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Intersectional factors: While not explicitly stated, it's possible Ava faces additional challenges at the intersection of being an older LGBT woman. Her isolation could stem in part from experienced or anticipated discrimination.

Cultural competence: The social worker should employ an understanding, non-judgemental approach that is culturally sensitive to Ava's lived experiences and identities. Building trust will be important given her reluctance to accept help.

Asset-based approach: The social worker could leverage any strengths and resiliencies, like past interests in hiking and ornithology, to engage Ava in improving her situation and connecting to supports.

So in summary, the article highlights issues especially relevant for marginalised groups like LGBT elders, and informs culturally-competent, holistic and strengths-based approaches the social worker may take when assisting Ava.

Adams (2016).

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Self-neglect - The condition of Ava's home, with piles of papers, food and garbage, ripped up flooring, and foul smells indicate she is self-neglecting by not maintaining basic hygiene, health and safety standards in her home. This puts her at risk.

Financial abuse - The man banging on her door claiming she owed him money could indicate financial abuse, if he is somehow exploiting her financially. Her dismissing this suggests she may be in denial.

Physical health risks - Her leg injury wrapped in a bandage and using a broom handle as a cane shows health issues that do not seem to be adequately addressed. Her previous health conditions of high blood pressure and diabetes also need monitoring.

Social isolation - The loss of her wife and distant relationship with her brother have left her socially isolated apart from one neighbour. This isolation leaves her vulnerable.

Mental capacity - Her denial of any problems and resistance to help could suggest deteriorating mental capacity that impairs her ability to make sound judgments about her safety and well-being.

Ava exhibits signs of self-neglect, financial abuse risks, untreated physical health issues, social isolation and possible mental capacity concerns - all of which are safeguarding issues. A social worker addressing these risks would be a priority to ensure her safety and prevent any abuse.

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Mental Capacity Act 2005:

If Ava lacks capacity to make certain decisions about her health/care due to physical/mental conditions, the Act provides a structure for acting in her best interests.

It requires service providers to avoid discrimination and enable participation/representation of those lacking capacity. The article suggests Ava's identity and agency must be respected in any capacity assessment.

It establishes advocacy/representation rights to protect those deemed to lack capacity. Ava may need an advocate to ensure her needs and values are upheld within the framework of the Act.

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Care Act 2014:

The Care Act places a duty on local authorities to assess and meet the eligible social care needs of people in their area, regardless of their characteristics like sexual orientation. Ava's situation suggests she may need an assessment.

It emphasises the importance of prevention, well-being and personalisation of care. The article highlights how tailored, identity-affirming support for LGBT elders like Ava can help maintain independence and well-being.

The Act is focused on promoting individual dignity, control and inclusion. The article discusses how traditional care systems often fail to respect LGBT identities, so different approaches may be needed for Ava.

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Inequalities in older LGBT people’s health and care needs in the United Kingdom: a systematic scoping review

The article discusses how older LGBT people may be at increased risk of social isolation, weaker social connections, mental health issues, and difficulties accessing appropriate health/social care that affirms their identity. All of these factors could be impacting Ava.

Ava's situation mirrors some of the experiences discussed, such as living alone after losing her wife, distant family relationships, possible mental/physical health issues impacting independence.

Qualitive studies found themes of heteronormativity, homophobia, invisibility, and denial of identity in social care settings. This compromises older LGBT people's identity and relationships.

Weaker social networks due to minority stress, estrangement from families, lack of children, all increase the risk of loneliness and social isolation, and increase the likelihood of needing formal care, However, it's important to note that the article highlights that formal care environments appear to be the focal point for the inequalities identified.

Social care was identified as exacerbating inequalities and an area needing reform to accommodate diversity.

Respecting Ava's identity as a lesbian woman, Asking sensitive questions and using gender-neutral language to make her comfortable sharing details is only a starting point for mitigate the systemic inequalities Ava may face.

Referrals may be needed for healthcare, better living conditions, counselling/therapy, befriending services, advocacy etc. But Ava should lead in decision-making, this evidence suggests that Ava may not feel comfortable disclosing her identity or history.

Bespoke attention on LBGT-focused elder services for advice/resources tailored for Ava's needs and identity.

The review identifies multiple ways older LGBT health and care needs in the UK experience inequalities, with social care environments emerging as a key area for reform. That said, with the lack of apparent cultural competency, its not surprising that the review highlights both qualitative and quantified data is limited.

Kneale et al. (2019).

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1. Promoting the rights, strengths and wellbeing of people: A social worker should focus on understanding Ava's situation from her perspective, exploring her strengths and what is important to her, while also ensuring her basic needs are met and she is safe.

2. Respecting and promoting human rights and dignity: It is essential to communicate respectfully with Ava, understand her views and wishes without judgement, and ensure her privacy and independence are supported as much as possible given any risks.

3. Working in partnership: Rather than imposing help, the social worker should work with Ava to identify what support she may be open to accepting, building trust over time through open communication.

4. Recognizing diversity and challenges faced: Ava's circumstances suggest possible vulnerabilities related to isolation, health issues and past trauma that may inform a non-judgemental, empathic approach.

5. Accountability and use of evidence/professional judgement: Any decisions need to balance risks with Ava's autonomy and preferences, using assessment of the situation and professional expertise. Clear documentation is important.

6. Upholding ethical standards: Protecting Ava from potential harm or exploitation while respecting her independence and privacy would require navigating complex issues ethically.

Social Work England (2019)

Its important to consider that if the social worker does not fully involve Ava in decision-making, acts too hastily based on third party information rather than taking time to understand her perspective, or fails to maintain privacy and earn her trust. This would disempower Ava, and they would be in direct conflict with the standards.

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1. Human rights and dignity: Ava's living conditions do not appear to uphold her basic human rights to adequate shelter, sanitation and safety. The social worker must consider her well-being and empower her to make changes that respect her dignity.

2. Self-determination: Ava has expressed not wanting help or "charity", so the social worker must respect her autonomy while also ensuring she can make fully informed decisions. Gentle engagement and explanation of available support options may be needed.

Social workers risk an overly paternalistic approach that could be seen as oppressive.

3. Risk assessment: Ava's injuries, vulnerable living situation and possible financial exploitation raise safety concerns. The social worker should assess risks in partnership with Ava, while respecting her right to take reasonable risks.

By failing to address these issues properly, would put Ava's human rights at stake.

4. Confidentiality: Information about Ava's sexuality, family estrangement and health issues must be kept private unless she consents to sharing.

5. Empowerment: The social worker should focus on Ava's strengths and explore empowering solutions respecting her preferences, rather than focusing only on problems. Community connections and history indicate resilience that could be built upon.

Focusing too much on risk and problems can undermine the principles of empowerment and respect.

6. Transparency: The social worker must be open about their role and any limits to confidentiality. Regular communication, respect and understanding are needed to establish trust.

Not fully explaining the role, limits to confidentiality and available support options limits Ava's ability to make truly informed choices and lacks transparency.

BASW (2021).

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Ava lead's the assessment and support planning process as much as possible, her needs, wishes and outcomes are the primary focus.

Take time to listen to Ava and facilitate her communication in a way that works best for her. respect her preferences around who else, if anyone, she would like involved.

Ava is the expert in her own life.

Support Ava to manager her own risks wherever possible, promoting her independence and choices. Aim to prevent issues.

Provide Ava with information about any support options available, whether to not she qualifies for formal services, so she can make her own decisions about what she believes is most suitable.

The social worker needs to place Ava's agency and autonomy at the centre of all interactions.

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How to make it person-centred for Ava

Establish trust and rapport through empathetic and active listening. Give Ava space to share her perspective without judgment.

Focus on understanding Ava as a whole person by learning about her values, interests, relationships and background.

Respect Ava's autonomy and right to make her own decisions. While safety concerns exist, engagement rather than coercion is ideal.

Inquire sensitively into Ava's current functioning and well-being without making assumptions. Use empathetic reflection to demonstrate care for her situation.

Explore Ava's desired outcomes and what support, if any, would respect her independence and wishes rather than impose the social worker's agenda.

Adopt a strengths-based perspective to identify Ava's capabilities and existing relationships that could aid well-being rather than focus solely on risks and deficits.

Maintain an open, patient and non-pressuring approach to build understanding and trust over time rather than expecting immediate disclosure or change.

Social worker should make themselves genuinely available as a support resource for Ava to consider without judgment if she declines assistance at this point.

Maclean (2020).

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Its important to develop a trusting relationship through using our 'personal self' to connect with Ava.

Establishing rapport will be key to addressing her needs and resistance to accepting help. Ava appears very isolated and reluctant, so developing the 'personal relationship' aspect may be challenging and take time.

Maintaining clear boundaries between the 'private, personal and professional' self is important to gain Ava's trust. The practical application of this model would require sensitivity to Ava, as a unique individual with her own history and situation.

Reflecting on how the different 'selves' might be in conflict, might help the social worker identify and navigate any tensions between professional responsibilities towards Ava and personal values around independence/ choice.

Ava's living conditions and self care concerns suggest deeper rooted issues that a relationship based approach alone may not fully address. Additional support services are likely to be needed.

Whilst the model provides a good starting point it must be adapted flexibly to Ava's specific needs and circumstances in a compassionate, person-centred way.

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When assessing Ava's living conditions and the other concerns raised, be cautious not to over step boundaries.

Ask non-intrusive questions to gather more information about changes in her functioning or well-being over time to assess needs.

Respect her right to decline answering too!

Explore Ava's support network and independence with daily activities. With consent and involvement to empower her decision making about any assistance offered, a referral to social prescriber's - a community support service, to explore the connection with the community to mitigate the isolation risk factor.

Access to healthcare is important, sharing concerns with GP and diabetes clinic, consider full medical assessment. Chronic conditions like Ava's, if not managed well, could impact her functioning over time.

The prominent photo of Ava and her late wife suggests she may still be grieving this major loss. Unresolved grief could contribute to behavioural changes and/ or isolation.

Explore willingness to engage with a mental health referral.

Environmental Health could help improve home conditions

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Any support or decisions made for Ava must be the least restrictive of her basic rights and freedoms.

Formal intervention like guardianship should only be considered if less restrictive options are ruled out (Social Care Institute for Excellence, 2017).

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Capacity refers to specific decisions at specific times, not general capacity. Ava's capacity to make smaller day to day decisions maybe in tact, however, she may lack capacity regarding decisions around accessing help or services.

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Capacity must be presumed unless established otherwise. From what is described, it appears Ava may lack capacity with decisions regarding her health, safety and welfare. However, a social worker must formally assess her capacity (Social Care Institute for Excellence, 2017a).

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relationship-based practice - Developing a trusting, empathetic and non-judgemental relationship would be paramount so Ava feels heard, understood and comfortable sharing what help she may need/want.

strengths based perspective - Rather than focusing solely on problems and risks, seeking to identify Ava's strengths, capabilities, values and resources would be a starting point. (Maclean and Harrison, 2009/2015).

person centred care - Placing Ava's own perspectives , wishes and preferences at the centre to ensure care and support is provided in a way that respects her humanity and individuality.

empowerment theory - The goal would be to empower Ava by supporting her autonomy, dignity and self-determination, working at her pace and involve her in all decision making. (Maclean, 2020).

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Best interests: any act done or decision made for, or on behalf of, a person who lacks capacity must be done or made in his or her best interests, British Medical Association (2019).

A primary consideration.

As an elderly adult who may lack capacity to make decisions about her welfare and care due to her living conditions and refusal of help. Allowing Ava to remain without help is unlikely to be in her best interests.

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Interaction Institute for Social Change (2016)

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Repeal of section 28 - 2003

15 years of vulnerability due to her sexual orientation.

Equality Act 2010 - Protected by law at 54 years old.

The Marriage (Same Sex Couples) Act 2013 introduced same sex marriage in England and Wales. - Able to marry her partner at aged 59.

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Impacts - these need to be understood in historical context.

Left home at 16, due to conflict regarding her sexuality.

Ave may have lack of trust in services due to living in a time when they were not protective of LGBTQ+ people under Sec28.

Ava lived with her partner Sydney for many years, this act was only repealed in 2003, they wouldn't of been recognised or supported in law or by local services during that time, making them vulnerable.

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Social Care Institute for Excellence (2014a)

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Ava's needs arise from physical and/or mental impairments or illnesses - she has high blood pressure, type 2 diabetes, struggles to answer the door and is using a broom handle to walk, indicating physical/mobility issues.

Ava is unable to achieve multiple specified outcomes without assistance - such as maintaining a habitable home environment (there is rotten food, ripped up flooring, piles of papers/dishes), managing personal hygiene given the odour of urine, and maintaining nutrition given the state of her kitchen.

This is having a significant impact on her well-being - she appears isolated as her friend hasn't seen her in months, she lives in unsanitary conditions, and refuses help despite clear needs.

Ava's health conditions are causing inability to care for herself/home autonomously, meeting the eligibility criteria under regulations 2(1)(a)-(c) and 2(3). The local authority would have a duty to offer care and support to meet her needs under sections 18 and 20 of the Care Act 2014.

The Care and Support (Eligibility Criteria) Regulations (2015).

Holistic assessment still needed.

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Importance of relationship with 'friend'

Potential role for neighbour Alisha, however, more details would be needed, and if so, Alisha's ability to sustain that role and any impact on her well-being and outcomes would need to be assessed.

Alisha may be an informal carer and form part of Ava's support network.

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Shifting away from deficits and problems towards recognising the knowledge, skills and abilities that Ava and her community already possess. Ava is the expert in her own life. Intervention should building on her existing strengths and capacities. This strengths-based lens is meant to promote empowerment, resilience, and independence. There is a lack of clarity around how to apply this approach in practice, especially when balancing risks.

Personal -

Ava has past independent living skills - however currently physical health and living conditions are deteriorating.

Long history of community and social engagement - now appears isolated.

Community -

Supportive neighbour Alisha - potential fractured relationship due to drift over the last 5 years, however, Alisha does state she wants to help.

Potential for local services/ support groups - the key will be gaining Ava's trust and presenting options positively as helping her maintain her independence. Her interests in hill walking, ornithology and football could provide a way to reconnect with her strengths and interests.

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Physical Needs

Injury to leg that needs bandage

Using broom handle as crutch suggests mobility issues

Unsanitary and unsafe living conditions

Mental Health Needs

Isolation from friends and family for many years

Refusal of help, could be pride and/ or mental health issues

Social Support Needs

Lost contact with her only brother due to family argument

Lost her wife Sydney 5 years ago and became distant from friend Alisha since then

No longer socialises with Alisha or participates in hobbies they previously shared.

No other friends or family checking on her wellbeing.

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Focus on the outcome for Ava by utilising person led decisions and support. (Local Government Association, 2023).

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Wellbeing - appears compromised for Ava, the social worker should endure her well-being is promoted, taking into account her views, feelings and wishes.

Person-centred care - person-centred assessment and care planning, any support must be based on Ava as an individual, inclusive of her history, preferences and relationships. Understanding her background could help to engage her with services.

Early intervention and prevention - an opportunity to prevent further decline for Ava, the local authority should take steps to prevent Ava's needs becoming more serious.

Proportionately - responses need to carefully consider her circumstances, and not be too intrusive.

Participation - all decision making should include Ava, she needs to be fully involved in any assessment and care planning.

Protection from abuse and neglect - Ava's living situation, with rotting food and the risky situation around the gas stove, raises safeguarding concerns. The social worker must make sure she is protected from harm.

Fundamental principles - respect, dignity, choice and control - Ava's wishes should be respected where possible, but her rights, dignity and autonomy may need protection if her ability to make decisions is impaired. Control and choice should be maximised within safeguarding boundaries.

Department of Health and Social Care (2023).

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Neglects and acts of omission - Ava seems to be neglecting her own self care and home care.

Evidence - unclean flat, smell of rotting food, bandaged leg suggests neglect of a medical issue.

Self-Neglect - Ava is not allowing help from the social worker or neighbour and and appears unwilling to acknowledge issues with her living conditions or health.

Psychological Abuse - The disconnection from her brother and pasts suggest possible historical

psychological abuse. Her hostility towards help now could also indicate current psychological issues.

Financial or Material Abuse - the man banging on the door claiming ever owes him money raises the potential for financial abuse or exploitation

Physical Abuse - the bandages leg raises questions about how that injury occurred, and if there

was any physical abuse involved.

Discriminatory Abuse - a lesbian woman who left home at a young age after an argument about her sexuality, may have faced past discriminatory abuse, that still impacts her distrust of others.

Department of Health and Social Care (2023).

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Defines “wellbeing” to include “protection-from abuse and neglect”

Wellbeing needs to be promoted

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The Care and Support Statutory Guidance 2017

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The Care and Support Statutory Guidance 2017

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Social Work Ethics, Values and Professional Standards

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Social Work Ethics, Values and Professional Standards

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Empowerment

Prevention

Proportionality

Protection

Partnership

Accountability

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Article 2

Right to life

Her untreated medical conditions like high blood pressure and diabetes, combined with unsanitary living conditions, pose risks to her if properly assessed and managed. Self-neglect could potentially lead to life threatening situations without support.

Article 3

The right to freedom from inhumane/ degrading treatment.

Ava's unsanitary conditions, with rotten food and urine smells could amount to this, if allowed to continue without intervention. Her physical and mental health needs appear neglected.

Article 8

Right to privacy and family life.

This should be respected by public authorities.

Ava's living conditions raise concerns about her ability to maintain a private life with dignity. She may require support to live independently that respects her privacy and autonomy.