Going to keep it short and sweet.  Do visit:

Merrolle's blog

Salford University Occupational Therapy Education Blog

Both have links to the College of Occupational Therapists Conference 2008 presentation about blogs / social networking.  Think this is important stuff and directly relates to the posting here about a year ago.  Is there any future in the web?!?  Errr...... yes.  Slightly out of date, but something that was highlighted in a presentation I attended for home care providers I went to this week (source Daily Mail):

"The figures, from a report by media regulator Ofcom, debunk the traditional image of pensioners as technophobes.

Although only 16 per cent of over-65s said they had used the internet at home in the 30-day period covered by the report, those that did use it stayed online for longer than any other age group.

It's been  a while since my last post (again).  Wanted to take the opportunity to make reference to the total transformation and personalisation of social care services.  I've recently changed jobs and now working as a Project Manager with a focus on implementing self directed support for a large local authority.  Would be keen to network with others in similar roles - do get in touch.

Really wanted to take opportunity to highlight to OT's, who I know do visit this blog, to raise the profile of Self Directed Support , or SDS, as it's commonly referred to.  Some OT's will be familiar with the In Control pilots, the methodology to calculate a Resource Allocation System (RAS) - so that people know up front how much their Personal Budget will be.  This really does give choice and control to people to use the money in a flexible way to meet the outcomes they want from life - not just recipients of a range of "shopping list" services available from the local authority.

SDS will be the basis of the biggest changes to social care since the Community Care Act in the 1990's.  I won't go in to the detail here, but do encourage you, at the very least, to read "Putting People First" and  if that grabs you, the Transforming Social Care Local Authority Circular (LAC) that was issued  in January 2008.  This circular outlines the Government's expectation  of introduction of personalised social care services throughout the next 3 years.

CSIP (Care Services Improvement Partnership) has, this month, launched the Personalisation Toolkit, which has a huge amount of information and guidance to assist local authorities to  plan and implement the change.  The launch was announced by Ivan Lewis,  the Minister for Care Services.

It's been a while since I posted a blog entry - needless to say, life has been very busy.  Anyway, the Government have finally published the DFG review outcome. 

From April, DFG's will have a mandatory limit of £30,000 (an increase of £5000).  Access to the garden will be mandatory.  For more details , please visit the Department for Communities and Local Government website, above.

Although I've been writing this blog for over a year now, I haven't really ever talked about blogging.

Since that first blog entry in March of 2006, there are more occupational therapy bloggers on the web.  More recently, this has been thanks to Merrolee, a lectuer at  the School of Occupational Therapy at Otago Polythechnic, New Zealand.  Merolee's blog introduces a project that she and other occupational therapists have been doing, exploring Web 2.0 and some of the opportunities and new ways of learning, sharing experiences and networking with other OT's that you probably wouldn't meet.

Will Wade's blog, Metaot, also links with the New Zealand project and has discussion about Web 2.0 tools.

So, just what is Web 2.0?  Wikipedia (an example of a Web 2.0 platform), can be visited for a more in depth description.  Web 2.0 is about the next generation of web based communities, using  blogs, RSS feeds, wikis, Skype and social networking sites like Facebook (where you can find the Facebook Occupational Therapy Association (FOTA) with 1994 members as at 9th June 2007), MySpace and the more advanced Second Life (with a Wikipedia description of Second Life here).

To view a 4 minute tutorial on using wikis - just click on the video below:


The Scottish Institute for Excellence in Social Work Education has published a two page leaflet on social care blogging (and  lists this blog as one to visit).

I won't repeat it here, but Merolee's blog entry from earlier today discusses why therapists might blog and I was able to identify with many of the ideas that she raises - definitely worth a read.  What about you?

The long awaited  "Community Equipment: A Vision for the Future" has been  made available by the Care Services  Improvement Partnership (CSIP).

The new  national model (although not mandatory - make of that what you will), proposes that  for the areas that take it up, community equipment stores will close, and instead  a system whereby therapists issues prescriptions for the person to take to a local retail outlet (I presume in much the same way as a GP issues a prescription).

There's to be a new role of Independent Needs Assessor (most likely to be occupational therapists and physiotherapists). 

The current system supports 1.5 - 2 million disabled people.  With 11 million disabled people living in the UK, the existing state focused system falls far short.  In addition to the people who also get help from social services, the new model also proposes to support people who don't meet eligibility criteria for assistance through the local council, as well as those who choose not to involve the state in their lives.

There are a number of documents laying all of this out in much more detail, all to be found at the CSIP Transforming Community Equipment and Wheelchair Services site.  There's further informatrion about the new Retail  Market Model and an easy read Executive Summary.  You'll also find guidance about the future of more compex equipment like hoists, adjustable beds and lifts (I imagine they're making an assumption that stairlifts will be redesignated as equipment following the recent DFG consultation).

I expect I'll look back here in another year or so and think about how the face of social care has changed and how it continues to change.

I think that we're about to see one of the biggest changes to social services that this country has seen for a long time, and the feel of this is captured really well in a speech that was made a few days ago by Dame Denis Platt, the chair of the Commission for Social Care Inspection (CSCI). 

This all follows the Government's vision, set out in January 2006, in the white paper, "Our health, Our care, Our say".

She talks about the way that direct payments and individual budgets will give citizens more control over their lives.  She talks of how councils will be measured on how well they're doing  - by asking questions, of people accessing support, about the outcomes for them, rather than counting the physical numbers of people who were assessed, helped, reviewed and number crunching how long it took to do for x, y and z.

This will affect occupational therapists, care managers and social workers - it's time to drop professional defensiveness, the way that professionals control services and embrace the changes.  By doing so, those skills that have been years in the making can be best used to benefit everyone.

I think that we've some exciting times ahead, with some new roles emerging for occupational therapists.  Maybe sometimes a rollercoaster journey, but some great opportunities to grasp.

"Direct payments and individual budgets –

the state of social care"

I always think it's important to keep up to date with new products on the market and this one is no exception.

If it's difficult to bend down to feed your pets, now, with the DinnerUp , your furry friends will always get those nutrients they need.  Great stuff.

The Department for Transport is currently consulting on Blue Badges .

One of the recommendations it makes is that OT's (and physios), rather than GP's are best placed to make assessment of mobility.  The consultation recommendations go so far as to say that GP's should be taken out of the Blue Badge administration loop completely.

Excerpt from Local Authority guidance:

4.11    Some form of medical opinion is needed in most cases.  The current practice of using an applicant's GP to verify that an individual meets the criteria for a blue badge is regarded as an unsatisfactory arrangement for both the GP and the administrators of the scheme.  The main argument against this approach is that it compromises the doctor/patient relationship.  A Cabinet Office report "Making a difference: reducing burdens on general practitioners (GPs)" published in June 2002 recommended that GPs be taken out of the loop. Appendix C gives details of how to view the report.

4.12    The DfT strongly recommends that independent health professionals, such as physiotherapists and occupational therapists, should undertake assessments in place of GPs.  Occupational therapists or physiotherapists are often best placed to assess eligibility due to their professional knowledge of mobility.  Transferring assessment to such specialists implicitly suggests the importance of making judgements based on physical mobility rather than medical conditions.  Furthermore, their specific expertise enables them to tackle other mobility issues in the course of the assessment, such as the need for special equipment.  Where authorities have adopted this approach it has proved beneficial to the applicant and has contributed to the success of the change in practice from GP to accredited health professional.

4.13    Many local authorities have already adopted this approach by running assessment centres.  Others use community physiotherapists in assessment centres whereby the local Health Authority provides the Community Physiotherapy Department with a budget in order to provide the service.  As well as reducing costs, a fair and equitable service is being provided to all applicants who are required to have an assessment to determine their eligibility.

I couldn't let this pass by without a mention - is it a first for OT? 

The song was written by Boaz and the Band about Occupational Therapy.  Click below and turn up the volume.  You can watch it for free here or download it to your MP3 player for the grand price of $0.99 on the Boaz and the Band website.  Anyone know how we make this a UK number one?

Must give credit to another OT blog for writing down the lyrics, which I'll reproduce here.........

I woke up this morning
I couldn't even get out of bed
I stumbled on my feet to brush my teeth
and I didn't have the strength...to find my sink

(chorus)
It sounds like I need some OT
It sounds like I need some OT
It sounds like I need some occupational therapy

So they dragged me out of bed
To do some therapy activity
To bake a cake and fold some clothes
They told me I can't go home
unless I'm safe when I'm alone
It looks to me instead...that someone is just lazy

(chorus)
It sounds like I need some OT
It sounds like I need some OT
It sounds like I need some occupational therapy

So if you find yourself putting on your t-shirt wrong
or sometimes wondering if you've left your stove on
Lets make it very clear...You don't need physical therapy

(chorus)
It sounds like you need some OT
It sounds like you need some OT
It sounds like you need some occupational therapy
lalalalalalalalala

Now wait a minute, is there a speech therapist in the house?

(chorus)
It sounds like you need some OT
It sounds like you need some OT
It sounds like you need some occupational therapy

Sometimes we forget about that other therapy
we always seem to think physical therapy
but without OT, people are going to think...and would be stinky

So thank you, OT
For all you do, thank you
Thank you, thank you occupational therapy

You need some OT? You know you do!
Who's the vice president?
You need some OT? Your shoelaces are untied
You need some OT? Your fly is open
You need some OT? You know you want some?
You need some OT? You know you do.

The Office for Disability has, this month, published a brilliant report called "Better outcomes, lower costs".  This is an evidence based research report carried out in association with Bristol University, co-authored by an OT.

If you click on the link above, it takes you to the main publications page - just scroll down to find the document as a PDF, under the "Independent Living Report" title.  There's the full report - 126 pages (good bedtime reading), or the 8 page executive summary for those of you with busy lives.

It demonstrates that huge cost savings can be made if housing adaptations are provided promptly, and particularly for younger disabled people and younger-older people.  It goes on to say that cost savings aren't so great with the older-older population, as they're likely to have help with personal care anyway, and may require assistance to use adapted facilities anyhow.

The deadline for responses was yesterday.  Foundations have published their response to the DFG consultation.

Shortest blog entry yet?

Well, I didn't get around to putting a synopsis of the DFG consultation on here   in the end - life has been busy.   Rather than re-invent the wheel, I'll list a couple of briefings, which outline things quite nicely:

Foundations - the National Co-ordinating Body for Home Improvement Agencies - briefing

Care and Repair England - briefing

I was invited to the College of Occupational Therapists a couple of weeks ago to be part of a small group to discuss and advise on College's response to the consultation paper.   The COT response to Communities and Local Government (CLG)  has been distributed to those people who contributed to the COT consultation, today, and should be published on the COT website  (I presume in the members area) very soon.

UPDATE 28th March:  COT DFG Consultation response is on this link.

The Communities and Local Government Department (formerly the ODPM) has finally launched the Disabled Facilities Grant consultation.  A copy of the Government's proposals can be found at the communities.gov.uk website.

I do aim to complete a more indepth review on here over the next few days and I encourage all OT's to read and submit comments.  The consultation runs until 13th April, with results being published on 6th July 2007.

Just a flavour of what's in there includes what's wrong with the current DFG system, joint working, individual budgets*, changes to the means test, Disability Housing Registers, changes to the maximum limit, redesignation of stair lifts as equipment............

*an example of Individual Budgets guidance , written for service users (with an initial focus on OT) is at the Essex County Council website.

The Disabled Living Foundation have, today, launched "Bathing Made Easy " - the first free, impartial online database where you can search for and compare bathing and shower equipment and adaptations.  You can choose up to 4 items and compare them side by side.  It includes cost, dimensions, diagrams and national suppliers.

I'm sure that this database will be of huge help to occupational therapists and to anyone wishing to find and compare different items.

As time goes by, the site will develop, including other categories of equipment and adaptations as well as bathing.  Another of the unique features of the site seems to be the option of people reviewing items that they have used, as a guide for others looking.

The guide will be of benefit to people who may be choosing to use direct payments to buy their own equipment, rather than choosing to accept what the local authority may be offering.  It will also be able to be used to complement the information available from your own occupational therapist.  Why not use it to explore options and ask them questions about your ideas?

The Occupational Therapy online self assessment  that I have been involved with developing with other colleagues has been launched today on the Kent County Council website. 

The assessment, for people living within Kent County Council boundaries, can be completed by the person themselves and they can receive equipment or adaptations directly as a result of doing their own assessment. 

It can also be completed on their behalf by a carer, friend, family member or other professional involved with their care, like a physiotherapist, nurse, social worker or housing officer.  It can also be used by people working in the voluntary sector for organisations like Age Concern.

Just a short entry to say that the abseil went really well, with the Ten Green Bottleits raising a total of £3000 for Macmillan Cancer Support.  Thanks go to all those who sponsored us.

Slightly off topic, but needed to share this with all www.housingot.co.uk visitors......

On Saturday 21st October, I'll be doing a 120 foot abseil, in aid of Macmillan Cancer Support.  I'll be abseiling down Charter House, in Ashford, Kent and hope to be raising a lot of money for this very worthwhile cause.  As you'll see from the picture, it's a very tall building and I'm a little bit scared of the thought of stepping over the edge.......

As well as me, 9 of my occupational therapy colleagues are doing the abseil too.  Occupational Therapists might understand and enjoy our team name "Ten Green Bottle Its" - it's a kind of very bad joke. 

If you would like to support me, and in turn the work of this great charity, please send a cheque payable to "Macmillan Cancer Support" to me (address details on my contact page) by 21st October 2006.

Macmillan Cancer Support improves the lives of people affected by cancer by providing practical, medical, emotional and financial support.  One in three of us will get cancer.  1.2 million people in the UK are living with cancer now.  Any donation will be very much valued - Thank you.

I have been on the working party, re-writing of the London-wide guidelines for criteria for major adaptations. 

I've learnt this week that the new "Guidelines for Major Adaptations to the homes of people with disabilities" is due to be published and available over the next week or so. 

The 50 page guidance has been reviewed and scrutinised by well-known legal advisor, Michael Mandelstam, and has been endorsed by the College of Occupational Therapists.

As well as working party members, the guidance has been available for wide consultation and comment, including members of the London Borough Occupational Therapy Managers Group (LBOTMG), the College of Occupational Therapists Specialist Section in Housing (COTSSIH) and the National Association of Paediatric Occupational Therapists (NAPOT).

The first part of the document covers the law on major adaptations in owner occupied, housing association, council and other rented properties.  It gives guidance on issues related to carers, careful assessment, ethnicity and culture, cost effectiveness and best value.

The second part of the document gives guidelines and clinical reasoning / rationale pathways leading to decisions about which major adaptation could be considered.  It also gives occupational therapists other factors to consider when recommending a specific adaptation, with some guidance also, on technical considerations.

I'll publish a link / contact details on the housingot website when the guidance has been published, so you can get a copy.  The cost will be £25 for London Boroughs and £30 for others.

It's got to be one of the most useful documents for local authority OT's.  An excellent learning tool for OT's new to recommending major adaptations and an excellent, up to date (Fair Access to Care Services compliant!), evidence based document upon which local authorities may wish to base their own eligibility criteria.

UPDATE 21st August:  For further details or to request a copy, please email Ruth Pink at the London Borough of Hounslow: Ruth.Pink@hounslow.gov.uk

Just a quick update really with a couple of new things of interest to OT's working in adult social services.

The Government, via CSCI (the Commission for Social Care Inspection) are planning on scrapping the current way that councils are measured on performance..... and doing it another way - in line with the outcomes mentioned in the recent white paper, Our Health, Our Care, Our Say.

If you've feelings about the current system - the D54 and D55 indicators in particular - that's the target of equipment delivery / minor adaptations being fitted within 7 days and the target of assessing people 65 years and over within 28 days, now's your chance.

To comment and see more details about the consultation on the performance assessment framework, visit the CSCI website, and to read more about it, see this article about the changes, in Community Care.

The other worthy bit of news is the change to the way that adult social services has to deal with complaints.  From 1st September 2006, there is a new way of managing complaints.  One of the changes is that people have to lodge a complaint within a year.  Another, is that complaints will need to be investigated more quickly.  For more details, click through to the Department of Health complaints guidance, issued as Section 7 guidance under the Local Authority Act 1970. 

Managing our own continence is one of those things that we barely give thought to - if everything is going OK.  We don't really think about it as we're growing up - as babies, we don't have any insight and our parents sort it all out with baby wipes and nappies.  There's a natural developmental process to learning how to manage our continence and when are where to get to the toilet.

Sometimes, as we get older, things happen that cause some problems.  It may be a transient problem, maybe following pregnancy or because of a urinary trat infection (UTI).  Incontinence may be caused by the aging process, because of injury, like a spinal cord injury, or due to a disease process like multiple sclerosis.

There are two types of urinary incontinence - stress incontinence  and urge incontinence.

Continence care is usually associated with nursing, but of course, other health professionals have key roles to play in the management of continence.  Physiotherapists sometimes specialise in bladder strengthening exercise or treatmnent programmes.

There is a lot that occupational therapy can offer too.

As an occupational therapist, it's important to have an awareness of the different treatment options that are available for people who either incontinent of urine or faeces, in order to be able to recognise the problems that clients face, and to refer them to the relevant specialist for treatment, to be able to provide advice, or to be able to recommend equipment to assist with the management of things.

It's important to remember that incontinence isn't something that people just have to put up with.  Even if it can't be cured, there are usually better ways of managing it so that it doesn't have such a negative impact on someone's life.  Very often, people are unaware of the help that is available to them.  They just accept that it's "part of getting old" or "part of the MS".  It's not.

Often, people who are incontinent limit their lives in some way.  It may be that they don't go out of the house very often, for fear of not being near a toilet.  They may be worried about the embarrassement of wetting themselves out in public.  They may be aware that they smell strongly of urine and, again, be embarrassed to go out.

One of the other risks with incontinence, particularly for people who are inactive, is that of damage to the integrity of their skin, which, in turn can lead to pressure ulcers (also known as pressure sores).  Sitting around in urine or faeces can lead to damage to the skin.  I won't go into detail on pressure ulcers right here, but basically, the area of skin tissue dies and breaks down.  Pressure ulcers take a lot of time and effort to treat and increase the chance of infection being able to pass into the body.  If left untreated, or they grow, they can be life threatening.  For more information about pressure ulcers, click through to the Waterlow site.

Therapists may be involved with provision of equipment relating to pressure care, for example, pressure relieving mattresses or pressure cushions for seats and wheelchairs.

Often, people who are prone to urinary incontinence don't drink enough, for fear of repeated trips to the toilet, or that they will wet themselves.  Although this may, initially, seem like a logical way of managing things, it's incredibly counterproductive.

Without enough water, we get dehydrated.  This can lead to fatigue, headaches, loss of stamina and concentration.  If we don't drink enough, we increase the risk of getting a urinary tract infection (which can mean we need to go to the toilet more).  Our urine becomes more concentrated, smells more and can be more damaging to our skin if it's against it for any length of time.  If we don't drink enough, it can affect the way our kidneys are working, can cause problems with our blood pressure, cause dizziness (and therefore increase risk of falls).  It can cause constipation, blood clots or confusion.

It's particularly important to drink lots and remain hydrated, particularly in the hot weather we've all been experiencing this summer in the UK.  The British Dietetic Association  recommends that we drink between 1.5 and 2 litres of water per day - that's between 6 and 8 glasses.

People who need to hurry to get to the toilet are at greater risk of falls.  At night time, people are at risk because they're feeling tired.  It may be a struggle to get out of bed, they may not be wearing glasses ( to see where they're going), may not be wearing hearing aids (which improve balance).  It might be dark.  They may not be wearing well fitting flat soled shoes or slippers (with a supportive back).  They may be taking medication to help them sleep, so feeling dozey.

At night, a commode in the bedroom may be useful, to make it easier and safer to go to the toilet.  Equipment to help someone sit up in bed, or get out of bed, like a mattress variator or bed leaver, will make this part of the activity safer.

If the only toilet is upstairs, again, a commode could be used, or a recommendation made for major adaptations for a stairlift, through floor lift, or ground floor toilet, to enable easier access to toilet facilities. 

Like any profession, occupational therapy has it's own jargon.  Even within the profession, there are differences between therapists' language depending on when and where they trained, the geographical area they work in, the organisation they work for and how, when and where they do their continuing professional development (CPD) activities.

There are plenty of occupational therapy dictionaries about, and without wanting to write a whole occupational therapy thesaurus (now, there's an idea), I thought I'd have a go at compiling a list, with alternative names or abbreviations, of some of the more common assistive equipment and adaptations that you might come across.

This isn't a definitive list by any means.  I'll come back and update it when other things spring to mind or if anyone thinks there's something missing (click on the comments button at the bottom of this blog entry).  Here goes:

Updated: 24.6.06 by James Lampert

Help from government resources has to be fairly distributed and to the right people, at the right time.  

From an occupational therapist's perspective there are usually two factors:   (1) actual physical / psychological need and (2) money.

Let's start at the beginning of someone's journey through the maze that is social care, using a case study.  

Donna is a 37 year old woman, living with her husband and three teenage boys.   She used to work as a care assistant, but unfortunately she seriously hurt her back about 2 years ago and is no longer able to work.   She and her family were living in a rented housing association house, situated in a hilly part of town.   There were about 10 steps from the pavement to get to her front door and she was really struggling.   Although she could still drive, she was unable to get out of her home on some of those days due to all the steps.  

She called social services and her referral details were passed to the occupational therapy team.   Under the NHS and Community Care Act 1990, anybody who may have community care needs is entitled to an assessment.   Due to the high numbers of referrals received in the team, there was a prioritisation system for dealing with referrals.   This prioritisation system was based on risk to safety and independence.

The therapists aimed to see people within a matter of days for those people falling within categories such as terminally ill, moving and handling risk of injury to carers, or crisis cases where someone may be admitted to hospital or to a care home without equipment or adaptations.

Donna didn't fall within those categories so her case was deemed to be non-urgent and she waited around 3 weeks to be seen.

An occupational therapist was allocated her case and visited to carry out an assessment of need.  Between them, they established that Donna was beginning to find it difficult to get in and out of the bath, and found that the external and internal steps were at least difficult and at most impossible to manage.    

Following the assessment, under Fair Access to Care Services (FACS), Donna was assessed as falling into the "substantial" band.   I'll discuss FACS in more detail another time, but if you want to know more, follow the link.

She was loaned a bathlift and discussed the options regarding the two sets of steps.  

Donna knew that if she wanted to lead a full, unrestricted   life, that she and her family would have to move.   Her application for rehousing was supported by her occupational therapist, who supplied a report detailing the type of property that she would need.   At that time, the therapist gained consent to get a report from her orthopaedic consultant, who was of the view that Donna was likely to need to use a wheelchair to get around within the next few years.     Donna applied for a transfer and a few months later was offered a ground floor flat.  

The flat was already adapted and was level access at the front door and within and had 4 bedrooms, a living / dining room, kitchen and level access shower room with toilet.   Donna was delighted and agreed to move.   Three weeks later she and her family were in and she returned her bathlift, which was recyled for someone else to use.

A couple of months passed and Donna found that everything was great, except for having a wash.  Although she had a shower that she could easily get into and use, she didn't like it.   She missed the pain relief she used to get for her back by having a bath.

She contacted her occupational therapist again and asked for a re-assessment, particularly with regard to her bathroom.

The therapist visited and they discussed Donna's wish to have a bath reinstated.

Although   the therapist empathised with Donna,   her decisions were guided by eligibility criteria (based on law, council policy and common practice).   Since Donna already had bathroom facilities that she could access and use to keep herself clean, she was not eligible for further spending on adaptations (or indeed, to take out adaptations that had already been funded to install a standard bath).   In addition, if a bath were to be reinstalled, the local authority would need to fund a bathlift.   This was clearly neither a good use of public monies nor would meet Donna's long term needs.

Of course, there   is the argument that Donna would benefit from a bath for pain relief.   Chances are she would.   This kind of situation presents challenging ethical dilemmas.

The bottom line is that there is only a certain amount of money in the public pot for spending on equipment and adaptations.   It has to be targeted at the people that need it most, with the highest levels of need.   Rationing of public resources is often a tough job, making decisions on "wants vs needs" and considering "essential vs desirable".  

Eligibility criteria exist to ensure that decisions are made consistently and fairly and that scare resources are targeted effectively.

Many OT's working in the field of housing adaptations will be familiar with the Selwyn Goldsmith book, "Designing for the Disabled", originally written way back in 1967 and updated 1976, published by the Royal Institute of British Architects  (RIBA).  It contains specific measurements for anything you want to know, based on ergonomic principles, from the recommended height of a wash hand basin for a wheelchair user to the gradient of ramps, to the recommended size and layout of a wheelchair accessible kitchen. 

Things have moved on in the past 30 years - the population has changed in size and shape, there are new building products available, design trends change and new equipment, including wheelchairs are available.  Selwyn Goldsmith's most recent book, written in 2000, called "Universal Design" takes on the concept of inclusive design and encourages architects to think about making all new buildings accessible for everyone.  Inclusive design is about making sure that everyone (examples include ambulant people, wheelchair users, visually impaired people and mums and dads with prams) can get into, around and to be able to use buildings and the facilities within them.

Of course, those buildings built pre the era of inclusive design may still need to be adapted - in fact, it's a multi million pound industry in the UK, adapting properties to make them accessible, keeping a huge number of builders, architects, surveyors, occupational therapists and access auditors in meaningful employment.

As an OT brought up on Selwyn Goldsmith, I still think that his original book gives some good firm grounding in some of the specific measurements that an OT should be aware of when considering redesigning a property to make it accessible for the occupant.  Alongside this, therapists should be carrying out evidence based practice, by using current knowledge, based on a number of other supporting publications like the current Part M of the Building Regulations (known formally as "Approved document M - Access to and use of buildings (2004 edition)") and Lifetime Homes Standards.

I've gone slightly off on a tangent with what I originally intended to write about - some nice 'n' simple measurements that all good OT's should know.  I suppose what this does illustrate, is that it isn't just as simple as knowing a few standard measurements.  The standard measurements that I'll attempt to list shouldn't be taken as definitive.  They're really just minimum guidelines and may need adapting to meet legal (building regulation) requirements or to meet the needs of individual people using the home or building.  I expect I'll update this blog entry from time to time as I think of more.

• Path's and ramps: 1000mm unobstructed width
• Ramps: Aim for 1:20 gradient (which is virtually level).  Accept 1:16 as a compromise.  Only go for 1:12 if you really must.  It's hard work for everyone.  75mm upstands are required on the exposed edges.
• Doorways: 900mm
• Thresholds: 15mm maximum
• Wheelchair turning circle: 1700mm.  Yes, Building regs state 1500mm, which is what most architects and surveyors will quote at you.  Don't believe it.  The 1500mm recommendation is based on a very able bodied, strong, young, wheelchair user, who's got a standard NHS 8L wheelchair (one of the self propelling ones), and can turn it on a sixpence.  Most people can't do that.  If you don't believe me, have a go at measuring a turning circle of a wheelchair yourself.  Stick on the reasonable side of things and push for 1700mm, unless you've measured the turning circle that the person you're designing for can manage - then go for that.
• A 90 degree turn, using a wheelchair: Needs 1200mm min width in a passageway, to turn through a (900mm) door. 
• Handrails on steps and stairs: Height 900mm, to extend 300mm beyond the bottom and top steps. 
• Toilets: Go for a standard 17" (about 425mm) height toilet.  Make sure there's a clear 500mm from the centre of the pan to the nearest wall, or obstruction (pipes, etc).  Leaves room for rails, equipment, or for someone to safely assist.  It's very tempting to specify that the toilet is raised on a plinth.  Like it or not, people do tend to change with time.  Whilst someone might manage a 520mm high toilet now, they might not in the future and may need to use a shower chair over it, or have other toilet equipment fitted.  Can't do that with a toilet raised on a plinth.  Better to go with a 4" rasied toilet seat, or if that doesn't look trendy, how about a fixed raised seat like the ones from Pressalit  (see pages 22 and 23 of the bathroom products brochure).  Easy to take off, should the need arise in the future.  Looks pretty good too.
• Height of light switches: 1000mm approx
• Grab rails:  I won't give specific measurements - it depends on the specific needs of the individual.  Just some considerations though:  600mm (24") plastic grab rails are good in bath and shower areas.  Gives the opportunity for that bit more to hang onto in wet, slippery areas.  If you do opt for a grab rail by the toilet, is it close enough to their body for someone to push up with, or is the effort being used in the wrong way by having it fixed to the nearest wall, half a mile away?  Consider wall or floor fixed drop down rails or other support rail.
• Level access shower rooms.  Aim for 2000mm x 2000mm if you can and are looking for wheelchair accessibility.  You'll get a decent sized shower area, wash hand basin and toilet in there.  Includes a turning circle.

Kitchen assessment, that's what.

On the occasions when I've worked in a hospital, it used to make me cringe when I had the responsibility of carrying out a "traditional" kitchen assessment with someone - usually a quick "making a cup of tea" assessment.  I'll explain a little more about why below.  Many occupational therapists reading this blog will be familiar with the concept of the standard kitchen assessment, and maybe other people reading this blog will have been active participants.

At risk of being a bit controversial, it's not top of my list for assessment methods that I favour, but I'll attempt to be objective and discuss it in a bit more depth.  Other than a couple of short spells working in hospitals, I've always worked out in the community in peoples' own homes.  With the type of work I've been doing, observing someone make a hot drink hasn't actually been a necessary part of the assessment process.

Having said that, there is a place for carrying out a kitchen assessment.  Before I move on, I'll try and summarise some the things that an occupational therapist will be assessing when doing a kitchen assessment.  It's not just about checking to see if someone is capable of making a hot drink, contrary to what some nurses, care managers, doctors and porters might believe.  The occupational therapist will be carrying out an activity analysis as part of the assessment process and be testing psychosocial, as well as physical abilities:  cognition, perception, sequencing of tasks, planning skills, presence of dyspraxia (and type), vision, hearing, reception and expression of information, problem solving ability, muscle strength, balance, grip strength and type, safety awareness, mobility, motivation and mood.  The assessment is likely to inform the therapist of how the person might manage with other activities requiring the use of some of these similar, or same skills.

"Kitchen assessments" are quite common in hospital settings, either acute medicine, with view to discharge planning, or in longer term rehabilitation.  One of the main criticisms of kitchen assessments in hospital - usually in the hospital OT kitchen, is that it isn't actually the same as in the person's own home, where they will probably be returning to.  Someone might quite happily manage to do all sorts of things in their own kitchen, but appear to be confused and unable to the OT kitchen. 

It too, will depend on the person themselves.  Being truy client centred, there is little point assessing someone who isn't interested in, never has, or never intends to use their kitchen at home.  For someone though, who would like the opportunity to relearn lost skills or to build confidence, then it's got to be a good thing.  Sometimes this gets a little lost, I think, in the conveyor belt type approach sometimes used, of the usual collection of assessments that people go through in hospital - the washing and dressing assessment, transfer assessments (bed, chair, toilet) and the kitchen assessment.

Personally, I believe it is much more realistic and meaningful to work out with someone, how they use, or wish to use their own kitchen at home.

The most recent paper on this topic published in the British Journal of Occupational Therapy was by Wendy Bryant and Elizabeth Mackay (Vol 68, No 2, Feb 2005, pp. 67-74(8)).  It explores the idea of adapting kitchens for people and states that the kitchen in a familiar environment in occupational therapy, being a key occupational space in meeting nutritional and social needs in a domestic setting.  They point out that it's not just the "physiological need for food and fluids" that drives people to spend time in the kitchen.  They explore case study examples of a number of people who find it hard to use their existing kitchen due to the limiting environment on them, making them more disabled.  An example includes a lady with low back pain, who has to stack tins on the floor as the cupboards are too high.  The authors summarise that through striving to achieve uniformity (in house adaptations), individual differences can be lost.  In someone's home, it is those individual differences that make all the difference to them, how they live and function in their home.  The feelings of "This kitchen is driving me crazy" shouldn't be something that continues after a well assessed, planned occupational therapy intervention.

Occupational therapists working in adult or childrens' services are often responsible for recommending house adaptations, like showers, lifts, stairlifts, ramps, wider doorways   or an extra ground floor bedroom.   They help people to access different kinds of funding to help pay for this kind of work.

Who can apply?

For owner occupiers, private tenants and some housing association tenants, these major adaptations are usually funded through the borough or local district council housing or environmental health department.  

Council tenants are also able to apply, however, the reimbursement of grant back to the local council from central government is different to other types of occupation or tenure, so councils who are landlords usually prefer to fund major adaptation work, in their own properties, from separate capital funds.   Council tenants should not receive a lesser level of service than those people applying for a DFG - it should be equitable.   Housing Association tenants will sometimes find that their landlord will arrange the adaptations.

Legislation

The mandatory grant is called a Disabled Facilities Grant and is available under the Housing Grants, Construction and Regeneration Act 1996   (HGCRA), sections 19 to 24.   This piece of legislation superceeded the Local Government and Housing Act 1989, with regard to this type of grant.

By mandatory, it means that if someone applies and submits a valid application, then the grant must be awarded within time limits defined in law.   The current mandatory limit is £25,000.   The Disabled Facilities Grants and Home Repair Assistance (Maximum Amounts)(Amendment No. 2)(England) Order 2001 increased the grant paid in England from £20,000 to £25,000 from 21st January 2002.

The Regulatory Reform (Housing Assistance)(England and Wales) Order 1992 gave more flexibility to councils about how they provided assistance under the HGCRA.   Councils had the opportunity to publish their own local policies about the type of assistance they would offer.   This additional legislation also gave councils the power to offer assistance with moving costs for disabled people, whether to continue with discretionary DFG's, the ability to offer loans to older and disabled people and   to offer other types of home repair grants.  The mandatory element of the DFG did not change.

The Office of the Deputy Prime Minister published the "Delivering Housing Adaptations for disabled people: a good practice guide" in November 2004, giving guidance to local authorities about best practice.

The HGCRA is, essentially, a piece of housing law.   Although it will usually be the occupational therapist (probably employed by social services) who makes the initial recommendation, they're actually doing with their "housing law" hat on.   The legislation states that the housing authority must consult with the social services authority as to what is "necessary and appropriate".   The law doesn't actually state that it has to be an occupational therapist, but this is usually the person best placed to accurately assess the needs of the disabled person and who will have an extensive knowledge of housing adaptations - what works and what doesn't in the long term.

The housing / grants / environmental health officer has to ensure that the grant aidable works are "reasonable and practicable" (given the age and condition of the property).   No point installing a stairlift if the stairs are going to fall down under it, or to build a bedroom with ensuite level access shower if the rest of the house is going to fall down the next time the postman rings the doorbell.

The DFG is a means tested grant - so it depends on the income and savings as to whether any grant may be payable.   The test carried out is known as the "test of resources".   Children, in England, (and their parents) have been exempt from any contribution (up to the mandatory grant limit) since December 2005.

What does is cover?

It must be for one or more of the following purposes (see the original wording at   section 23   of the Act):

1. Enabling access by the disabled person to or from their home.   Covers things like ramps, steplifts, handrails, half steps, widened front doors, automatic door openers.
2. Making the home safe for the disabled person and for other people living there.   Bit of a fluffy clause, but can be useful.   An example might be re-forming a cracked, broken path to the front door, that may otherwise present a tripping hazard.
3. Enabling   access by the disabled person to a room used or usable for the main family living room.   The person doesn't have to stay in their bedroom all day - they can take part in normal family life.
4. Enabling access by the disabled person to, or providing for them, a room that can be used for sleeping (a bedroom).   This makes it distinct that it would not be acceptable to expect someone to sleep in the same room as the family living room.
5. Enabling access by the disabled person to, or providing for them, a toilet that they can use.   This will include wash-dry toilets like the Clos-o-mat Samoa  or Geberit.   May also include lever flush mechanisms or raising the toilet on a plinth (often not a good idea if a shower / commode chair will need to be wheeled over it).
6. Enabling access to a room in which there is a bath, or shower, (or both), and ensuring that the person can use them OK, i.e. accessible shower controls.   May need to accommodate adjustments for people with a visual impairment.
7. Access to and use of a wash hand basin.
8. Enabling the preparation and cooking of food by the disabled person.   Depends on the local authority how generous the allowance is.   Sometimes councils refer to space standards and minimum worktop / storage allowances referred to in other housing legislation.   Can include accessible ovens, wheelchair accessible (maybe height adjustable) work units / surfaces, accessible sink and hob.
9. A heating system that can be accessed by the disabled person.   This may mean changing the type or location of the controls or may mean the provision of a new heating system if there is none, or the person is unable to manage.   Examples may include someone who has a new spinal cord injury and may have difficulties with thermoregulation (controlling their own body temperature) or may be someone who is no longer able to carry in coal to light a fire.
10. Enabling the disabled person to control power, light or heat by altering the position of controls.   An example may be to raise plug socket heights for a wheelchair user.
11. Facilitating access around the home to enable the disabled person to care for someone else.   For example,   a disabled parent who uses a wheelchair would need to be able to get to their childrens' rooms to look after them properly.
12. Finally, there's a really fluffy clause that says that the Secretary of State can decide on any other purpose.   Never known that be done and would be interested to hear if anyone has any examples.

So, how about a case study example of how it all works?

Follow the link to this case study about DFG's  to see how it all fits together.

Sometimes it doesn't all run smoothly when someone applies for help through the local authority for housing adaptations.

In cases where it has not been possible to resolve the complaint by the local authority, the Local Government Ombudsman  (LGO) gets involved to investigate further and form judgement.

There have been some interesting cases recently and I'd like to share examples of those in order to promote good practice and prevent similar things happening again.

The most recent case was only reported yesterday (12th May).  Leeds City Council were found guilty of maladministration and causing delay in providing adaptations for one of their own disabled tenants.  The gentleman had to wait for about 3 years for facilities to be provided for him.  There was a delay in reaching a decision, with the council losing track of the case for a period of several months.  The council ordered to pay £5000 compensation and to fund a 2 week holiday this summer for him and his family to reflect the strain placed on them due to the delay.  Full details of the case can be found at the LGO website.

Another recent example  (26th April), was a finding against Northumberland County Council.  The LGO found that the council was guilty of maladministration as someone was told that they would have to wait for 6 to 9 months for an assessment.  The person was having difficulty managing the stairs and wanted a stairlift.  The council were told to pay compensation and to find ways to reduce their waiting list.

A futher example  (8th February), cites the failure to communicate policy and decisions to the applicant for a disabled facilities grant, by the housing authority.  The applicant's expectations were unreasonably raised and results of decisions were not conveyed.  There was poor communication between the housing authority and the occupational therapist.  Compensation was ordered to be paid. 

If things aren't going well, the first thing to do should be to speak to the person responsible for looking after things, be this the occupational therapist, or the housing officer.  If that doesn't resolve things, you can ask to speak to their manager.  Hopefully things will get resolved at this stage.

The next step would be to raise a formal complaint.  This is best done in writing, if you can.  Local authorities will all have set procedures for fealing with complaints and will have to respond within a set time period.

Of course, you can always contact your local councillor or MP who can help you to represent your case.

If the complaint is resolved through the council's own complaints procedure, then you can ask the Local Government Ombudsman to get involved.  They will have wanted you to exhaust all other lines of complaint internally before they will take up the case. 

I felt inspired to write this entry becasue this was the title of a search that someone did recently on one of the search engines.

I think that it says exactly what occupational therapy aims to achieve - the sense of personal wellbeing.  It's about moving from a state of unbalance to a state of balance.  From being unable, to being able.  From feeling down and unmotivated to upbeat and motivated.  From being unable to do to being able to do.

OT's and OT students will know that occupational therapy is based on the premise that everyone wants to carry out purposeful activity.  By carrying out purposeful activity, we achieve the sense of wellbeing that we all crave.  For theorists, you'll be able to think about Maslow's hierarchy of needs and the quest for self actualisation.

Diagram of Maslow's hierarchy of needs.
1. Physiological
2. Safety
3. Love/Belonging
4. Esteem
5. Actualization

from Wikipedia.

What Maslow says is that we all have basic physiological needs - things like food, drink and warmth.  Once these are met, we can start thinking about our surroundings.  Are we safe?  Do we need to find shelter from sabre toothed tigers, or a thunder storm?  Assuming we're fed and watered and feeling secure, we want to love and be loved.  We find this with our parents, lover, friends and children.  Then we need to feel good about ourselves, the way we look, our body image, the things we wear, our standing in society, how we think other people perceive us.  Finally, we aim for self actualisation - the pinnacle of occupational wellbeing, where everything is just as we want it.

Sometimes things - life, gets in the way of this.  We get ill, we grow older, we acquire disability.  Very often we can get around things.  Sometimes we work things out ourselves.  As humans, we're very adaptable, we change accorsing to circumstances and our environment.  But sometimes we need a little help with this, so our quest for self actualisation and wellbeing can be complete.  This is when we seek the help of our own friends and family or doctors, nurses or therapists.

I thought I'd write something about the basics of occupational therapy.   I know that a number of students read this blog and that other people are interested in finding out a bit about some of the basics of what occupational therapy is all about.

Remembering back to when I started training in the early '90's, one of the first things we were taught was the "occupational therapy process".   I'm not convinced now, that today's students are taught this fundamental basis of how to actually proceed with an intervention.   I've found that students that come out on practice placement somehow seem to struggle with what to do first, what to do next, and how it all ends.   Hopefully, this will help structure those thoughts.

Without all the other "clutter" that you need in your head to be an occupational therapist (all that biology, physiology, psychology, sociology, abnormal and normal development theory, models of practice, legislation and law, activity analysis, occupational science, research skills, technical skills and so on), the process is definitely worth understandng and remembering.   Here's the OT process in a nutshell:

It's really just a loop.   You'll get it right if you start at the beginning and take it step by step.   If you try and jump a step without thinking about the one in between, you'll end up in a muddle and most likely will miss something important.

Let's think about a practical example.   Health and social care professionals love a good case study, so enjoy this little story:

Pauline lives with her husband, Kevin.   They've recently moved into a new house, from a flat that was in another part of town.   They're both in their early thirties and hoping,   soon, to start a family.   Kevin works full time for the traffic planning department at   the local council and he loves his job.   Pauline used to work   in a school for kids with autism, but hasn't been able to do this for a couple of years as   she has a few problems   caused by her psoriatic arthritis.     Nevertheless, she still keeps herself busy.   She's teaches on the local NHS expert patient programme, helping other people with long term conditions manage themselves better.   She also spends some time with her mother, who's recently retired.

When   Pauline and Kevin moved into their new home, they knew that they'd need some changes to be done because Pauline sometimes uses a   wheelchair to get about and she's been finding it a bit hit and miss as to whether she   can   use the bath or not.   They moved from their flat because stairs were becoming a bit of a struggle on some   days.

They decided to see an occupational therapist to get some advice about what they should do.   (Here comes the clever bit with the OT doing the OT process).  

The occupational therapist visited Pauline at home, and carried out an assessment, also speaking to Kevin to find out about him and his views on things.   Between them, the occupational therapist helped them come up with a list of identified problems and they agreed on some goals.   As chance would have it, here's what they came up with:

Problems identified:

1. Occasional wheelchair user - unable to move through doorways on ground and first floors.
2. Sometimes unable to climb up and down stairs to access bedroom, bathroom and toilet facilities.
3. Unable to get in and out of bath independently.
4. Step at front door - some difficulties accessing home.

Goals agreed:

1. Widen all doorways in home to 900mm wide, to enable wheelchair access throughout.
2. Install a stairlift to enable access between ground and first floor.
3. Bathroom adaptations.   Remove bath and install a level access shower, with seat, grab rails and   thermostatically controlled shower, to enable safe and independent washing.
4. To provide   a half step at the front door to enable Pauline to access and leave her home safely and independently.

OK - so that's the first two steps in the process.

The occupational therapist helped Pauline and Kevin to get the proposed work organised.   When it was all completed, the therapist visited them again to check how it was all working - that's right, she did a reassessment.  

Pauline saw the occupational therapist arriving through the window.   She walked down the new step that had been installed at her front door to greet the occupational therapist at the gate.     They went back inside and the therapist   checked that Pauline could move from room to room   using her wheelchair and she saw how Pauline could whip up the stairs using her stairlift.   When they got to the top, Pauline proudly showed off her new bathroom that she could use without Kevin's help.  

They discussed how things had been going since the building work was all done.   Pauline was pleased with the new found independence and they decided that the whole scheme had been a huge success.   The evaluation was complete.   They agreed that there was no need for the occupational therapist to visit again.

The End.

I've chosen to write about my own experiences of disablism.   I'm not disabled, but for many years have worked with people who directly experience discrimination, sometimes "in your face", and sometimes things said or done in a subtle way.   I've seen lots of examples myself and I've heard many stories and I'll attempt to recount some of them here.

I started training as an occupational therapist in 1993 - before the days of the Disability Discrimination Act (I won't go into the pro's and con's of the Act here - generally I think there's been a change in public perception since it's inception, but I'm sure other people will have their own views on it's success, or lack of it).   I was working weekends and uni holidays in a small residential home for young people who were deaf and had learning disabilities.   We used to communicate by using a combination of Makaton - a kind of basic sign language and the standard British Sign Language finger spelling alphabet.   The residential home was just a regular house, in a regular street, and there were 4 people living there.   We used to get up to regular stuff.   Shopping, going to the beach, everyone did their own laundry, helped out with making dinner, watched the telly, going out to cafes for a drink.....

One day we went to a café in Ramsgate.   It was upstairs and had a balcony, so you could look down on the street below.   We asked for a table and were refused entry.   Simple as that.   The cafe staff didn't like the look of us and said that we would upset other customers.   So we weren't welcome.

Sometimes, even people who should know better, because they provide services specifically for disabled people get it wrong.   I'm not sure what it is?   Whether it's thoughtlessness, lack of training, no insight, deep rooted stereotyping.   I'm not sure.   If I see it happening, I do challenge it.   I'll give you a couple of examples.   The first one is about the use of language.   Local Authority "A" has a duty to keep a register of disabled people (the law says so).   When people were being registered, they were sent a little card letting them know that they had been registered as "handicapped".   Probably OK in America, but in Britain, the word handicapped has negative connotations - back to the Victorian days of "cap in hand" / begging / charity.   Needless to say, the wording has been changed now.

Another example I can think of was when I was with one of my clients.   Let's call him Tom.   Tom was a young man who was a new full time wheelchair accident after a fall from a ladder.   I'd been working with him for a while.   We'd been working out what kind of equipment he needed and what kind of adaptations we were going to do to his home to get him independent again.   He had a little boy, a toddler, and lived with his wife, who worked full time.   There had a been a change in role and Tom was going to be house-husband while his wife went off to work.  

We'd got to the point where we'd got the housing officer was involved because we needed a grant.   I'd made recommendations - we were looking to do all sorts - ramping, a through floor lift, an accessible bathroom, widening doorways so Tom could get around his home, a new heating system and a wheelchair accessible kitchen.

The housing officer came around and we discussed everything.   All was fine, until we got onto the kitchen.   I'm not sure what was said next was sexism or disablism - I think it was both rolled into one.   The housing officer asked "Why can't your wife do the cooking?".  

Deathly silence.