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Tips on supporting learning disabled adults at risk of manifesting challenging behaviour
- Do a thorough assessment covering everything that a support team needs to know about the individual.
- Ensure service providers undertake challenging behaviour training before working with this client group.
- Staff need to be consistent in approach and maintain routines; this is particularly important for someone with autism.
- The staff team also needs to be consistent – unknown agency staff can be distressing for adults with learning disabilities.
- Keep accurate records of any behaviour and what happened before, during and after to help identify what is upsetting someone.
Source: Salford learning disabilities service
By June, all people with learning disabilities placed in hospitals, often after manifesting ‘challenging behaviour’, must have had their needs reviewed with a view to supporting their return to their community by 2014.
Social care professionals seeking inspiration on meeting the key objective of the government’s response to Winterbourne View may want to look to Salford, one of three areas cited as good practice in this area by the Department of Health.
Out-of-area placements cut
From 2009-12, only one person with learning disabilities from Salford was placed in a hospital assessment and treatment unit, while from 2007-12 16 people were supported to return to Salford from out-of-area placements.
Salford’s success is built on integration across health and social care. A pooled budget between Salford Council and Salford NHS, via section 75 of the National Health Service Act 2006, has helped set up a single-point-of-entry learning disability service, co-located under a single manager.
It includes a community team, consisting of, among others, six social workers and eight learning disability nurses; and a learning disability health professional team (LDHP) which includes a psychiatrist, a psychologist, a clinical nurse specialist, and a range of therapists.
“The aim of this model of care is to support people already living in Salford to stay in their own homes and to support anyone in an out-of-area placement to return to Salford,” says Tracy Hancock, one of the social workers and also a challenging behaviour lead.
The social work role
As the professional attending review meetings, the social workers’ prime role is to identify whether someone wants, or is ready, to return to Salford. Once this has been agreed, a coming home plan guides staff through the process.
An essential starting point is a thorough assessment, says social worker Ailsa Reynolds. “The assessment has to tell us what they need because the clearer it is, the better services we can commission so that it works.”
A project team is set up around each person and it is part of the social worker’s role to decide what disciplines they need to draw on from the community team and the LDHP team. The project team looks at the service the person will need; the type of housing; whether their family has been involved; choosing the right provider; and induction training for the provider, the staff support team and family.
Salford works with 16 providers and has a rolling training programme for them on challenging behaviour, autism and communication.
Causes of challenging behaviour
“It is lengthy work,” says Hancock. “As co-ordinators we are feeding back all the time to let everyone involved know where we are with the individual and when they are ready to move. When it comes to challenging behaviour we always say there is a reason for someone to behave like that. We want to know what happened before, during and after the behaviour. We collect that information and you can often see a pattern.”
It can take up to 18 months from assessment to the move for someone with a complex learning disability and complex needs. Working with the families is a key relationship in the coming home plan, says clinical nurse specialist Dave Williams. “Sometimes it can be about regaining their trust because if their child moved out of area because the service wasn’t able to support them they are going to lack that trust. But that might have been 10 years ago and now we believe we can offer a better service in terms of quality of life back in Salford.”
Once a place for someone has been identified and a service commissioned much work is done to develop relationships between the individual and their support team. The vast majority of adults with learning disabilities are supported in tenancies with 24-hour support, though some live on their own with minimal support, some in sheltered housing and some with families.
“The assessment doesn’t stop when people move,” says Reynolds. “The package usually starts off with a high level of support but people flourish and develop skills so there is constant discussion about whether the support is appropriate.”
Case study: From secure accommodation to supported living
Andrew (not his real name) had been in an out-of-area placement for eight years when it was felt he was ready to move back to Salford. Andrew, who has moderate learning disabilities with a good level of communication and understanding, had been placed in secure accommodation because he had set fire to things and there had been issues around inappropriate sexual behaviour.
He was very institutionalised and it took about three years to prepare him for the move, says Phil Marsland, a learning disability nurse in Salford's community team. An attempt had been made to move Andrew back before Marsland started working with him, but it hadn’t worked out. Marsland spent a significant amount of time with Andrew building a relationship: “I visited him on a weekly basis so we got to know each other and we spoke on the phone.”
Preparation for move
To prepare him for the move, Andrew was encouraged to do things that he hadn’t done before, such as going to the local shops. “We wanted him to get some community experience while he was at the secure unit and he was happy to go with staff. He was a bit uncomfortable when we suggested that staff would shadow him rather than be at his side, but he did it. But when we suggested he could do it on his own he couldn’t handle it.”
Whenever Andrew became anxious about dealing with new things such as this there would be subtle changes in his behaviour, for example, he would set fire alarms off, or let car tyres down in the grounds of the unit.
“When this happened we knew we had to slow it down,” says Marsland. “This meant it was a very lengthy transition but that’s why it worked so well. We had to go at Andrew’s pace and were guided by his behaviour.”
While Marsland was working with Andrew, two other men of the same age, with similar backgrounds, interests and support needs – who were in a placement together – were also being prepared to return to Salford. It was thought that the three of them might enjoy living together and they were introduced.
They hit it off and the amount of time they spent together was gradually increased over the months. “We were confident that the service provider that had supported the two men for a few years would be an appropriate provider for all three back in Salford,” says Marsland.
With support they started looking at properties and in 2010 they moved into the house they chose where they are tenants with 24-hour support.
“From the day he moved he has blossomed,” says Marsland. “He goes out, he has been on holiday for the first time, bought his own clothes for the first time. He is a changed individual.”
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How Winterbourne-style placements can be brought to an end