Scale 11 Problems with living conditions
This scale requires a knowledge of the patient’s usual domestic environment during the period rated, whether at home or in some other residential setting. If this information is not available (usually because someone is in an acute setting who has not previously been in contact with services), rate 9 (not known). Where a patient is in a longer term placement such as a long stay rehabilitation setting, if the plan of care is for that person to remain in that setting for at least 6 months then it is that environment that should be rated.
Consider the overall level of performance this patient could reasonably be expected to achieve given appropriate help in an appropriate domestic environment. Take into account the balance of skills and disabilities. How far does the environment restrict, or support, the patient’s optimal performance and quality of life? Do staff know (as they should) what the patient’s capacities are? The rating must be realistic, taking into account the overall problem level during the period, ratings on scales 1-10, and information on the following points:
• are the basics provided for – heat, light, food, money, clothes, security and dignity? If the basic level conditions are not met, rate 4;
• consider the quality and training of staff relationships with staff or with relatives or friends at home; degree of opportunity and encouragement to improve motivation and maximise skills, including: interpersonal problems; provision for privacy and indoor recreation; problems with other residents; helpfulness of neighbours. Is the atmosphere welcoming! Are there opportunities to demonstrate and use skills: e.g. to cook, manage money, exercise talents and choice, and maintain individuality? If full autonomy has been achieved, i.e. the residential environment does not restrict optimum performance overall, rate 0;
• a less full but adequate regime is rated 1. Between these poles, an overall judgement is required as to how far the environment restricts achievable autonomy during the period – 2 indicates moderate restriction and 3 substantial.
Scale 12 Problems with occupation and activities
The principles considered at scale 11 also apply to the outside environment. This scale requires a knowledge of the patient’s usual day time environment during the period rated, whether at home or in some other residential setting. If this information is not available (usually because someone is in an acute setting who has not previously been in contact with services), rate 9 (not known). Where a patient is in a longer term placement such as a long stay rehab setting, if the plan of care is for that person to remain in that setting for at least 6 months then it is the environment around that placement that should be rated.
Consider arrangements for encouraging activities such as: shopping; using local transport; amenities such as libraries; understanding local geography; possible physical risks in some areas; use of recreational facilities. Take into account accessibility, hours of availability, and suitability of the occupational environment provided for this patient at day hospital, drop-in or day centre, sheltered workshop, etc. Are specific (e.g. educational) courses available to correct deficits or provide new skills and interests? Is a sheltered outside space available if the patient is vulnerable in public (e.g. because of odd mannerisms, talking to self, etc.)? For how long is the patient unoccupied during the day? Do staff know what the patient’s capacities are? The rating is based on an overall assessment of the extent to which the daytime environment brings out the best abilities of the patient during the period rated, whatever the level of disability rated at scale 10. This requires a judgement as to how far changing the environment is likely to improve performance and quality of life and whether any lack of motivation can be overcome.
• If the level of autonomy in daytime activities is not restricted, rate 0. A less full but adequate regime is rated 1.
• If minimal conditions for daytime activities are not met (with the patient severely neglected and/or with virtually nothing constructive to do), rate 4.
• Between these poles, a judgement is required as to how far the environment restricts achievable autonomy – 2 indicates moderate restriction and 3 substantial.
