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Case Notes

Practitioners:   Martin Elliott, service manager; Rose Powell, team leader; and Brice Hands, deputy team leader.

Field: Adults with learning difficulties.  Location: Islington, north London.

Client: Forty-year-old Ron Bryant has learning difficulties. He has always lived in residential care. He is also non-verbal.

Case History: Ron's behaviour has been consistently difficult to manage through his life. He has never really enjoyed living in a residential setting - his most recent placement being a small community-based home for five residents. However, the design of the Victorian building did not lend itself well to a care environment. Ron's increasing displeasure at living there resulted in more frequent aggressive and property-damaging incidents. This escalated to such a point that he had become a high risk to the other people living in the home and to staff. Social and health care professionals began to think it might be better for Ron to live on his own where he could control his own environment. 

Dilemma:  Although in need of 24-hour support, Ron was very unhappy in residential care and was often violent and aggressive.

Risk factor:  By placing Ron in his own flat with only one support worker at any given time both Ron and the worker might be potentially unsafe and vulnerable.

Outcome:  Ron enjoys living alone, his life experience is improving and his aggressive outbursts have been all but eliminated. 

Arguments for risk

• Bryant was unhappy sharing his home. He needs to feel in control of his environment. Being non-verbal meant that he would express his frustration in aggression and violence. He deserved an opportunity to live on his own - with flexible support.
• The alternatives did not wash. Another residential placement would compound the problems as would a specialist unit which would also prove prohibitively costly.
• While having staff working alone with a service user has its worries leaving both parties potentially vulnerable, risks are managed, according to Elliott, "through good communication between the people working with Ron. Risks when taken are shared professionally, advice is sought and given, and we talk through the possible consequences."
• Having knowledge of Bryant and being able to work exclusively with him meant that staff could take the time needed to improve his choices and quality of life. 

Arguments against risk

• Bryant has a long history of violent and aggressive behaviour. He has had many placement breakdowns. He has damaged property and has put at risk many other people who have lived in homes with him. Such a history, whatever the root causes may prove to be, should point to the possibility of a specialised placement where skilled, qualified and knowledgeable staff can work with him therapeutically. However, this appears to have been ruled out on grounds of cost.
• If Bryant was still living in a community home the decision to work one-to-one with him would seem sensible. However, taking the decision to do so while he is alone in his own flat is a dangerous one to make. Not only does it place Bryant at risk from poor practice or abuse but it would leave the staff member poorly protected - particularly if an allegation was made against one of them: they would find it hard to defend themselves.

The move from long-stay hospitals and large residential care units into smaller homes in the community is generally seen as a positive advance for people with learning difficulties. But how many of us, given the choice, would still be happy with having to share a house with others who may be strangers?

Moving into to their own homes, often with support, is seen as the next step for more independent service users. But those with more challenging behaviour often stay in community homes or are placed into expensive specialised units.

Forty-year-old Ron Bryant had lived his whole life in some institution or other, but did not like doing so. His frustration would boil over into violence and aggression.

"His most recent placement was becoming untenable. He was a risk to other people living in the home, to staff and to himself. He was unhappy - and so was everyone else. It was clear that he had to be moved out," says Islington Council's service manager, Martin Elliott. But not this time into another home. "The best thing was to put him in on his own."

One of the borough's community homes had a part of the building that could be converted into a self-contained flat. While this was being prepared Bryant moved into an out-of-borough emergency placement. Given his dislike of new people, two staff from his previous home went with him and worked on the idea of living alone.

"Ron finds it difficult to trust people and tends to only like certain individuals - staff turnovers are one cause for his aggression," says deputy team leader, Brice Hands. "Other triggers for his aggression include new places and unexpected events."

Bryant's first two weeks in his new flat were difficult. "It was a risky move for him. He had to adjust and realise that this was his new home; this wasn't a holiday, this was it," says Hands. Living on his own meant that Bryant's staff team - he has 24-hour support - could be flexible and focused on his needs. "The best way to manage his aggression is to get out of the way and allow him time to calm down on his own. Obviously we have to make his environment safe. For example, because he smashes windows we have safety glass; because he throws over wardrobes we have them all fixed to the floor," says Hands.

Crucially, it was agreed that staff would only work with Bryant one-to-one. "Our experience over the years has told us that if two or more staff get involved he does get much worse, although he does receive two to one support when we're out in the community trying new activities," says Hands.

Elliott adds: "The traditional way to manage someone who is aggressive is to have more staff. The risk here was just having one worker at a time; because that's what Ron responds best to." For team leader Rose Powell it was a risk that had to be taken: "Until we take that risk, we would never know if it worked."

With Bryant now settled, work is continuing in developing his quality of life. "He is quite institutionalised so even something like shopping at a supermarket can be difficult - lots of people and things happening that you can't predict," says Hands.

However, increased contact with his family has been very positive. "His sister spotted him walking past her house. It turns out she hadn't seen him for 20 years and lives close by. Her two children pop by now and again - they like him and he likes them. The more Ron goes out into the community and develops relationships - such as with his family - the easier life will become for him," says Hands. Powell agrees: "He now sees the flat as his own. For example, if he wants to go out - he'll point to his jacket. But if he wants to be alone in the front room he'll take the staff member by the hand and walk them to the door and close the door behind them, which is really positive."

Staff have worked with Bryant on reducing the high level of medication he has been taking to help control his behaviour. Indeed, with no aggressive outburst in three months, it shows that patience can be the best medicine. "A lot of people have pulled together to try and make this work - and they have succeeded," says Powell.

Independent Comment    

It looks as though Ron has been telling people how he wants to live his life for many years. He wants to live alone, to be able to express himself and go out when he feels like it, and have time alone too. He wants to work with people whom he trusts, who know him and who show him respect, writes Joanna Perry.   What is really positive to see is that not only has Ron been supported to communicate what he wants, but his service has helped him make his dreams a reality. This model of supported decision-making allows Ron to be in control of his own life - what Valuing People is all about.    As a public body, the service is upholding Ron's human rights. For example, by supporting Ron to live how he wants, his article 8 rights to private and family life are being upheld. Importantly, Ron's right to physical integrity is also being upheld by supporting him to reduce his medication.  It isn't just Ron's rights that are being protected.  By supporting him to move to a place he is happier with, his former flatmates' right to be and feel safe is also being protected. Also, now that Ron has access to a more ordinary life, he is enjoying his family. So the service is upholding his sister's and her children's right to family life too!   We at Rights for All think that it's great that Islington took this risk. Now they can use this positive experience to have a human rights-based approach in the future and be a role model for other services.    Joanna Perry is project leader, Rights for All at Values Into Action