Challenging assumptions and improving people’s quality of life within a large social care provider organisation

The project was undertaken with the combined aims of:

• Decreasing the number of individuals and events labelled as caused by ’challenging behaviour’
• Reduce the actual number of ’behavioural’ incidents
• Significantly reducing the use of physical intervention when supporting an individual with ’challenging behaviour’
• More importantly, to improve their quality of life, access to community facilities, levels of engagement and communication abilities of the people with a learning disability or autism that the organisation supports.

The project sought to implement and embed the NICE guideline on learning disabilities and challenging behaviour (LDCB) (NG11) and the relevant matching quality standard (QS101) across the organisation.

The organisation supports, in residential or supported living accommodation, approximately 5100 individuals with a learning disability and/or autism. Of that total, some 1640 were categorised as displaying behaviours that can challenge others (as per the NICE guidelines definition in NG11, taken from British Psychological Society (BPS) ’Unified Approach’). Within that number were 535 individuals whose behaviour posed, at times, such a risk to themselves or others as to have a physical intervention protocol (PIP) as part of their support plans.

Challenging behaviour can encompass verbal or physical aggression, self-injury, destruction of property, fire setting, absconding, and a myriad of potentially anti-social behaviours, such as smearing of bodily substances, removing clothing in public places, inappropriate sexualised behaviours etc.

Individuals labelled as having challenging behaviours would be viewed as people who posed a risk to themselves and the community and thus this would often limit their use of community facilities and inevitably have a detrimental effect on their quality of life. Equally, these individuals would also have had a physical intervention protocol as part of their support plans further impoverishing their situation.

The project was devised utilising a PBS (Positive Behavioural Support) approach, which is (adapted from Gore et al, 2013). See the supporting document here for a summary of the approach.

The project ensures that the organisation is using NICE Quality Statements 2-5 of the 8 statement from NICE Quality Standard QS101 and meets all of the standards that are applicable to an adult supported living or residential service.

To implement the project meant a multi-strategy approach:

• Obtaining board approval for the project and accompanying budget by the Board of Directors. The budgeted was for £150,000 which included:
  • Two additional full time staff (on top of the two existing staff, which included the author)
  • Staff pay uplifts for approximately 60 staff
  • IT (laptops and projectors for staff)
  • Travel & accommodation
  • Resources/materials costs.

(This board approval was obtained due to strong support from the Chief Executive and Director of Quality).

• Publicising and awareness raising of the project. This was achieved by making presentations at Regional Directors meetings, forming a Project Steering Group of key senior executives and attending local team meetings and specialist teams meetings to raise awareness. In addition, nationally 55 individuals were recruited within the organisation who would take on the role of Area Behavioural Specialist (ABS) alongside their substantive role (as ’Champions’ for the project).
• Recruiting two additional Lead Behavioural Specialists. It was fortunate to be able to recruit two highly skilled and motivated individuals to take on these roles and that made a huge difference. These two individuals, along the author and another existing behavioural specialist formed the core implementation team.
• Devising and providing a series of 5-day intensive training course for the ABS’s in Positive Behavioural Support (PBS).
• Producing a monthly report on progress. This is a compilation of the reports for each behavioural specialist of the work they have undertaken in the previous month and the outcomes in brief, i.e. what actions did the team to develop to better support the individual and have these been implemented and are they proving effective in shaping or changing behaviours of concern? This is sent to the directors and the senior management team plus all the contributors.
• Weekly clinical update sent to all ABS’s summarising any recently published reports, research, policy initiatives (Lifeways or National government), campaigns by e.g. Mencap, relevant TV documentaries etc. or best practice articles that by reading and implementing will help the ABS improve their practice and help maintain their CPD.
• Bi-annual Continuing Professional Development (CPD) Conference to reflect on progress, to learn more clinical skills, and to listen to an internationally renowned guest speaker. Once an ABS has been trained they are mentored and clinically supervised by either myself or one of the full time behavioural team to ensure they work within their competency level and feel fully supported.

• Since the commencement of the project 52 Behaviour Specialists plus a further 6 PBS ’supporters’ (managers of services) were appointed and trained giving a total of 58 Behavioural Specialists. i.e. PBS practitioners within the organisation available to train staff.
• We now have five Principal Instructors in total (each able to mentor 15 ABS’s).
• Since March 2106, the Specialist Support Team and the Area Behavioural Specialist have held 507 PBS workshops training 3549 staff in Positive Behaviour Support and, where necessary, Physical Intervention.
• As the organisation has continued to expand, mainly via winning new business, and also by acquisition of competitors, so has the numbers of people being supported who require a PBS approach. This has meant there is a need to expand our project to encompass these services.
• The author's work in overseeing the project was supervised by Professor Dr. Julie Beadle Brown who is a Reader in Intellectual and Developmental Disablities at the Tizard Centre of the University of Kent, a Chartered Psychologist, an Associate Fellow of the British Psychology Institute, author and an internationally recognised researcher in the field of Learning Disablities. Regular meetings took place to update her on progress and get feedback and suggestions for improvements for the project.

Outputs:

An in-house, comprehensive, Lifeways PBS training resource that when fully delivered takes three days and covers:

• Active Support and Quality of Life
• Proactive Strategies
• Communication
• Environments
• Functional Analysis
• Crisis Management
• Keeping Safe
• Behavioural Psychology
• Practice Leadership
• Avoiding Restrictive Practices
• Record Keeping
• De-briefs.

Benefits of the project:

• Upskilled and empowered workforce utilising latest best practice.
• Developed a PBS integrated model that will be used for all services.
• 98.7% positive feedback from staff attending PBS workshops.
• Significant reductions in the use of physical intervention and number of behaviour related Incidents. An audit was carried out by the quality audit department in March 2017 which revealed that of the original 535 individuals who had a Physical Intervention Protocol as part of their support plans,
  • 108 PIP’s (20%) had been discontinued as no longer needed and archived.
  • 117 PIP’s (22%) were still required to be part of the persons support planning but had not needed to be used
  • 97 PIP’s (18%) had only five or less occasions of use in the previous 12 months.
  • 213 PIP’s were still in use on a regular basis but were in process of review and the aim will be to either considerably modify or eliminated by the end of 2017.
• There was only 2 incidents throughout 2016 of a service that has used our PBS module, breaking down i.e. the staff team no longer being able to support the person in a community setting, and the service user moving to another provider. Statistics for previous years are not available but it is believed the number of placement breakdowns would typically have been higher than this.
• Anecdotally, a reduction in staff and service user ’churn’ within the group. Statistics to support this claim for this are being sought but may well be inconclusive as many other factors can affect staff turnover.
• Again anecdotally, an improvement in the practice and understanding of staff using physical skills which in turn has led to an improvement in the quality of life for the people we support and safer practices for the organisation. Ultimately this will, we hope, result in an increase in our reputational soundness for managing people with complex needs.

In essence the project has been rolled out exactly as envisaged and the only variation has been that it has expanded to cover other acquisitions. The use of PBS has also been extended to services that are failing or where there are other performance issues and has been used as a tool to improve quality and upskill staff.

Barriers faced:

• One of the main barriers has been middle managers either saying they will support the project and then being entirely passive or saying that all their staff are too busy to take away from ’front line’ work. Overcoming these obstacles is slow going and has required determination and persistence on behalf of the implementation team.
• One of the key tools we developed was the use of local ’Clinical Meetings’ to discuss behavioural matters. By using these we provided a forum for problems but also reinforced that the solution lay in implementing the LDCB project.
• The ripple effect? Implementation in one area raised the profile of what we were doing. Successes were discussed locally and the ’word spread’ such that other managers wanted to buy in.
• Management Training: when we had developed the 3 day PBS training tools (noted above) I wanted to ’road test’ it. I decided the best people to give me informed feedback would be a panel of middle managers, who we invited to a ’PBS for Managers’ three day workshop. This workshop proved highly effective, not only in testing out the resources but also in getting ’buy in’ from mangers. So much so, that this is being run as a regular event, bi-monthly, and the take up has been excellent.