Providing Direct Support or a Manual Handling Assessment (Occupational Therapy)

1. What is Direct Support?

Direct support refers to the range of ways that an Occupational Therapy practitioner works directly with a person or a carer to ensure safe and effective use of equipment, aids or an adaptation.

Direct support includes:

1. Training of informal and paid carers in the safe and proper use of equipment; and
2. Supporting the person to safely and confidently use equipment or adapt to their environment after an adaptation.

Direct support:

1. Builds the person's confidence to use equipment and access their adapted environment;
2. Builds the confidence of any carers to use the equipment;
3. Ensures that people using the equipment are suitably skilled to do so;
4. Ensures that people using the equipment know when it may be faulty;
5. Reduces the risk of unsafe use of the equipment;
6. Reduces the risk of injury from unsafe or improper use of the equipment;
7. Maximises the effective use of the equipment or adapted environments to promote independence or prevent, reduce and delay needs.

2. When Direct Support should be Provided

When direct support can be provided

Decisions about the need for direct support should be made with regard for:

1. The person's views about the need for direct support;
2. The carer's views' and
3. The impact of direct support on the person's Wellbeing.

Direct support can be provided whenever:

1. The person consents to it;
2. The person lacks capacity to consent but a decision is made under best interests to this effect;
3. The carer consents (when support is to be provided to the carer).

Direct support can be provided in:

1. The person's home;
2. A care home;
3. Another environment where equipment is used and direct support would be beneficial (for example a day service).

Declining direct support

If the person or carer declines

If the person or any carer declines the provision of direct support you must:

1. Consider whether the person or carer has taken appropriate steps to obtain support elsewhere (for example from the equipment manufacturer); and
2. Explain to them the purpose and benefit of direct support.

If they continue to decline you need to consider the need to raise a safeguarding concern (if you feel that the person is a vulnerable adult and at risk of harm from improper or unsafe use of equipment).

Click here to access the safeguarding adults procedures, including how to recognise abuse and neglect, how to raise a concern, how to record safeguarding information.

If a service provider or care home decline

If direct support is to be provided to a service provider or a care home and they decline support you should consider whether they have taken appropriate steps to obtain support elsewhere (for example from the equipment manufacturer or their own in-house OT).

If no alternative appropriate steps have been taken you should consider the need to:

1. Raise a safeguarding concern; and
2. Raise a concern about their ability to meet the person's needs.

Click here to access the safeguarding adults procedures, including how to recognise abuse and neglect, how to raise a concern, how to record safeguarding information.

Click here to access the procedure for raising a concern about a service provider.

When direct support should be considered

You should consider providing direct support whenever:

1. New equipment has been provided;
2. An adaptation to the person's home has been carried out (major or minor works);
3. The person or a carer requests support to use equipment;
4. A service provider requests support to use the equipment;
5. The Registered Manager of a care home requests support to use equipment provided by the Local Authority.

When direct support should be provided

With consent (or in the best interests of a person who lacks capacity), direct support should be provided in any of the following circumstances:

1. There is evidence that the person or any carer (informal or paid) will not be able to safely use the equipment without support;
2. There is evidence that the person may not use the equipment or access an adapted area of their home (either regularly or at all) without a period of direct support;
3. The equipment is complex and requires direct support to understand how it works;
4. There is a doubt about the effectiveness of the equipment to meet the person's identified need (and thus there is a need to 'test out' the equipment).

3. Arranging Direct Support

Direct support arrangements should be made with:

1. The person (or their representative if they lack capacity);
2. Any carer;
3. Anyone service provider or care home who will be receiving direct support.

You will need to agree appropriate and proportionate arrangements as follows:

1. When direct support needs to start (this must be timely to reduce risk and maximise the benefit of support to promote independence);
2. The purpose and desired outcome of direct support;
3. The frequency that direct support will be provided;
4. The duration of each episode of direct support;
5. Who will provide the direct support;
6. Who will require direct support;
7. How long it is anticipated that direct support will last; and
8. How the progress of, and need for direct support will be monitored.

When deciding the arrangements for direct support you should consider:

1. The level of risk associated with improper use of equipment (risk of harm and to independence);
2. Whether equipment is in situ or not yet provided;
3. The complexity of the person's needs;
4. The person's ability to 'carry over' learning from one day to the next;
5. How often the equipment will be used/is used;
6. The time of day that direct support will be most beneficial (you should try and provide direct support in line with normal the routines of the person);
7. How many carers will need direct support;
8. The specific skills required of the person providing direct support; and
9. The current skills and abilities of carers to meet the person's needs.

A manual handling assessment should be completed prior to arranging direct support whenever it is necessary to do so.

A proportionate record of the direct support arrangements agreed should be made and, where deemed appropriate a written copy provided to the person.

4. Recording Direct Support

Providing direct support

Direct support should be provided in the manner agreed unless there is evidence to confirm that the arrangements are no longer appropriate or proportionate.

Recording direct support provided

All direct support activity should be recorded within the timeframes set out in the Local Standards of Timeliness of Recording. This can be found in the Local Resources area by clicking here.

Records should include:

1. The nature of the support provided (including which equipment and who direct support has been provided to);
2. Progress made towards safe and proper use of equipment;
3. Whether direct support is still required (including the views of the person and any carer about this);
4. Whether direct support arrangements are still appropriate; and
5. Any actions agreed (for example to arrange support for a carer who has not yet engaged with direct support).

5. Ending Direct Support

Deciding whether to end direct support

Decisions about ending direct support must be made with regard for:

1. The views of the person about ending or reducing direct support;
2. The views of any carer;
3. The impact of the decision on the person's Wellbeing.

Indicators that it may be appropriate to end direct support include:

1. The outcomes of the direct support agreed have been met;
2. The person and any carers are consistently using equipment safely;
3. Equipment is being used appropriately and effectively to meet needs and promote independence;
4. Everyone who was identified as being in need of direct support has received it;
5. There are no concerns about sustainability of safe use.

You should seek the advice of your line manager about the need to reduce or end direct support if this is not clear.

Whenever a decision is made to end direct support you must record:

1. The rationale for any decision made;
2. How you have given regard to the person's views and the impact of the decision of Wellbeing; and
3. How you have given regard for the views of any carer.

Ending direct support

Upon ending direct support you must provide the person (or their representative if they lack capacity) with the following in writing:

1. Information and advice about maintaining and repairing equipment;
2. Any other information and advice requested, or that you feel would be beneficial;
3. What they should do if their needs change;
4. What to do if the equipment no longer appears to be meeting their needs; and
5. What they should do if they (or a carer) requires further direct support in the future to use the equipment safely.

Closing the case

You can proceed to close the case when:

1. There are no outstanding actions for the Occupational Therapy service following the direct support (for example further assessment or referral to another service if there has been a change in need); and
2. The person has been provided with all information and advice required (or that would be beneficial) as set out above.

Make sure it is only your own involvement that ends when the Local Authority is to remain involved in some way, for example:

1. Appointeeship;
2. Deputyship;
3. Carers support;
4. Tenancy in extra sheltered housing.

Click here to access the process for ending your involvement and closing a case.