Good practice in residential care for people with learning disabilities

With proper recruitment and training standards, residential settings for people with disabilities can be beacons of good practice. By Mithran Samuel (pictured: Emma Lewes, care home manager, trains staff in non-violent crisis intervention)

It’s very difficult for us to truly comprehend how that could happen. We have all talked about it and been quite disturbed.”

This view of the Winterbourne View abuse case comes from Emma Lewes, a home manager working for Voyage, which has a similar client profile to Castlebeck, the organisation at the centre of the scandal.

But Lewes and colleagues are determined to show families that the scenes of service users being hit, kicked, pinned down and taunted are not just an anomaly but the converse of the reality of many services.

“It’s made us think how we can show people that it’s not like that everywhere,” she says.

With 96% of its care homes rated as good or excellent before the abolition of Care Quality Commission quality ratings last year, Voyage seems in a good position to carry this message, and its approach to workforce development is a key part of this.

While staff at Winterbourne abused service users with apparent freedom from scrutiny, Voyage chief executive Bruce McKendrick says the culture of the company would prevent this.

Operations managers carry out monthly reviews of services, whose results are passed to a quality assessment team, which decides what action the service needs to take to improve and timescales in which to complete them.

“That holds our staff to account,” says McKendrick. “If they are not doing things right they will be taken to task about it.”

He gives an example of a staff member who successfully calmed down an anxious service user recently, but failed to follow the care plan, which stated that the client needed two people to support them in such situations.

“Nothing went wrong,” says McKendrick. “But that person is now in a disciplinary process. There are certain things that are non-negotiable.”

Many watching the Panorama programme would have questioned how such abusive staff could have been employed and retained to work with such a vulnerable client group.

Voyage’s approach to preventing this starts with detecting whether job applicants come with a caring attitude, says Sally Tommy, head of employee development.

“If someone comes to us with no qualifications [for a support worker role] we don’t see that as a problem so long as they have the right values, which involves seeing how they react to service users during interviews.” Those who betray discomfort are unlikely to get past the interview stage.

Voyage’s annual staff turnover rate is 20% – low by sector standards but high compared with other types of business. McKendrick says this reflects the rigour of the company’s six-month probationary period for new staff, which involves 12 weeks of induction on average.

“Some people will start working in a home and then decide that it’s not for them. Quite a lot leave early on. If you take people who are at the company for over six months or a year, turnover rates are very low.”

The company structure – with three levels of seniority for support worker and senior support worker roles – enables people to progress up the ladder, while staff success is celebrated in an annual awards ceremony.

Allied to this is significant investment in training, equivalent to at least 5% of annual turnover when indirect costs are taken into account, which Tommy claims is well above the sector average.

A training analysis is done for each service based on the nature of the service and the development needs identified by staff and managers, leading to a training plan for the year.

Apprenticeships

Training comes in several forms. Tommy says that it aims to offer all staff the opportunity to study for an apprenticeship in health and social care, something that is rarely refused. The company also provides various e-learning courses, annually refreshed training for relevant staff in managing challenging behaviour as well as more bespoke training,

“You get some very strange requests,” says Tommy. “Last year we had a request for lifeguard training because one of the service users wanted to go swimming but didn’t want to go to the public pool but to a private one that didn’t have a lifeguard.”

Tommy, who has been at the company for three and a half years, says Voyage’s investment in management training distinguishes it from other companies she has worked for.

“Managers are trained to know how to support and train their staff,” she says. “You can train staff all day but if the managers are not able to recognise where support is needed it will not be so significant in terms of benefit.”

McKendrick says Voyage has been relatively protected from cuts because it works with users with high needs, though some councils are applying pressure to cut fees. He says the company feels it can compromise on price but will not take referrals if it feels it cannot deliver a high-quality service at the price proposed.

“We will never position ourselves as a low-cost operator,” he adds.

Managing challenging behaviour

The Winterbourne View case presented an object lesson in how not to handle cases of challenging behaviour among people with learning disabilities.

Instead of helping defuse situations, staff at the Castlebeck hospital escalated them, using physical restraint as a first – rather than a last resort.

Home manager Emma Lewes is one of Voyage’s in-house trainers in managing challenging behaviour. Like all Voyage trainers, she has been instructed in “non-violent crisis intervention” by training body the Crisis Prevention Institute, which emphasises de-escalation and the use of non-harmful physical interventions as a last resort.

This training programme is accredited by the British Institute of Learning Disabilities (BILD), which sets national standards on the use of physical interventions with people with learning disabilities. BILD says accreditation is a “rigorous process” involving observation of training and record keeping and an appearance before a panel.

Lewes says her training emphasises the need to understand why service users behave in a challenging way.

“People with challenging behaviour are not behaving like that all the time. Our duty is to work out what the function of that behaviour is and what are they trying to tell us. The training I hope to deliver is about trying to understand that. When you get a grip of that it’s a wonderful feeling.”

Lewes’s staff development role extends to her day job as manager of The Bungalow, a care home for six people with profound learning disabilities and physical disabilities. As a hands-on manager, rather than an office-based one, she is able to “help shape people’s ethic”, particularly through the induction process.

She welcomes the support that Voyage provides managers. “There’s a very clear line of responsibility and an enormous team of experts that we can draw upon. If I have an issue it’s very swiftly managed.”

Voyage details

● Services: 266 services including home, day care, residential and nursing care and supported living for people with learning disabilities, autism, acquired brain injury or other complex conditions.

● Staff turnover: 20%

● Training budget: At least 5% of annual turnover.

● Training provided: 12-week induction; service-specific training, including in managing challenging behaviour; all staff given opportunity to gain health and social care apprenticeships.

● Outcomes: 96% of care homes rated good or excellent by Care Quality Commission as of 2010.

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Full story of Winterbourne View learning disabilities abuse scandal