NICE Guidance for adults (NG 11) Challenging Behaviour and Learning Disabilities : prevention and interventions for people with learning disabilities whose behaviour challenges, published in May 2015 and updated in January 2017, recognises that the environment may be a factor in triggering challenging behaviour, and that adjustments or adaptations to the physical environment may be needed, and considered, as part of an overall strategy to manage behaviour.
The Safe Home Environment Assessment Tool (SHEA) and planning process was developed by a group of Occupational Therapists as a pragmatic response to the Transforming Care agenda (NHS England 2015) to support the move of people with autism and learning disabilities from inpatient hospitals in to safer and more suitable community accommodation due to the lack of alternative planning tools that addressed the physical environment.
The SHEA is a process, which consists of;
- A referral-screening tool which helps identify who may benefit from having an assessment completed.
- The Safe Home Environment Assessment tool.
This helps identify high-risk behaviours that need to be considered as part of the planning process but also recognises individual sensory issues that may be triggers within the environment AND any individual preferences that need to be considered to make this feel like a home for the person who will live there.
- A site visit tool which matched identified risk issues with the proposed placement
- A “Live” solutions guide which has useful links to adaptations, guidance, fixtures and fittings so that the individual therapist or team can reduce time spent looking at solutions.
The aim of the tool is to help identify common risk behaviours that need to be considered when planning future accommodation options such as highly destructive behaviour, hygiene issues, absconding risks and sensory preferences, which need to be considered to minimise distress, and support dignity and independence. The tool is one component of creating a capable environment, but by identifying potential risk issues early in the planning process, it can help with the design of resilient personalised home environments within the local community that can reduce the risk of placement breakdown, and re-admission to inpatient facilities. We are also interested in the potential emerging link between the physical environment in the restraint reduction initiative and if we can design a home that feels safe for the individual this may be a component in this initiative.
Aims and objectives
NICE guidance - NG11 (2015) recognises that the environment might be a factor in the trigger of challenging behaviour and recommends that physical adaptations should be considered as a strategy to manage this.
Currently, there is a lack of research and tools that help with planning and adapting the physical environment to deflect potentially high risk challenging behaviour whilst considering individual preferences and choices in a meaningful way.
The SHEA uses a likert measuring scale and contains a list of potential risk behaviour statements which need to be considered as part of the planning process.
There is an additional section which reflects sensory preferences that need to be considered such as need for space, noise minimising strategies or features that will help make the property feel like a home whilst minimising potential risk issues.
The tool has been helpful for those individuals who:
- may have had extended periods in a inpatient facility
- who may not be well-known to the local clinical team who are required to provide advice as part of the process of identifying possible properties and then matching identified risks with a detailed site visit tool to help minimise risk issues.
Though the tool was initially developed in response to the Transforming Care agenda it is now being utilised in planning transition placements for adults with challenging behaviour whose behaviour may lead to risk of placement breakdown.
Reasons for implementing your project
Prior to the development of the SHEA there was a lack of a tools to help with the planning of the physical environment for people with high levels of challenging behaviour. Potentially costly decisions were being made without any robust assessment or planning tools that allowed for multi-agency or multidisciplinary discussion of potential risk issues and how these might be managed or reduced.
The tool operates from the principal of promoting the least restrictive options, being hopeful that by reducing potential triggers to challenging behaviour the team supporting the individual can focus on other more proactive goals to promote independence and choice and provide high quality care to improved life outcomes for a complex and vulnerable group.
A pilot was launched in 2016 which has been revised in the interim period. The initial pilot helped identify the most common high risk behaviours that needed to be considered in the planning process which are now reflected in the current tool.
RAG rating is used to identify the likelihood of certain behaviours occurring.
The introduction of the SHEA is being shared Trust-wide as part of the Transforming Care board and in January 2019 we presented the work so far at the inaugural AHP Autism conference as a practice initiative and we are sharing the tool with other colleagues involved in the transforming care agenda.
Though the current number of individuals in our local transforming care cohort is small we are focused on high cost, high risk individuals where good initial planning around the physical environment can help with long term sustainability and reduce costs associated with need for frequent repairs and damage to a property.
There is potential for the tool to be standardised and implemented at other key points such as when an individual is transitioning between placements to ensure moves are sustainable longer term.
The second stage of the tool is to develop an accessible tool to involve individuals with complex communication needs to be more fully involved with the planning of their home environment.
How did you implement the project
Sussex Partnership Trust Learning Disabilities are using care pathways to deliver support for people with challenging behaviour and the care pathway recognises NICE guidance.
The development of the SHEA was to meet clinical demand for Occupational Therapists (OTs) to provide placement advice in a way that met the defined NICE guidance NG11.
This was a piece of collaborative work initially between a group of Occupational Therapists with the support of colleagues with expertise in positive behaviour support who also have a high level of knowledge about the importance of the physical environment.
Initially, no funding was identified for the project but implementation of the tool in a small number of complex cases helped identify its potential role in the planning process in identifying risks that might have otherwise have been overlooked. We did however have a very motivated group of clinicians who were committed to supporting discharge from hospital who felt that the tool was helpful in clarifying potential high-risk behaviours and looking at solutions to support discharge.
Identified risk behaviours are ranked in accordance with likelihood and frequency of occurrence so that limited funds for building work can be targeted at the most appropriate physical adaptations.
Subsequently, a small amount of money was identified via NHS England to support the development of a solutions guide that accompanies the tool and a "live" tool, which lists possible solutions to address risk issues so that this reduces individual clinical time.
The tool is still being evolved as we gain more examples of its successful implementation in the discharge planning process.
We are planning to collaborate with a colleague at a local university who is planning to do more in-depth work and research as part of the implementation process and also share evidence around the physical environment and restraint reduction so we can learn from some of the emerging evidence in this field.
The process from identifying someone is ready for discharge to the actual move into the community can take in excess of 2 years.
Phase 2 of the project is aiming to;
- Demonstrate effectiveness of the tool once the individual has moved from hospital back to the community.
- Develop an easy-to-read accessible tool for gathering the individual's perspective in the planning process as currently we are reliant on information-gathering from others who know the individual well, such as personal preferences. The goal is to achieve this in partnership with a local learning disability user group.
We are hoping the review of the tool will indicate that for those individuals with high levels of destructive behaviour, the tool will have helped:
- reduce risk of re-admission due to property damage
- carers better manage possible hygiene issues
- planners recognise that addressing sensory preferences will help reduce the distress of the individual
- planners recognise and lessen potential triggers of challenging behaviour
- promote more positive engagement and skills development
Key learning points
The Safe home environment tool was initially developed in response to a lack of guidance and formal tools to help identify and manage risks in the physical environment for individuals with challenging behaviour.
The tool was developed and piloted over a period of 18 months, which gave an opportunity to implement and revise it following practical application. One element which we did not take sufficient account of was time associated with completion of the process, from completion of the initial screening tool, to visiting perspective placements and supporting provider organisations implementing solutions to reduce identified risks.
Due to the complexity of the individuals we have worked with it has also been difficult to involve service users as much as we would have liked in planning aspects of their home but we hope to resolve this with phase 2 of the project.
Part of the success of the tool has been that it has been a process of collaboration and sharing with others involved in the transforming care process. Its practical application with "real life" cases has helped it develop credibility with providers, clinicians and commissioners of services.
We are currently sharing our learning with other trusts doing similar work as part of the transforming care agenda as this will help contribute to our learning on the effectiveness of the tool.