crooks, Learning Disabilities Physiotherapist

09/12/2014 All changes made and guideline documents sent to Corporate Services and IT for upload to Internet/Intranet pages

Version 3 produced by Learning Disabilities Physiotherapist November 2013 For Review November 2017

Referral Guidelines for the Adults with Learning Disabilities Physiotherapy Service

Referral Criteria

1. Adults (=> 19 years old)

2. With a diagnosed learning disability

For the following problems:

Pain

Mobility and Movement difficulty

Respiratory Assessment/Management

Please complete a Physiotherapy referral.

For general advice or information regarding an individual who is already

known to the Learning Disabilities Physiotherapist, for example:

New Staff member requiring instruction/supervision in Physiotherapy

management of Individual

Concerns about equipment provided by Physiotherapy

Changes to an individual’s ability/compliance with Physiotherapy

Management Programme

Please contact as below:

Lisa Crooks, Physiotherapist

Email: lisa.crooks@nhs.net (preferred method)

Post: Physiotherapy Department, Gilbert Bain Hospital, South Road, Lerwick,

ZE1 0RB

Telephone Number: 01595 743323

Please note: the Physiotherapist is a part-time/community worker so please leave a message.

APPENDIX 1

Adults with Learning Disabilities Physiotherapy Referral Pathway

SelfUse Self

Referral Form

Input to service

Complete Professional Referral Form

(paper)

Complete Electronic Referral Form

OR

Physiotherapy

Department

Contact with

Patient/Carer

Referral Process

Version 3 Produced by Clinical Governance Support Team November 2014 For Review November 2017

Appointment with Patient/Client

GP

Consultant

Senior Social Care

Worker/Manager

Allied Health

Professional

Community/

Specialist Nurses

Parent/Carer

Contact Learning Disabilities

Physiotherapist

via

Email, Telephone, Letter

Learning

Disabilities

Physiotherapist

APPENDIX 2

Physiotherapy Request for Assessment and Treatment

HIGHLIGHTED AREAS MUST BE COMPLETED OR REFERRAL WILL BE RETURNED

Referred by: Surname: Preferred place of treatment

Health Centre First name:

Gilbert Bain Hospital

Address:

Day Care

Department Health Centre (specify)

Email:

Consultant/GP Date of birth: Home Visit – say why below

Male/Female

Other (specify) CHI Number: Other (specify)

Preferred person to contact:

Daytime Number:

This Referral is: URGENT SEMI-URGENT ROUTINE

- Acute Problem - Not in severe pain - Chronic/Recurrent problem

- Severe Pain - Moderate loss of function - Mild pain

- Severe loss of function - Loss of mobility - Mild loss of function

Past Medical History

Has patient had previous physiotherapy for this problem? Yes No Additional support required? Yes No If Yes, please specify

Has a GP been consulted? Yes No

All Current Medication

Communication difficulties? Hearing impaired Signer required Other (specify)

X-Ray report/other investigations

Preferred method of contact? Phone Email Letter

Clinical Reason for Referral/Pre-existing level of mobility (if applicable)

Pace Maker Wearer ? Yes No Is the patient/client aware that a referral is being made? Yes No If No, is their welfare guardian aware? Yes No

Signature

Date

Print Name

Designation

For Physio use only:

Date received: Date made:

Appointment date: By: Card/Phone/In person

Generic Referral form produced by Physiotherapy Department May 2013 Version 2 Amended by CCGG November 2014 For Review Nov 2017

APPENDIX 3

Shetland Islands Council

THERAPIST CHECKLIST FOR DELEGATION OF TASK

Patient / Client Name:

Address:

Tel No:

D.O.B

Print name of the Therapist:

Designation:

Therapist contact details:

Telephone Number:

Carers name:

Organisation:

Tel. no:

Name and contact details of Line Manager:

Date the task was agreed by Carer/Staff

Member’s Line Manager:

Task to be delegated:

Location for task

(environment) :

Has the Carer/Staff member

completed Moving and Handling

training?

Date completed:

Y /N

Comments:

Date: Signature:

Does the service user understand and

consent to delegated task undertaken

by the Carer/Staff Member?

Y / N

Comments:

Date: Signature:

Risk Assessment Form completed and

attached

Yes/Not

required

Comments:

Date: Signature:

Clinical reason for task discussed with

Carer/Staff Member Y / N

Comments:

Date: Signature:

Carer/Staff Member able to

demonstrate the task without verbal

or physical prompts

Y / N

Comments:

Date: Signature:

APPENDIX 4

Shetland Islands Council

THERAPIST CHECKLIST FOR DELEGATION OF TASK continued

Patient / Client Name:

D.O.B

Therapist contact details:

Telephone Number:

Number of observed and demonstrated

sessions attended (with dates)

Date: Signature:

Date: Signature:

Date: Signature:

Date: Signature:

Written and signed instructions of task

given to Carer/Staff Member Y / N

Comments:

Date: Signature

Additional comments/detail:

Print Therapist name:

Signature:

Date:

Print Carer/Staff Member’s name:

Signature:

Date:

Review date:

Adapted from All Wales Treatment Handling Group Guidance on Delegation 2011-Therapist

Checklist for Delegation of Task