CHALLENGING BEHAVIOUR Insight Specialist Behaviour Service Jackie - - PowerPoint PPT Presentation

CHALLENGING BEHAVIOUR

Insight Specialist Behaviour Service Jackie Hales

Who are Insight

• 24 hour residential care service for adults with intellectual disabilities and

behaviours that challenge service provision.

• Partnership established 21 years
• Both Partners worked for the NHS as LD nurse specialists / adult

residential services manager and, established Insight in response to lack of provision for 5 people with CB who had not been placed during the final stages of Leybourne Grange Hospital closure in 1991

• Currently provide care and support to 31 adults within seven community

based homes. (24 male & 7 female)

• Have a staff team of approximately 150 (4:1 staff /service user ratio) &

remaining staff in clinical / administrative roles.

• Referrals primarily from Social Services and PCT’s, self funding referral is

possible.

• All service users have either had a number of failed placements or have

been detained under the MHA (1983 amended 2007).

Insipid Abuse

• The most difficult area of practice is recognising staff / organisational

practices that set the scene for significant abuse.

• Institutional practice commences with staff / organisation “taking the line
• f least resistance”.
• Abuse is most likely if staff are unclear about the service philosophy.
• Do not have the guidance on how to respond appropriately and safely

when faced with challenging behaviour(s).

• When staff feel unsafe at work and devise their own strategies for

intervening or avoiding.

• When physical intervention as a last resort “Risk Management Strategy “ is

implemented before all other pro‐active strategies have been exhausted. (line of least resistance).

Group Work

• Divide into groups of 5
• Nominate a scribe
• Discuss & Record your answers to the

following three questions

Questions

Vignette

Gary is 26 years of age, he has a diagnosis of Moderate intellectual disability, autistic spectrum disorder, epilepsy and is non verbal. He communicates using objects of reference to indicate his basic needs (drinks, drive, walk etc.), other than that he is reliant upon staff identifying his social, emotional & health support needs. Prior to moving to Insight he was detained under Sec 3. MHA 1983 in a private special hospital for 18 months. Detention under MHA followed four successive placement breakdowns. Each placement broke down due to the service being unable to manage Gary’s behaviour(s), and in his final placement he hospitalized two members of staff within a three week period. Functional Assessment identified that challenging behaviour(s) was multi functional and included, demand avoidance, tangibles gain and attention. Behaviours exhibited ranged from 1. severe physical aggression towards staff, 2. severe environmental damage, 3. superficial self injury 4. absconding. It was not unusual for Gary to exhibit a combination of two or more inappropriate behaviours when distressed. Incidence last anywhere between 10 & 120

• minutes. Gary is resistant to engaging in personal hygiene activities,

his sleep pattern is erratic, with him often choosing to remain in bed all day and awake all night.

• 1. What makes this gentleman

potentially more vulnerable to abuse than someone who does not have an intellectual disability and behaviours that challenge services?

• 2. What are the potential

tensions that might exist between this gentleman, the staff that support him , the

• rganisation and the

commissioner? 3 What are your responsibilities within your role to minimise tensions and therefore the potential for this gentleman to be abused?

How to Recognise Early Signs of Abuse

Service User

• Decrease in community contact
• Missed appointments
• Service user Isolating, declining engagement
• Decline in self help skills, learned helplessness
• Marked change in presentation around some staff
• Appearance, hygiene etc.
• Increase/ decrease in verbally demanding behaviour
• Increase/ decrease in Challenging behaviour
• Increase in RPI
• Service user speaking negatively about one or more staff

How to Recognise Early Signs of Abuse

Staff

• Staff speaking in non positive terms
• Reduced level of empathy/ understanding
• bstructiveness
• One size fits all approach
• Failure to follow agreed care plans
• Lack of recording / reporting
• Lack of transparency
• Sub cultures (the “I know best” subversives)
• Displaced management
• Bullying of other team members

How to Recognise Early Signs of Abuse

Organisational Level

• Poor financial investment in service provision
• Disparity between mission statement and delivery
• Lack of Transparency
• Isolation
• Failure to update knowledge base
• Unwilling to work with outside agencies / other professionals
• Obstructiveness
• Inability to recognise own limitations
• Over critical of other professionals input
• Accusatory / aggressive toward external agencies

How to Recognise Early Signs of Abuse

External Professionals

• Disregard for collaborative working with provider
• Unreasonable waiting times for medical appointments
• Delays in best interests decisions
• Regularly cancels appointments
• Failure to complete agreed actions

Potential Service Provision Indicators that Increase the Likelihood of Abuse

Practice areas most likely to lead to abusive interactions Organizational level:

• Lack of clear leadership
• Lack of multi‐disciplinary working
• Poor communication systems
• Failure to empower service user group
• “Good enough” culture
• Lack of reporting & Monitoring systems
• Failure to adhere to policy & procedure
• Failure to act
• Inadequate staffing levels / cross age, gender mix

Staff:

• Lack of training / induction/ tools available
• Poor role modelling / supervision
• Organisational expectation is unreasonable
• Staff feeling unsafe, unsupported
• Disillusionment with managements ability /

willingness to act

• Dis trust in confidentiality
• Sub‐ culture

External Agencies:

• Failure to monitor and support placement due to lack of

understanding of Service user group complex needs

• Dis‐jointed working
• Response delay
• Economic climate

Service User:

• Vulnerability
• Lack of or, absence of external contacts
• Lack or information / understanding of how to complain
• Likeability factor
• Key worker standing in team
• Communication skills
• Previous life experiences
• Challenging behaviour

Empowerment

Service Users

• Client forum
• PCP
• On‐going education/ skills development
• Access to external professionals
• Access to senior staff
• Control over review meeting agenda and

presentation

• Family contact, advocacy
• Health Action Planning
• Communication passports

Staff Team:

• Training
• Team meetings
• Clinical review meetings
• Supervision
• Role modelling / development of empathy
• Daily access to senior staff
• 24 hour senior management support
• Self reporting of anxiety levels
• Involvement in development of care plans,

risk assessments

• Clear communication and recording tools to

raise concerns

• Inter staff monitoring of interactions
• Regular feedback on outcomes
• Confidentiality assured
• Evidence that concerns are acted upon

Organisational Commitment to training across the whole service Commitment to providing advice and guidance Assured confidentiality Visibility across service Flexibility of organisational structure Planned progression Networking Access to information Clear policy and procedure for all Registered Home Managers / senior staff / staff to respond quickly to any suspicion / reported abuse Dedicated HR and administration staff Communication pathways Transparent culture

Safeguarding

• “Safeguarding means protecting people’s

health, wellbeing and human rights, and enabling them to live free from harm, abuse and neglect. It is fundamental to creating high‐quality health and social care”. http://www.cqc.org.uk/public/what‐are‐ standards/safeguarding‐people

Prevention is Better than Cure

• Insight believes that there is no one single

thing as an organisation that can be done to prevent an incident of abuse occurring however; the risks can be considerably reduced through a multi element approach that is continuously reinforced throughout the life of the service.

• The biggest threat to any vulnerable person is
• rganisation complacency!

Prevention Strategies Service Users & Family

• Insight provides every service user, their family members and interested others with details of

actions they can take in the event that they have concerns .

• This information is supplied on commencement of placement and provides details of all agencies

that can be contacted in the event that they feel unable to speak to us first, or their concern is so serious that a report to statutory service is necessary in the first instance .

• Transparency and an approachable attitude is promoted within the organisation, we have found it

beneficial to encourage people to voice minor niggles before they become major worries, not least because the potential for safeguarding actions is expedited, it also reminds staff that their actions are being monitored.

• Service users have six weekly PCP meetings, they are asked if they wish to have the support of their

keyworker or wish to see the co‐ordinator on their own. Meeting agenda’s are individual, but always include some standardised items one of which is, “are you upset about any aspect of your care and support”.

• Monthly client forum meetings are facilitated by an external person and concerns, complaints are
• raised. These are fed back only to the partners to ensure confidentiality is maintained, service

users can complain then about the home managers etc., knowing that issues will be addressed sensitively and without recourse.

Staff

• Staff members receive the same information upon

commencement of employment, which is incorporated within the staff handbook as well as within a detailed Organisational Policy.

• Standardised forms and confidential posting area’s are

made available to all staff in all the homes

• Concerns can and will be investigated in confidence and

the complainant can easily access senior staff outside of the home in which they work, via telephone, office drop in, email etc.

Preventing or Responding to Abuse

• Commitment to engage in all activities which are

recognised as helping to prevent abusive practices

• ccurring, e.g. individual accountability &

responsibility can be traced through clear audit trail throughout the whole organisation.

• Preventing abuse commences at the point of staff

application , e.g. pre‐screening, comprehensive recruitment process

• Identification of emotional intelligence?
• Zero tolerance of what might be considered minor

infringements

Responding to Abuse

• Insight has the right to suspend a member of staff immediately it comes to our

attention that a service user may be at risk of being abused. This is underwritten by our insurer and would be done under the guise of “concern raised”.

• Any concern raised can be done verbally or in writing, confidentiality assured. If

concern is deemed serious enough to “exclude from duty”, the person raising the concern must put this in writing

• Any member of staff more senior than the one for whom the concern has been

raised, is able to send a person immediately off shift. All staff above basic carer level are trained to do this and would implement this under the guidance of the senior on‐call person at the time.

• Investigations are completed within 24 hours of the report and would be done by

either the RHM or more senior person.

• Assessment of concern severity will determine whether or not an AP1 alert is

raised immediately with safeguarding, the police informed and the Care Manager prior to investigation.

• Non specific concerns of the “I can’t put my finger on it” type are always explored

directly in supervisions, or through team meetings in a less direct manner.

LEGAL MANDATE & REGULATORY FRAMEWORK

A vulnerable adult is described in “No Secrets” and “In Safe Hands” as a person ‘who is or may be in need of community care services by reason of mental or other disability, age or illness and who is or may be unable to take care of him or her self, or unable to protect him or her self against significant harm or exploitation’ 1 Primary responsibility for safeguarding all vulnerable adults falling within this definition remains with the local authority Social Services authority. In the context of adult 1 ‘No Secrets – Guidance on developing and implementing multi agency policies and procedures to protect vulnerable adults from abuse’ Department of Health/Home Office 2000.

Legal Mandate

• All vulnerable adults are entitled to access the legal system

regardless of intellectual disability, LACK OF Mental Capacity.

• This includes but is not exclusive;

Police Solicitors Court of Protection Generic Court ECHR OPG MCA & Dols Health & Social Care Act 2008. (Statute law), its intention was to modernise and integrate health and social care.

Regulatory Framework

• Contract between commissioner and service

provider

• CQC “Essential Standards of Quality & Safety”

(March 2010)

These standards clearly set out what providers should do to comply with the section 20 regulations of the Health & Social Care Act 2008. Clear outcome measurements are detailed to monitor a service providers adherence to standards detailing how they are safeguarding people who use services from abuse.

Regulation 11 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2010

Vision for Adult Social Care, Capable Communities and Active Citizens November 2010. CQC: Essential Standards of Quality & Safety www.cqc.org.uk/public/what‐are‐ standards/standards/standards‐care‐homes Mental Capacity Act (2005, amended 2007) www.legislation.gov.uk/ukpga/2005/9/pdfs/ukpga_20050009_en.pdf MCA Dols (2009) www.kent.gov.uk/adult.../dols.../contact_the_dols_office.aspx Tizard PCP & Applied Behavioural Analysis training www.kent.ac.uk/tizard PBS Advanced Professional Diploma www.mle.wales.nhs PROACT‐SCIPr‐UK www.proact‐scipr‐uk.com KCBN (Kent Challenging Behaviour Network)