Effect of Service Structure and Organization on Staff Care Practices in Small Community Homes for People with Intellectual Disabilities

Background An important question in community living is what factors influence the extent to which staff provide ‘active support’. Methods Engagement, care practices and a range of staff and organizational characteristics were studied in 72 residential homes serving 359 adults with intellectual disabilities. Managers in 36 settings were trained in person‐centred active support (PCAS). A group comparison design and multivariate analysis was used to investigate the relationship between variables. Results The PCAS group showed more active support, assistance, other contact from staff and engagement in meaningful activity but no difference in choice‐making or assessment of participation in activities of daily living. The PCAS group had more staff with a professional qualification, were more likely to think that challenging behaviour was caused by lack of stimulation, had attitudes more in line with a policy of community care, rated most care tasks as less difficult, and were more organized to deliver active support. The comparison group were more likely to think that challenging behaviour was learned negative behaviour, showed more teamwork and were more satisfied. Multivariate analysis identified a range of staff and organizational variables associated with engagement and active support. Conclusions The results suggest that some variables which have not hitherto been studied in relation with active support are associated with it. Professional qualification, knowledge and experience appear to be important as do some staff attitudes, clear management guidance, more frequent supervision and team meetings, training and support for staff to help residents engage in meaningful activity.     

Care Standards in Homes for People with Intellectual Disabilities

Background National minimum standards for residential care homes were introduced following the Care Standards Act 2000 in response to concern about the lack of consistency and poor quality services. These standards are intended to reflect outcomes for service users and to be comprehensive in scope. Method This study compared ratings made by care standards inspectors with research measures for 52 homes for people with intellectual disabilities serving 299 people. The research measures focused on the lived experience of residential care, including engagement in meaningful activity, choice and participation in activities of daily living. They also included measures of related care practices and organizational arrangements. Results The research measures were in general significantly correlated with each other. Most of the care standards ratings were also correlated with each other. However, only two of 108 correlations between care standards and research measures were significant. Possible reasons for this are discussed. Conclusions This study confirms that the review of national minimum standards and modernization of inspection methods recently announced by the Department of Health and the Commission for Social Care Inspection are timely and appropriate.     

Resource Input,Service Process and Resident Activity Indicators in a Welsh National Random Sample of Staffed Housing Services for People with Intellectual Disabilities

Background The aims were to: (i) explore the association between age and size of setting and staffing per resident; and (ii) report resident and setting characteristics, and indicators of service process and resident activity for a national random sample of staffed housing provision. Methods Sixty settings were selected randomly from those accommodating six or fewer adults with intellectual disabilities in Wales. Nine settings subsequently withdrew. Information from the remaining 51 was obtained on resident ages, gender, adaptive behaviour, physical and sensory disabilities, social impairment and challenging behaviour, the number and working hours of staff, staff:resident ratios at different times of the day, working practices, resident receipt of attention and assistance from staff and resident activity. The sample of 51 residences was divided into four groups of 12, 13, 13 and 13 settings each, according to ascending average adaptive behaviour scale scores. Results Age of residence was associated with larger size of residence and fewer staff hours per resident. Higher staffing per resident was associated with smaller setting size. Staffing per resident differed across adaptive behaviour groups to a limited extent. Size and age of residence, working practices, resident receipt of attention and assistance from staff did not differ across groups but resident engagement in activity did. Considerable within‐group variation was found. Conclusions The data illustrate trends in provision over time. In addition, they give a picture of recent practice and raise questions about whether staff input, on one hand, and staff training and performance, on the other hand, are well enough matched to the different needs of residents at different points of the adaptive behaviour spectrum.     

High Cost Residential Placements for Adults with Intellectual Disabilities

Background Concern has been expressed repeatedly about the cost and quality of residential placements for adults with learning disabilities and additional needs. This study sought to identify characteristics of the highest cost placements in the South‐East of England. Method Lead learning disability commissioners in the South‐East of England were asked to provide information about the five highest cost residential placements that they commissioned for adults with learning disabilities. Results The average placement cost of £172k per annum disguised wide variation. Individuals placed were mainly young and male with high rates of challenging behaviour and/or autism spectrum disorder. Most placements were in out‐of‐area residential care. The highest costs were associated with hospital placements and placements for people presenting challenging behaviour. Conclusions Young, male adults with learning disability, challenging behaviour and/or autism continue to receive very high cost residential support, often in out‐of‐area residential care. There remains limited evidence of plans to redirect resources to more local service developments.     

The Quality of Residential and Day Services for Adults with Intellectual Disabilities in Eight Local Authorities in England: Objective Data Gained in Support of a Social Services Inspectorate Inspection

Objective data on the quality of 15 residential homes and 17 day centres were collected as part of a Social Services Inspecorate inspection of services for adults with learning disabilities in eight local authorities in England. A sample of 56 residents was drawn from the former and information collected on their behavioural characteristics, social and community integration, autonomy, receipt of attention and assistance from staff, and participation in activity. The activity timetables of the latter were analysed to determine their emphases. Representative group activities taking place within the centres were observed and user:staff ratios, user receipt of attention from staff and user engagement in activity recorded. Findings from the residential settings demonstrated that the frequency of community integration, the extent of autonomy and the level of activity were associated with resident ability. However, there was a lack of association between staff:resident interaction and resident needs for support. Given the ranges on the quality of life indicators investigated, people with more severe disabilities were found to lead segregated and under occupied existences. These findings add weight to the need to be more precise about the determinants of quality and, in particular, the role and performance of staff. A cluster analysis of day centres based on their activity distributions produced two clusters in common with an earlier Welsh survey; centres with an emphasis on ‘recreation and personal development’ or ‘recreation’. The English sample, however, had a lesser emphasis on both contract work and open employment and contained centres which had a greater representation of personal development and education. Developing consensus on the functions and goals of day services is required if day service reform is to lead to the most effective organisational and operational arrangements.     

Person‐Centred Active Support – Increasing Choice,Promoting Independence and Reducing Challenging Behaviour

Background Previous research has found that active support is effective at increasing levels of participation in activities and supporting a good quality of life for people with intellectual disabilities. However, there has been little research on the effect of active support on other outcome measures. Methods This study uses observational methodology, combined with staff‐rated measures, to explore the impact of the implementation of person‐centred active support on the lives of 30 people with severe and profound intellectual disabilities living in small group homes. Results Analysis indicated that significant increases in both the amount of assistance people received and the quality of that assistance were accompanied by significant increases in engagement, participation, choice‐making opportunities and a significant reduction in challenging behaviour and in particular, self‐stimulatory behaviour. Conclusions The paper discusses the implications of the findings for both practice and for further research.     

Parents' experiences of general hospital admission for adults with learning disabilities

General hospital care for people with learning disabilities is strongly emphasized in recent health policy. Ten sets of parents were interviewed about their experiences of general hospital inpatient care for their adult sons and daughters with learning disabilities. Findings in the areas of placement, occupation, basic nursing care, feeding, toileting, nursing attitudes, staffing and procedures are presented. Recommendations are made for changes to reported nursing practice to improve the quality of general hospital care for people with learning disabilities.     

RESIDENT BEHAVIOUR AND STAFF INTERACTION WITH PEOPLE WITH INTELLECTUAL DISABILITIES AND SERIOUSLY CHALLENGING BEHAVIOUR IN RESIDENTIAL SERVICES

The behaviour of 16 residents with severe intellectual disabilities and severely challenging behaviour and the interactions they received from staff were observed. Eight people lived in traditional hospitals and eight in community settings. The two groups were individually matched by adaptive ability. Differences in the occurrence of various categories of staff/resident interaction and resident activity between die two groups were not statistically significant. There was some indication that interaction and engagement in activity were improved in those community settings which were genuinely small and based on ordinary housing. However, a more striking finding for all residents was their lack of constructive occupation and the low level of assistance given by staff to help individuals participate more. Although generally responsive to the social overtures of residents, staff were otherwise not found to have an evident focus on encouraging resident engagement in activity. Two case studies are presented which, with other recent research, point to the impact which the content and focus of staff attention can have on resident activity patterns. Comparison to research on people with less severe challenging behaviour supports the contention that individuals with the most severe challenging behaviours tend to lead more impoverished lives.     

Active Support,Participation and Depression

Background Staff training in Active Support is designed to enable direct support staff to increase the engagement and participation of people with intellectual disabilities in a range of daily activities. Method Residents (n = 41) and staff of nine group homes participated. The effectiveness of Active Support was evaluated with a pre‐test:post‐test design, using a number of standardized assessments and other questionnaires, with group home staff as informants. These assessments were conducted before Active Support training and an average of 6.5 months later. Results Following implementation of Active Support residents experienced significant increases in domestic participation and adaptive behaviour. There were significant decreases in internalized challenging behaviour, overall challenging behaviour and depression. There was no significant pre–post change in other forms of challenging behaviour. Conclusions Our findings confirm and extend previous Active Support research showing that implementation of Active Support is followed by increased resident participation in activities. The significant improvements in adaptive behaviour, challenging behaviour and depression are of particular interest as the present study is among the first to report such effects. The study’s limitations are discussed.     

Australian Implementation and Evaluation of Active Support

Background The implementation and evaluation of Active Support in Australia is reported, the first such formal evaluation outside the UK. Method Residents and staff of five group homes participated. Active Support was introduced by training staff in one home at a time. Effectiveness was assessed using direct observation of resident engagement in activity and of staff help, as well as written assessments of resident outcomes. Results Staff help and resident engagement increased in four of five group homes. There was significantly greater participation in a wider variety of domestic activities, as well as more frequent and varied community participation. Change in resident engagement was positively related to change in staff help, but not related to residents’ level of adaptive behaviour. Conclusions Most of our findings were consistent with earlier UK studies. There was evidence of the successful transfer of Active Support training skills to an Australian training team. Nonsignificant trends towards reduced depression and increased adaptive behaviour warrant further investigation.     

AN EXAMINATION OF THE RELATIONSHIP BETWEEN STAFF BEHAVIOUR AND STRESS LEVELS IN RESIDENTIAL CARE

This paper examines the relationship between levels of stress and the observed performance at work of direct care staff in one community unit and two group homes for people with learning disabilities. Staff completed a questionnaire which measured their levels of stress and factors which they perceived could have influenced them. Staff were observed in detail at work and asked to report on levels of stress during these observation periods. No significant differences in levels of stress were found between the staff in group homes and community units. There was greater staff/resident interaction in the group homes, suggesting that quality improvements in residential environments can be achieved without affecting staff stress. A number of factors, particularly relationships with other staff and management, are discussed as of vital importance in influencing stress levels.     

Staff Activity in Supported Housing Services

Background Variation in staff performance between small community housing services indicates the need for research on the factors which predict high‐quality care. Methods The associations between service sector, staffing levels, staff characteristics, internal organization or working practices, non‐institutional milieu, and staff activity and the nature and extent of staff attention to residents were explored in a study of 10 statutory, 10 voluntary and nine private sector community housing schemes. Results There were few significant differences between sectors after differences in resident abilities were taken into account. Higher staff to resident ratios predicted greater resident receipt of attention and assistance but also a lower proportion of time during which each member of staff was directly concerned with residents. A greater range in resident ability predicted lower resident receipt of attention and assistance. A higher proportion of qualified staff was not shown to be a positive attribute but greater prior experience was associated with staff spending more time directly concerned with residents, less time doing ‘other’ activity and residents receiving more assistance. Measures of the internal organization and non‐institutional milieu of the settings were not strongly related to staff activity. Conclusions The findings are consistent with previous research that there are diminishing marginal returns associated with increasing staff. Size of residence was unimportant. Links between service organization and staff performance require further research but retaining experienced staff appears to be important. As resident receipt of attention and assistance was unrelated to their adaptive behaviour level, there is a need to find ways to ensure that staff support matches the needs of residents better.     

Caring in residential aged‐care. Qualitative findings from an e‐cohort sub‐study

Aim. The aim of this e‐cohort sub‐study was to explore and describe nurses’ understandings of ‘caring’ in residential aged‐care. Background. The quality of the work environment is an important issue for recruitment, retention and workforce planning. Knowledge about the people in and the place that is the residential aged‐care facility may assist with the problems surrounding the recruitment and retention of nurses in the workforce. Design. Qualitative electronic cohort sub‐study. Methods. This paper presents the qualitative research findings from an electronic cohort sub‐study of 58 registered and enrolled nurses working in the residential aged‐care sector in 2007. Data were collected through an open ended question and a qualitative content analysis was used to generate the core categories. Results. The concept of caring was grounded in and constrained by, the everyday reality of the nurses in the study. Organisational imperatives for the completion of documentation necessary for accreditation and funding combined with under‐staffing restricted the time available for caring practices. Some nurses represented residential care faculties as devoid of care, others as a place where the resident was central to their work and care. The staff perceived of themselves as an ageing workforce in need of rejuvenation and resourcing. Conclusion. The concept of caring is manifest in nurses’ language as they describe their workplace, the residents, themselves and the structures that impact on what they do. Good caring manifests itself when the residents are central to the business of the aged care facility. However, nurses in this study describe a range of restrictive factors impeding caring practices and diminishing workforce morale and motivation to create environments that can truly be called a ‘home‐away‐from‐home’ and one that all people would find acceptable. Relevance to clinical practice. These findings have implications for aged‐care sector recruitment, retention and workforce planning within residential aged‐care facilities.     

Effective health care for people with learning disabilities: a formal carers' perspective

This paper explores the perceptions and experiences of formal carers, working in three different geographical locations in the south of England, in accessing primary health care for people with learning disabilities. The sample included six multidisciplinary, community learning disability teams and 11 managers of small homes for residents who had learning disabilities. Data were collected through focus group and individual semistructured interviews. Levels of collaboration between primary health care groups and the community learning disability teams and the managers of small homes were assessed. Questions were focused upon the importance of primary health care and the key care provider within the community setting. Although some good experiences were recorded, the overall levels of collaboration were poor. Health care was perceived as very important by all of the respondents. The general practitioner (GP) as the coordinator of health care was perceived as the normal model within our health care system but the majority of respondents questioned the effectiveness in relation to their own experiences of accessing health care for people with learning disabilities. The relocation of this role to the learning disability nurse was perceived as a possible solution.     

Death in homes: bereavement needs of residents, relatives and staff

This article reports findings from a study in the UK, which investigated the case for applying the principles and practices of palliative care to caring for older people dying in residential and nursing homes. It focuses on the emotional and practical consequences of a death occurring in these settings. It outlines the bereavement needs of residents, relatives and staff as well as obstacles to providing adequate support. Homes differed in policies and practices in relation to providing bereavement support for relatives. Most managers felt some responsibility for relatives of deceased residents, but rarely felt capable of providing what they perceived as appropriate bereavement support. They recognized the need for practical as well as emotional support for staff and other residents after a death but felt that they lacked the skills and time to provide this. Certain types of home prioritized bereavement support, but many homes operated under considerable resource and staffing constraints. Even where support needs were recognized it was often difficult to put the requisite help into operation. This study identified a lack of training in communication skills and in particular little access to training in bereavement care. This area needs to be addressed if residents, relatives and home staff in these settings are to have their bereavement needs met.