The Law Commission’s proposals on reforming adult care law this year broached the thorny issue of extending personalisation, specifically direct payments, to people in residential care. Some are uncertain whether this is workable. But the experience of autism and learning disability provider Dimensions suggests it could dramatically improve the lives of service users.
Dimensions has charted the steps it took to personalise care at Old Street*, a six-bed residential home for adults with learning disabilities in the south of England in a book (see notes at end).
“We support large numbers of people who live in care homes or group living,” says Dimensions chief executive Steve Scown. “The fundamental flaw is that they have not chosen who they live with and, because the team on duty works with everyone, they have a limited choice about who supports them and how their time is spent.”
Dimensions worked with Helen Sanderson, chief executive of training and development consultancy Helen Sanderson Associates (HSA), to provide residents with individual service funds, a type of personal budget held by a provider.
After asking permission from their families and telling the local authority that commissioned the service of its plans, the challenge was to allocate existing funding to individuals in a fair and equitable way to reflect their individual needs.
Dimensions decided that each person would pay an equal share of the core costs of the home and any shared service costs they needed. They would then each be left with an individual service fund over which they had choice and control, including the freedom to spend it with another provider.
Once the money was in place they used a process developed by HSA called Planning Live whereby the six residents, their families and staff worked together for two days to learn what was important to each resident and how they wanted to be supported using person-centred thinking tools (see “It’s changed her whole life”, above).
One unexpected issue to come out of this process was what to do when there is a member of staff who no one wants to be supported by. “The starting position is that you help the employee understand what the issue is,” says Scown. “In this instance the member of staff raised her game. But he is clear that if this hadn’t been the case she would have had to leave. “This is about listening to people; you can’t do this if you are not prepared to see it through.”
It is a hugely different way of working for staff, says Scown. A lesson learned in hindsight was that person-centred thinking tools have to be embedded in practice before the process starts – something not done there.
“You have to help staff understand that this is not some big shiny idea that is going to go away, it is how it’s going to be now. This is cultural change and anyone knows that it’s not quick, it’s not a smooth ride and you have to keep going.”
“For the support and service to be led by the residents was a monumental change, not only for staff but for the individuals,” says Carolynn Wilkinson, manager of Old Street at the time of the work with HSA. “[Residents] now know that they can say ‘I want to do this and with this person’ and it’s going to happen.”
The rota system had to change for this to be possible, which meant a big adaptation for staff used to traditional early and late shifts. Wilkinson’s challenge was to adjust the shift times to make sure residents had the right support when they needed it, creating personalised rotas to match their perfect week. This now happens on a weekly basis.
While the Dimensions example is on a small scale, Sanderson believes that the principles can be applied in larger residential care homes. “At Old Street they could individualise most of the residents’ time. I know of one larger care home for older people where there is two hours per week of one-to-one time when residents can choose who supports them and what they want to do. Even if it’s only possible to have one hour a month you can start there and see how that can be built up.”
If this is not possible, she says, homes’ activities co-ordinators could dedicate some of their time to one-to-one support, rather than group activities, or volunteers could provide the necessary one-to-one time.
“The biggest choices that make the most difference to people are who supports them and what they do with their time,” she says. “Anything that moves towards that will demonstrate that it can be done.”
As far as Scown is concerned, it should be done: “People get a better life and that’s what it’s about: end of.”
* Name has been changed.
‘It’s changed her whole life’
Anne-Marie*, who is in her fifties, came to live at Old Street* from a long-stay hospital when the service opened in 1996.
During the Planning Live meeting to help her shape her support a number of person-centred thinking tools were used, including a one-page profile summarising what is important to her and what she thought good support should look like; a relationship map highlighting the people who are important in her life; and community mapping to outline the places that Anne-Marie likes to go to spend her time.
From this her “perfect week” was created, which included what she wanted to do, when and where, and who she wanted to support her. All staff had also done one-page profiles and then a matching tool was used to see whether any of the staff Anne-Marie wanted to spend time with had similar interests.
Baking was in her perfect week, so she was matched with a member of staff who enjoyed cooking.
Similarly, Anne-Marie wanted a job and a dog so she was matched with someone who had their own dog and was supported to become a paid dog-walker.
Support worker Becky Hardy says: “When we were asked to do a one-page profile I don’t think we realised how important that would be later on, but then it slots into place.
“One of the things on Anne-Marie’s ‘perfect week’ was that she’d like to put on make-up every day. That upset me a bit because I’d worked with her for all these years and it had never occurred to me before.
“We did her hair and make-up when we went out but without the open environment the meeting created I don’t know if we would have found this out.
“She wanted to be out in the community more and work in a coffee shop, so I spoke to a local vicar about letting her volunteer at the coffee morning after church. If we hadn’t started the personalisation journey and used all the tools we would never have even thought about taking her there because she isn’t religious.
“It’s changed her whole life.”
* Names have been changed
Caption: Support worker Becky Hardy (top right) says personalisation has transformed resident Anne-Marie’s life
How to make it work
l Agree the value of the individual service funds first so people can start planning how to use them.
2 Be prepared for when there is a member of staff who nobody wants to support them.
3 Plan rotas in a way that enable people to choose how they are supported and by whom.
4 Staff should be trained in person-centred thinking tools: One-page profiles of themselves help to match them with residents, for example.
5 Staff should receive regular supervision informed by the views of service users.
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