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 • of 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
Vignette Questions Gary is 26 years of age, he has a diagnosis of Moderate 1. What makes this gentleman intellectual disability, autistic spectrum disorder, epilepsy and is potentially more vulnerable to non verbal. He communicates using objects of reference to indicate abuse than someone who his basic needs (drinks, drive, walk etc.), other than that he is reliant does not have an intellectual upon staff identifying his social, emotional & health support needs. disability and behaviours that Prior to moving to Insight he was detained under Sec 3. MHA 1983 challenge services? in a private special hospital for 18 months. Detention under MHA followed four successive placement breakdowns. Each placement 2. What are the potential broke down due to the service being unable to manage Gary’s tensions that might exist behaviour(s), and in his final placement he hospitalized two between this gentleman, the members of staff within a three week period. staff that support him , the Functional Assessment identified that challenging behaviour(s) was organisation and the multi functional and included, demand avoidance, tangibles gain commissioner? and attention. Behaviours exhibited ranged from 1. severe physical aggression towards staff, 2. severe environmental damage, 3. 3 What are your superficial self injury 4. absconding. It was not unusual for Gary to responsibilities within your exhibit a combination of two or more inappropriate behaviours role to minimise tensions and when distressed. Incidence last anywhere between 10 & 120 therefore the potential for minutes. Gary is resistant to engaging in personal hygiene activities, this gentleman to be abused? his sleep pattern is erratic, with him often choosing to remain in bed all day and awake all night.
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 • obstructiveness • 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 Staff Team: Client forum Training • • PCP Team meetings • • On ‐ going education/ skills development Clinical review meetings • • Access to external professionals Supervision • • Access to senior staff Role modelling / development of empathy • • Control over review meeting agenda and Daily access to senior staff • • presentation 24 hour senior management support • Family contact, advocacy Self reporting of anxiety levels • • Health Action Planning Involvement in development of care plans, • • Communication passports 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 organisation complacency!
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