Integrated Children’s Disability Service (OT) - Guidance for Recommending Minor and Major Adaptations

• A minor adaptation is a scheme of work completed under section 2 of the Chronically Sick and Disabled Persons Act 1970. The upper limit for a minor adaptation is currently £1000 (works costing above this amount are considered major adaptations);
• Minor adaptations in Local Authority and Housing Association properties are funded by those organisations and are subject to those organisation’s policies;
• For minor adaptations in privately owned or privately rented properties, Nottinghamshire County Council contributes to the Integrated Community Equipment Loan Service (ICELS), a Partnership between Health and Social Care across Nottingham City and Nottinghamshire County. Since 2011 the British Red Cross have been commissioned to provide the service. Some minor adaptations services are contracted out by the British Red Cross;
• As part of the ICELS contract there is a range of ‘standard’ minor adaptations that can be ordered from a catalogue. If standard stock minor adaptations are assessed to not meet the child’s needs, it is possible to request alternative minor adaptations by obtaining a quotation through ICELS.

• A major adaptation is a scheme of work costing over £1000 (works costing less than this amount are considered minor adaptations);
• Major adaptations in Local Authority and Housing Association properties are covered by those organisation’s policies, though a Housing Association may request that ICDS-OT refer for a Disabled Facilities Grant;
• Major adaptations in owner occupied and privately rented properties are funded through a Disabled Facilities Grant (DFG), awarded by the local Housing Authority (District/Borough Council) under part 1 of the 'Housing Grants, Construction and Regeneration Act 1996'. A DFG is awarded when the District/Borough Council (the 'Grants department') are satisfied that the relevant works are "necessary and appropriate to meet the needs of the disabled occupant", AND "reasonable and practicable to carry out the relevant works having regard to the age and condition of the building" In considering which works are ‘necessary and appropriate’ the Grants department should consult with ICDS-OT;
• A DFG is available for essential adaptations which will make it possible for a disabled child to remain living at home or to ensure that they are cared for safely. Adaptations must be for the main or permanent residence. The purposes for which a grant may be given are listed in legislation and includes:
  • Improving access for a child into and out of their home by, for example, widening doors and installing ramps;
  • Making the home safe for the child and other persons living with them;
  • Improving access to the main family living room;
  • Providing or improving access to the bedroom, toilet, washbasin and shower (and/or bath) facilities;
  • Improving access to facilities for food preparation and cooking;
  • Improving or providing a heating system which is suitable to the needs of the disabled child;
  • Adapting heating or lighting controls to make them easier for the disabled child/young person to use;
  • Improving access to and from the garden, where feasible.

• Restrictive interventions include adaptations such as stairgates, door gates, stable doors, locks on doors, monitoring systems;
• Restrictive intervention should only be used when absolutely necessary, in accordance with the law and clear ethical values and principles which respect the rights and dignity of children, and in proportion to the risks involved. Behavioural management should always be used in the first instance to try and avoid the need to employ a restrictive physical adaptation;
• A Restraint Risk Assessment should be completed in cases where a restrictive intervention is being considered.

For children who use two addresses (for example shared care arrangements), an assessment of the second address can be offered. However, any intervention at a second address is considered on a case by case basis. This policy is currently under review.

This is a level car parking area with access from the road.

1. Hard standing will not be provided to prevent car vandalism;
2. Will not be considered in place of parental supervision appropriate for the developmental age of the disabled child;
3. Hard standing will not be provided as a result of families having difficulty parking a car outside their property;
4. For those with challenging behaviour, provision will be considered as part of a behavioural management strategy and an understanding of how safe vehicle transfers are managed in the wider community;
5. For those with challenging behaviour, provision will only be considered if behavioural management strategies have been exhausted;
6. Although ICDS-OT may assess for and recommend that a kerb is dropped to the local council, permission to proceed is required from the Highways department, who may not approve the request. A hard standing cannot be provided unless a dropped kerb is also provided as it is illegal to drive a vehicle over a footway without a dropped kerb.

Consider:

• The child is dependent on their vehicle to get out. A clearly defined need for car journeys must be discussed and the service user should be unable to walk or have considerable difficulty in walking due to a permanent and substantial disability;
• The disabled child has little awareness danger/road safety and where no alternative arrangements can be made;
• Developmental age against chronological age;
• Very young siblings;
• Behavioural strategies.

Statutory Instrument 2008 No.1189 adds to the list of mandatory works:

1. Facilitating access to and from a garden by a disabled occupant; or
2. Making access to a garden safe for a disabled occupant.

Access does not imply that the recommendation would include for the provision of patios, drying areas, terraces, raised beds or the whole garden.

• Recommendations may include access to existing areas, where this is considered reasonable and practicable
• Access will not be considered for the purpose of therapy.

This includes grabrails, handrails by a path, half steps, and shallow steps.

1. Only one entrance will be considered for adaptation unless there is a clearly defined need. For example, the need for a child to have independent and safe access to garden facilities;
2. Handrails by a path will be considered where the child is unable to manage a slope or steps, or needs a guide rail as a result of their disability;
3. Path widening will be considered where the child uses a wheelchair or walking aid, or needs support to walk from another person;
4. Adaptations will not be provided solely for a fire exit.

Consider:

• Height and diameter of rail;
• Does child use a walking aid;
• Will provision improve child's potential for independent mobility? Ideally a child would use their prescribed walking aid to support their walking wherever possible.

Only one entrance will be considered for adaptation unless there is a clearly defined need.

1. Only the entrance which is the easiest, most appropriate to need and most cost-effective will be adapted.
2. A ramp may be considered if a child’s mobility is dependent on the use of a wheelchair or anyone caring for them is at risk from the current method of access. For example, a ramp would not be provided if family can safely negotiate a wheelchair up and down small steps.

Consider:

• Is a ramp the safest option? If the child occasionally walks with a frame or prosthetic limb, consider shallow steps or a ramp with steps;
• Which type of ramp is most suitable?
• Is the ramp to be fitted on communal steps and how will this affect other people?
• Will the permission of anyone else be needed before the work is done?
• Is the door threshold level or, if not, can it be adapted/replaced?

May be considered if the guidelines for a ramp have been met but there is insufficient space for the provision of a ramp of the appropriate gradient and the child is unable to walk up and down steps, for example, where there are a number of steep steps to reach the property.

Consider:

• Does the person using the lift use a wheelchair or are they able to walk?
• Is outside lighting and power supply needed?
• Will the lift be at risk from vandalism or misuse?
• Ongoing servicing/maintenance costs.

1. Changes to doors, doorways or hinges may be considered where the child is unable to get through the doorway to access essential facilities, or family need to access a child (e.g. in event of a seizure);
2. A door handle may be re-positioned, changed or provided to promote independence, for example changing a doorknob to a lever handle;
3. An additional external door for fire escape purposes will not be provided through social care but will be at the discretion of the local District/Borough council.

Consider:

• Construction of door (glass, wooden, UPVC);
• Style of door (swing, pivot, slide);
• Width of doorways and suitability for the future;
• The impact on other members of the household;
• Removal of the door;
• Door furniture (hinges, kick plates, hand plates);
• Hinges and door swing.

Stairlifts will be considered where essential facilities are not available on the ground floor. They will not be recommended where a child has access to a suitable bathroom and toilet downstairs and where there is adequate and appropriate space to sleep, having taken into account the accommodation needs of the family, the age of the child and anyone else caring for the person.

They will not be recommended if the provision will be detrimental to the development of the child’s independent mobility (liaison with appropriate health colleagues will be required).

Consider:

• Is it possible for the child to sleep downstairs?
• Is the child unable to manage the stairs?
• Is the child or family at risk from the current method of using the stairs?
• Are the stairs suitable for fitting a stairlift? Is a hinged track required? (Seek advice from stair lift reps);
• Does the lift need to be in immobilised when not in use, for example if there are other children in the household who might play with it?
• Is the child user able to use a stair lift? Do they need to try a stairlift?
• Is the child able to get on/off a stairlift independently?
• Is there space for safe transfers at the top and bottom of stairs?
• Does the child have a disability that contraindicates the use of a stairlift? Complete a risk assessment if needed (e.g. if a child has uncontrolled movements or epilepsy);
• Would a vertical lift or ground floor facilities be a better long-term solution?
• Is there room for other family members to use the stairs safely?
• Are there pets which might be at risk?
• Ongoing servicing/maintenance costs;
• Type of controls that are needed for example joystick, push button;
• Supportive seat/safety harness.

May be considered if the child is unable to manage the stairs.

1. Access to essential facilities is not available on the ground floor;
2. A stairlift has been considered and is not appropriate. For example, the child uses a wheelchair or would be unsafe using a stairlift;
3. A stairlift is likely to be inappropriate in the future. For example, the child’s condition is likely to deteriorate.

Consider:

• Can the child enter and leave the lift independently?
• Could family get the child safely in and out of the lift?
• Does the child need a padded lift car, for example do they have epilepsy?
• Does an alarm or telephone need to be fitted as the child is using the lift alone?
• Is there enough room for a lift to be fitted? If there is insufficient room, is it possible to install an external lift shaft or would ground floor facilities be more appropriate?
• Have the needs of the rest of the family been considered?
• Are the facilities to be reached upstairs adaptable, for example, the bathroom and doorways?
• Could a lift be viewed or tried?
• Behaviour. Is an enclosed lift needed?
• Will the size of the lift accommodate a larger wheelchair if needed in the future?
• Ongoing servicing/maintenance costs.

1. Delivering Housing Adaptations for Disabled People – A Good Practice Guide (updated 2015) states that “Where most of the cooking and preparation of meals is done by another household member, it would not normally be appropriate to carry out full adaptations to the kitchen. However, it might be appropriate to carry out certain adaptations that enable the disabled person to perform minor functions in the kitchen, such as preparing light meals or hot drinks”;
2. May be considered when it is assessed that a child may achieve a level of self-care and independence skills;
3. It is the responsibility of the family to provide their own kitchen appliances.

Consider:

• Is the child dependent on a wheelchair and requires extra space for manoeuvring?
• Is there a requirement to facilitate care of the child by a single carer for supervision purposes?
• Are lever taps/tap turners an alternative to moving the sink?
• Do power points require moving in order to give access?

An automatic door opener that allows a child who uses a wheelchair independently to independently access and egress rooms.

Consider provision if the need is permanent and long term and where the child will achieve a significant level of independence e.g. ability to access and egress the property independently.

Consider:

• How the door opener will be operated/controlled – may require referral to EATS service (see Electronic Assistive Technology);
• Type of automatic door opener required;
• Space - consideration for door swing;
• Where independent access is a need and not a preference;
• Ongoing servicing/maintenance costs.

The Electronic Assistive Technology (EAT) service provides environmental control systems and alternative means of computer access for children with complex disabilities. Basset law is covered by the Barnsley hub and the rest of Nottinghamshire is covered by the Derbyshire hub.

Equipment that is controlled via an environmental control system but affects the structure of the building would be funded through the adaptations process. This includes door, window and curtain opening mechanisms and electrical/joinery work needed to facilitate installation.

This includes adaptations such as stable doors, gates at door, stair gates, repositioning door handles out of reach, locks on the outside of doors including specialist locks such as fingerprint locks etc.

1. May be considered as part of a behavioural management strategy;
2. Will not be considered in replacement of parental supervision;
3. Restraint risk assessment should be completed.

Consider:

• Safeguarding & restraint;
• Purpose of the provision and whom this is for;
• Siblings;
• Environmental risks;
• Purpose of the provision and whom this is for;
• Height and position of gate;
• Child’s ability to climb; construction/footholds;
• Method of fixing and closing; child’s ability to access/open this;
• Environment;
• Construction of door – (Glass, wooden, upvc);
• Width of doorways – suitability for future;
• The impact on other members of the household;
• Removal of the door;
• Door furniture – (hinges, kick plates, hand plates);

1. Window locks, jammers and restrictors will not be provided for security or vandalism reasons;
2. Will not be provided in replacement of parental supervision;
3. Window grills and shutters will not be provided.

Consider:

• Safeguarding and restraint;
• Fire risks;
• Locks vs jammers vs restrictors;
• Purpose of the provision and whom it is for;
• Siblings;
• Ventilation;
• Rooms to be fitted in.

1. Will not be provided for the purpose of security or vandalism;
2. Will not be considered where existing fencing or gates would meet the child’s needs but are in a state of disrepair;
3. Will not be considered to keep other children and/or dogs in or out;
4. Fencing and gates will not be provided in replacement of parental supervision. e.g. if and when fencing or a gate has been recommended parental supervision relevant to the child’s developmental age would still be an expectation to ensure the safety of the child;
5. Provision may be considered when the child is unable to understand danger and is at risk of injury due to wandering off the property and when alternative solutions are not practical;
6. Either provision may be considered in order to create a safe space for the child, for the whole garden or whereby a part of the garden is sectioned off;
7. Will be considered when high fencing and/or high gate is already in situ but the child continues to be able to climb over and leave the boundaries of the property;
8. Ironmongery will be provided for the purpose of the child’s disability and not for security reasons.

Consider:

• Safeguarding and restraint;
• Purpose of the fencing and whom it is for;
• Footholds;
• Height and construction;
• Planning restrictions;
• Siblings;
• Behaviour management;
• Garden levels/layout;
• Boundaries – whom they belong to.

A safe area is a safe environment for someone who may need it as a result of their disability.

A calming space is used as part of a behavioural management plan to allow a child to calm if in a heightened state.

Neither safe areas nor calming spaces are a substitute for parental supervision.

Both safe areas and calming spaces can be created with room padding, a ‘SafeSpace’ or other solutions.

A Restraint Risk Assessment should be completed.

1. Provision is normally considered as part of a behavioural support programme to address the challenging behaviour in the long term;
2. Will not be considered where provision will inhibit the independence of the child e.g. by preventing a child independently accessing a toilet;
3. Will not be considered as an alternative to parental supervision appropriate to the child’s developmental age;
4. Provision will be considered as part of a behavioural management programme;
5. If provision is made, this will be subject to review and may result in the removal of the provision if it is assessed as no longer being appropriate;
6. Provision will be considered when a safe area is required on a temporary basis;
7. Provision maybe considered to provide a calming area, when all other options have been explored.

Consider:

• Safeguarding and restraint;
• Siblings;
• Purpose of provision and whom it is for;
• Fire risks;
• Anticipated length of time to be used;
• Behaviour management;
• If a SafeSpace, made to measure or off the shelf;
• Flooring;
• Lighting;
• Room to be used in and furniture;
• Windows;
• Review.

Sound proofing of a wall adjoining another property will be considered if a child with severe challenging behaviour is causing /or is likely to cause a breakdown in community relationships. This to be considered as either a part of a behavioural management strategy to enable the child to remain at home or when the child with severe challenging behaviour has undergone a behavioural management programme but continues to frequently disturb the neighbourhood with making exceptionally loud noises.

Consider:

• How the child would be heard if requiring attention;
• Use of monitoring system;
• Rehousing;
• Carpeting the wall;
• Would the provision of soundproofing have an effect on the child’s safety and wellbeing in terms of being heard by family.

Will be considered when the need is long term and permanent.

Consideration should be given when the child is unable to reliably and consistently weight bear for an assisted transfer and/or is totally dependent on family for all transfers.

Will be considered when family are finding it increasingly difficult to either lift a child or assist with transfers.

Will be considered to promote child development through floor play.

Will not be considered to aid transfers just for physio exercises.

Consider:

• Room to room transfers and transfers within a room;
• Need for single track, turntables or H hoist system;
• New build or existing dwelling;
• Ceiling and wall structure (spacing of ceiling joints);
• Door headers;
• Double hinged doors;
• Manual or electric traverse;
• Height of ceiling/height of lift for clearance;
• Potential weight of child;
• Spreader bar design;
• Bed position – present and future.

1. Running costs will not be considered as a reason for changing heating systems;
2. Will not be considered simply as a replacement for an existing heating system that is in a poor state of disrepair;
3. May be considered to promote a child’s independent use of heating appliance;
4. Only rooms which are used by the child for significant periods of time should be considered for additional heating;
5. May be considered where a child has limited thermoregulation as a result of their disability;
6. May be considered where a child is unable to recover themselves during the night and where a family’s rest would be disturbed.

Consider:

• Government-funded schemes for improving heating systems;
• Local District/Borough council home improvement schemes;
• Control of heating – involves the adapting the controls of existing heating;
• Will the provision of adapted controls allow/promote the child to achieving a greater level of functional independence and has the provider of gas/electricity been consulted regarding possible adaptations to controls?
• Type of heating required;
• Will the existing boiler tolerate additional radiators on the system?
• The provision of an independent heating appliance, for example, an electrical wall.

1. Can be provided only where a raised toilet seat has not been deemed appropriate and where increasing the height of the toilet will enable the child to get on and off independently;
2. Can be considered if the increase in height is required for the successful use of equipment over the toilet.

Consider:

• Needs of other household members;
• Has the overall required height been considered?
• Could a change in height affect transfers from other equipment e.g. a wheelchair.

Can be considered for those children who have a condition that results in limitations to their height e.g. achondroplasia, and where such provision will enable them to complete toileting independently.

Will not be considered where difficulties with standard height toilet transfers are short term because of the child’s height and provision would not meet their long term requirements as they grow.

Consider:

• Needs of other household members;
• Could a change in height affect transfers from other equipment e.g. a wheelchair;
• Would equipment e.g. steps, meet the need?

Any consideration for provision of the above for those who present with challenging behaviour should be considered only after appropriate behavioural management strategies have been implemented or as part of a behavioural programme.

1. Will not be considered as a result of a child refusing to access a toilet, and a behavioural management programme has not been implemented;
2. Will not be considered simply as a replacement if the existing toilet is in a poor state of disrepair;
3. Will be considered when the existing toilet cannot be accessed safely or independently due to the child’s disability, or if an outside toilet is not considered to be appropriate;
4. Will be considered when assisted or supervised access is unsafe or difficult due to space limitations, placing both child and family at risk;
5. Will be considered when installation of a stairlift or vertical lift is not feasible or does not meet the need;
6. Will be considered when continence cannot be maintained by using the existing toilet because the child’s disability prevents them from getting to the toilet in time.

Consider:

• Can access to existing facilities be improved?
• Has medical advice been sought to assist in assessment?
• Is the child likely to achieve continence?
• Has a commode been considered?
• Would it meet the long-term need?
• If living downstairs, is there access to bathing facilities?
• Toileting Programme;
• Dignity;
• Emotional wellbeing of child.

A toilet that can both clean and dry the child eliminating the need to self-clean or be cleaned by someone else.

Consider when a child with restricted movement wishes to have independence in toileting hygiene.

And/or

When a child with limited understanding is unable to achieve personal hygiene skills following toileting and where family would like to move towards a more age appropriate strategy for meeting their toilet hygiene.

And/or

In readiness for the onset of girls’ puberty.

And/or

To allow the child/adolescent age appropriate control, dignity and privacy over intimate care tasks.

1. Only one specialist toilet will be provided where it is not possible to independently maintain reasonable personal hygiene after toileting.
2. Will be considered when a child has had the opportunity to develop independent personal toilet hygiene skills, but their functional abilities remain limited.
3. Will be considered where the provision will allow the child independence in toilet hygiene.

Will be considered to assist family in the completion of personal hygiene tasks if provision will reduce hoist transfers.

Consider:

• Equipment or as part of an adaptation
• Childs upper limb/hand function and therapeutic input from Health to maximise this
• Independent or assisted transfer
• Ongoing servicing and maintenance
• Versatility of ‘douche’ pressure and position
• Size of aperture
• Need for accessories
• Need for a plinth
• Whether bathroom is used by all family members
• The compatibility of specialist equipment, e.g. shower chair, toilet chair. ? need for skirt.
• Position of controls and method of activation. If using an over-toilet chair an alternative to toilet seat pressure sensor will be needed
• Efficiency of different types of toilet seats/inserts

1. Will be considered to assist in maximising a child’s independence;
2. Will be considered as a solution for those children who have continence difficulties or smearing issues.

1. Will be considered to assist in maximising a child’s independence;
2. Will be considered when a child cannot be safely transferred into a bath, or over a bath to use an overbath shower;
3. Will be considered to maximise space within the current bathroom.

A height adjustable bath that is purposely designed for people with disabilities.

1. Will not be considered if a standard bath with adaptations and appropriate equipment will meet the assessed need;
2. Will be considered to facilitate safe moving and handling practice throughout the child’s growth and development;
3. Spa facilities, lighting and sound will not be provided.

Consider:

1. Space and position (can it be islanded);
2. Who will use the bath;
3. Drainage;
4. Combined bath and changing facility or separate;
5. Capacity of water tank;
6. Integral internal handles (could be a contraindication);
7. Weight of the bath – does it affect the floor structure;
8. Internal and external dimensions;
9. Does the child have a disability that contraindicates the use of a bath?
10. Ongoing servicing/maintenance.

A wash hand basin that can be adjusted in height to facilitate access to washing facilities.

1. Will not be considered if a standard wash hand basin fitted at an appropriate height with adaptations and appropriate equipment will meet the assessed need;
2. Will not be considered for those children who do not have the cognitive ability to perform personal care tasks independently;
3. Will be considered for those children whose independence in personal care will be promoted and maintained.

Consider:

• Space;
• Type of taps to be used;
• Electrical supply;
• Type of wheelchair, shower/toilet chair to be used.

To consider when a child has restricted upper body movement which limits their independence and dignity when drying themselves.

Consider:

• Environment – space;
• Controls on the drying unit;
• Ability to stand;
• If to be used in a seated position consider type of shower chair/stool to be used.

1. Will not be considered as a result of crowding;
2. Will not be considered if existing bathroom can be suitably accessed and adapted to meet the need;
3. Will be considered when space limitations in the existing bathroom do not allow the child’s needs to be safely met;
4. When a child’s needs are long term and they will not be able to access the existing facilities in the future;
5. When it is unsafe for family to provide adequate support;
6. When provision will maximise the child’s dignity and independence when other solutions are impractical;
7. When it is considered that direct access to bath/shower room facilities from a bedroom will benefit the child and family positively, for example a very dependent child who requires hoisting.

Consider:

• Growth of child;
• Longer term care needs;
• Space;
• Property layout;
• Bathroom layout;
• Specialist equipment required within the facility, including hoists;
• Shower versus bath;
• Changing area.