1
• Thehospitalinformationbookletaimstoassistinthedevelopmentof individualised careplans forpeoplewith learningdisabilities inhospitalsettings,forexampleTheVictoriaInfirmary,TheSouthernGeneralHospitalorLeverndaleHospitaletc.
• Theseguidelines are intended to support thepersonfilling in thebooklet.
• Itishopedthatthehospitaladmissionbookletwouldbecompletedalongside the person with a learning disability, by someone whoknowsthepersonwell,suchasafamilymemberorapaidworker.
• Thebooklet shouldbe completed as near to the timeof hospitaladmissionaspossible.
• Anewbookletshouldbecompletedforeachtimethepersongoesintohospital.
• Please take the booklet with you when the individual goes intohospitalandgiveittothememberofstaffwhoadmitstheperson.
• ALSO,pleaseremembertotelltheLocalLearningDisabilityTeam(LLDT),oftheadmissionandthatyouarecompletingabooklet,seeattachedsheetforcontactdetails.
• Complete thisbooklet as if youwerewriting it for someonewhodoesn’t know the individual at all, and try to be as accurate aspossible.
• Whencompletingthebooklet, ifyoudonothavetheinformationrequestedoryoudonotknowtheanswer,pleaseindicatethis.
• Makesurethehospitalstaffknowhowtocontactthepersonwhocompletedthebookletortheirproxyincasetheyneedtoaskanyquestions.
• Ifanindividualhastogointohospitalasanemergency,thebookletshouldbecompletedassoonaspossibleafterwards(withinatleastoneday)andhandedintothehospitalwardwherethepersonhasbeenadmitted.
• Please ensure that any aids, adaptations and equipment requiredgoeswiththepersonwhentheyareinhospital.
• Symbols are included at the back of this booklet to supportcommunication.
• TheHospitalInformationBookletaimstoassistinthedevelopmentof individualised care plans for people with Learning Disabilitiesand further inform staff within acute care.The booklet has beendevelopedinpartnershipwithusersandcarersandawiderangeofprofessionals.Thebookletisevidencedbasedandhasbeenpiloted,evaluated and reviewed extensively including Governance bodiesandPartnershipProviderForums.Manythankstoallinvolved.
2
Thefollowinginformationmaybeofhelpwhencompletingthehospitaladmission booklet. Please refer to this guidance when completing thebooklet.
Introduction• Thissectionlooksatgatheringkeyinformation.Forpeoplewhoare
supported by paid workers this information may be found in theindividualscareplan.
• This sectioncontainskey informationabout theperson, includingtheirname,addressetc.ItalsoincludesdetailsoftheirGPandLocalLearningDisabilityTeam(LLDT)member.
• The persons care first number is a unique identification numberusedbysocialwork,ifyouhavedifficultyinfindingthiscontacttheLLDT.
• Similarly,thepersonsCHInumberisauniqueidentificationnumberusedbytheNHSitcontainsthepersonsdateofbirthfollowedbya4digitnumber, itshouldbefoundinanyrecentcorrespondence/lettersfromhealthprofessionals.IfyouhavedifficultyinfindingthispleasecontacttheLLDT.
• Ifsomeofthisinformationisunavailableorunknown,thisshouldn’tpreventthebookletbeingcompletedorsentintohospitalwiththeindividual.
• MentalHealthCareandTreatmentAct(MHA)mayapply.
Informationaboutthepersoncompletingbooklet• Thissectionisaboutthepersoncompletingthebooklet,pleasesign
anddateandremembertohighlightyourcontactdetailstothewardstaffincasetheyneedtoaskanyquestions.
HowIcommunicatepain:• This section should be used to provide information on how an
individualcommunicatespain.• Itisimportanttoremember,thatsomepeoplewithlearningdisabilities
areunabletoreportpainandcanhavedifficultyindescribingthetypeandintensityofpainthattheyareexperiencing.
• Peoplewhoknowapersonwell,canbe thekey factor inhelpingothersrecognisewhenapersonwithalearningdisabilityisinpain.
• Pleasewritedownall theways inwhichtheperson indicatespaine.g. thepersoncanverballycommunicatepain,points toanareathatispainful/sore,anybehaviourchanges,theirfacialexpressions/bodylanguagemayindicatepain.
3
• Thisinformationshouldbeincludedintheindividualscareplan,orifneedbe,discussthiswithotherpeoplewhoknowthepersontogetafullpicture.
• Youcouldincludeanyhelpfulwaysyouknowtohelpthepersonsmanagepaine.g.redirection,humour,medication,havingabath,havingamassage.
• Itwouldbehelpfultoindicateifthepersonswillaskor indicateiftheyrequirepainkillers(sometimescalledanalgesia).
• •The DisDat is a distress assessment tool. It is designed to helphealth professionals identify distress cues in people with learningdisabilitieswhohaveseverelylimitedcommunication.Pleaseattachiftheindividualhasone.
Healthrisks:• Peoplewithalearningdisabilitycanhaveverycomplexhealthneeds
thatrequirespecialattentionandsupport.• Using the corresponding box to indicate if any of these risks are
presentgivingabriefdescription,youcanexpandonthese issuesusingthespaceontheNotespage.
• Please consider if the person requires close supervision from thehospitalstaffandwhatthingsthehospitalstaffcandotohelpthepersonstaysafe.
Someexamplesare• Eating:
» CantheindividualfeedthemselvesordotheyneedsupportANDwhattypeofsupportisrequired.I.e.onetoone,verbalprompt?
» Cantheindividualtellstaffthattheyarehungryorfullup?» Doesthepersonhavespecificroutinesaroundmealtimes?» Wouldthepersonbeabletounderstandthattheymayhaveto
fast?» Isthereanythingthatimpactsontheperson’sabilitytoeati.e.
sensoryimpairment(visual),dementiaoranyotherconditions?» Doesthepersoneatthingstheyshouldn’t(thisiscalledpica)
• Drinking:» People with learning disabilities may be at risk of dehydration
wheninhospital» Thepersonmaynotbeabletoindicateiftheyarethirstyandmay
notaskstaffforadrink.» Does the person require additional prompts and additional
attentiontomakesuretheydrink?
4
» Isthereanythingthatimpactsontheperson’sabilitytodrinki.e.sensoryimpairment(visual),dementiaoranyotherconditions?
» Isthepersonabletotakeadrinkfromabedsidecabinetwithoutsupport?
» Does the person drink excessively or recognise what fluids aresafetodrink?
• Swallowing» Istheindividualatriskofchokingwheneatinganddrinking?» What type of help reduces the chance of the person choking,
i.e. someone helping the person eat, specially prepared foodconsistency.
» Whattypesoffoodanddrinkmakesthepersonchoke?» Isthepersonawareofthisrisk?
• Mobility» Isthepersonmobileordotheyneedsupportandifsowhatkind
ofsupport?» Dotheyrequiresupporttogetinandoutofbed,aretheyatrisk
offallingoutofbed?» Dotheyrequiretobeturnedwheninbed?» Doesthepersonwander?» Is there anything that impacts on the person’s mobility (i.e.
sensoryimpairment(visual),dementiaoranyotherconditions?• Toileting
» Isthepersonabletousethetoiletoraretheyincontinent?» Doesthepersonwearcontinencegarments(pads)?» Does the person have constipation and what helps them with
this?» Doesthepersonhaveacatheter?» Isthepersonabletowalktothetoiletordotheyneedsupport
togetthere?» Doesthepersonrequireverbalpromptstousethetoilet?
5
• Epilepsy» Isverycommoninpeoplewithlearningdisabilities.» Pleasewritedownthetypeofseizuresthepersonhasforexample
toniccolonicorpartialseizuresetc.» Pleasenoteanyknowntriggersetc.» Youcouldincludetheirepilepsycareplaniftheyhaveone.» Pleaseincludeanyrescuemedication.» Youcoulddescribethebestwaytohelpthepersonwhenthey
haveaseizureandwhattheyarelikeafterwards.
Please indicate in theboxprovided if the individual experiences anyofthesehealthneeds.
• Visualandhearingimpairment» Visualandhearingimpairmentsareverycommoninpeoplewith
learningdisabilities.» Hearing and visual impairments are frequently unrecognised
andareunder-reportedandcanimpactonapersonsbehaviour,their ability to understand their environment and day to dayinteractions.
» Please remember to send thepersonsglasses, hearing aids etcintohospital.
6
Permissiontotreatment,thefollowingpointsmaybeusefultoconsider:
• A welfare guardian is a person appointed by the courts who canlegallymakedecisionsonperson’sbehalfregardingwelfarematters.Awelfareguardiancanmakedecisionsaboutthepersonscareandtreatmentandmustbeconsultedabouttreatmentwhilstthepersonisinhospital.
• Forfurtherinformationpleaseseewww.mwcscot.org.• If the person has a welfare guardian then their name should be
includedinthissection.• If thepersonhasawelfareguardian the informationshouldbe in
theircareplan.IfyouareunsurediscusswithyourlinemanagerorcontactLLDT.
• The individuals support worker is not able to give consent totreatment.
• Pleasedocumentusingthetickboxesanyissuesaboutconsenttomedicaltreatmentthatthehospitalstaffneedtobeawareof.
• Indicateinthespaceprovidedthepeoplethatareinvolvedinhelpingthe individualmakedecisionsabouttheircare, thepersonmayormaynotbetheirwelfareguardian.
• ThelastsectionsuggeststhathospitalmedicalstaffshouldcompleteSECTION47PART5oftheAdultswithIncapacityAct.
• Part 5 of the Adults with Incapacity (Scotland) Act 2000 gives ageneralauthority tomedicalpractitioners totreatpeoplewhoareincapableofconsentingtothetreatmentinquestion.
• Medicalpractitionerswillberesponsiblefordeterminingincapacityandfortheissueofthemedicalcertificateconfirmingincapacity.
• For further information please see www.enable.org.uk/docs/An_Introduction_to_the_Adults_with_Incapacity_Act.pdf
CommunicationProfile• Communicationdifficulties are commonamongst individualswith
learning disabilities and can be a significant barrier to accessingappropriatehealthcare.
• The person may require support with expressing themselves,understanding what is being said and making themselvesunderstood.
• Therefore, it is important that we can provide information abouttheircommunicationneeds.
• Please indicate thepersonsfirst languageandother language the
7
personunderstands.• Usingthetickboxes,pleaseadviseontheperson’scommunication
profile.• Please make sure that you involve all the people who know the
person, so that you come to a consensus and are as accurate aspossiblewithyourdescriptions.
• Ifthepersonusesacommunicationaidorpassportensurethatthisgoesintohospitalandstaffareawareofthis.
• Youmaywishtotellthehospitalstaffaboutwhatisthebestwaytocommunicatewiththeperson,whatworksandwhatdoesn’t.
• AdditionalinformationcanberecordedonNotespage.
Medication:• Please note any know medication allergies the persons has, also
indicateanyotherknownallergiesforexamplepenicillinorallergicreactionstofoodetc.
• In the tableprovided,writedownall thepersonsmedicationandincludeany‘overthecounter’medicinesthatthepersontakes.
• Beasaccurateaspossibleandattachthemostrecentprescriptionsheetifyouhaveone.
• Toaidaccuracy,allmedicationinformationMUSTbetakendirectlyfromtheperson’sprescriptionsheetortheprintedmedicationsheetthatisdispensedfromthepharmacist.
• Thisinformationmayalsobefoundonprintedmedicationboxlabelsorprintedlabelsonadosetteboxdispensedfrompharmacist.
• Pleasetrytocompleteallsectionsofthispagesothatstaffarewellinformedaboutmedicationthatthepersonistaking.
• Itisimportantthathospitalstaffknowifmedicationistakenintabletorsyrupform.
• Remembertonoteifmedicationneedstobethickenedortakenwithwater.
• Pleasenoteanyhelpthepersonneedstotaketheirmedicationsuchasdoesthepersonneedtobegiventhemedicationorwillrespondtoaverbalprompt.
• Some people may have to take their medication without theirknowledge.Ifthepersontakestheirmedicationcovertlypleasenotethisandincludetheircovertmedicationpolicy.Thisshouldbefoundintheircareplanandisagreedbytheperson’sfamily,carers,GPandotherprofessionals.
• Forfurtherinformation:www.mwcscot.org.uk/web/FILES/Publications/Covert_Medication.pdf
8
• Pleaserememberitisthehospitalstaffsresponsibilitytoensuretherightmedicationisgiven.
Informationaboutgeneralhealth• Pleaseindicatethecauseofperson’slearningdisabilityforexample
geneticcausessuchasdownssyndrome,pre/postnatalinjury.
Specifichealthneeds• Peoplewithlearningdisabilitiescanexperiencespecifichealthneeds
thataremorecommonthan in thegeneralpopulation, thesecanincluderespiratoryproblems,epilepsy,mentalhealthandbehaviourproblems.Peoplewhodonotknowthepersonmayrequirealotofhelptorecognisethesehealthneeds.
• Tohelpsupporttheindividual inhospital, it is importanttolistallknownhealthneeds.Pleasebeasaccurateaspossible,forexampleit is really easy to mix up dysphagia (swallowing problems) withdysphasia(difficultyinspeaking).
• Ifthepersonshasapaidcarer,youshouldgetthisinformationfromthepersonscareplan,youcouldalso lookat letters fromHealth/SocialWorkprofessionalscorrespondence.
• Please include information about the specific health needs forexamplediabetes,epilepsy,respiratoryconditions.
• Ifrequired,youcangiveadditionalinformationonNotespage.
Risk• Peoplewithlearningdisabilitiescanbeatriskofaccidentsandinjuries
occurringwheninhospital.• Inorderforhospitalstafftosupportandkeepanindividualwitha
learningdisabilitysafeitisimportanttheyknowaboutanythingthatmayposearisktothepersoni.e.falls,wandering,aspirationetc.
• Pleasetickappropriatebox,youcantickmorethanonebox.IfyourequiretogiveadditionalinformationpleaseuseNotespage.
Tissueviability• Some people with learning disabilities can have problems with
pressuressores, theycanbruiseeasilyorcanhaveskinormedicalconditionsthatmakethemsusceptibletoskinproblems.
• Tissue viability can include pressure ulcers (bedsores), putting onbandages, or other issues concerning the health of the person’sskin.
9
• Pleaseticktheappropriateboxorboxesandclearlymarkanyareasofconcernonthediagram,youcanalsogiveabriefdescriptioninthespaceprovided.
• If you require to give more information please do so on Notespageforexampleindicatetheneedforpressuremattressesorsleepsystems.
Eatinganddrinking• Some Individuals with learning disabilities are at increased risk of
havingeating,drinkingandswallowingdifficulties.• Pleaseindicateasaccuratelyaspossiblewhatthepersonseatingand
drinkingneedsare.• Some people require to have their food and drink prepared to a
certainconsistencyanduseadaptedcrockeryorcutlery.• Otherpeoplerequirefullphysicalsupportwheneatinganddrinking.• Somepeoplewithlearningdisabilitiesrequiretobehavetheirfood
anddrinkthroughanasogastricorgastrostomytube,pleaseinformthestaffofthebestwaytohelpthepersonwiththis.Forexamplethepersonmaybeabletohavesmalltastersoffood.
• Somepeoplemay have routines aroundmeals times for exampletheyeatwithaspoonoreatfoodinaspecificorder.
• Thisinformationshouldbeinthepersonscareplan.
10
Activitiesofdailyliving• This is a snapshotof the things that youdo for someone tohelp
themlivetheirlife.
Mobility• Some people with a learning disability require help with their
mobility.• Usethespaceprovidedtohighlightthehelpthepersonneedsto
getabout.• It is important to ensure that any aids e.g. wheel chairs, walking
framesetcgointohospitalwiththeperson.• Please also consider any issues that may impact on the persons
mobilitye.g.footcare,posturalmanagement,theenvironmentetc
Personalhygiene• Somepeoplewithlearningdisabilitiesrequirehelptomaintainand
maximisetheirpersonalcare.• Using the spaceprovided indicatewhathelp thepersonneeds to
wash, dress and clean themselves this can be in the morning orduringtheday.
Toileting• Thiscanincludeincontinence,constipationortheuseofcontinence
garments(pads)andcatheters.• Please note any help the person needs to use the toilet, this can
includeproblemswithincontinence,constipationorwalkingtoandusingthetoilet.noteifthepersonmayneedacommode.
Sleeproutine• Pleaseindicateanysupportneedsorroutinesthepersonhas.
11
• Arrangementsfordischarge» Pleasegivecontactdetailsofcarer,typeoftransport,amountof
noticerequiredandanypostdischargemedicationneeds.» Trytokeepinformationsuccinctandaccurate,ensurethecontact
personincontactableevenatnighttime.• Additionalinformation
» Specific health needs, lack of information and communicationbarrierscanimpactontheeffectivecareforpeoplewithlearningdisabilitiesinhospital.
» Itisimportantthatweprovideaccurateandreliableinformation.» Please use this section to cover things like emotional and
behaviouralsupport,thepersonsroutines,likes,dislikesandhowandwhenthepersonpreferstosleep(sleeppattern).
» This page can be used to offer additional information it mayincludesignpostingtospecificsupportplans
» Previoushospitaladmissions» Recentmedicaltestsandwhentheywerecarriedout» Anyfearsorphobiasforexamplegettingbloodtaken,anymedical
interventionssuchashavingacanularinserted.» Risksaroundpullingoutlinesandtubes.