Our latest response to the Winterbourne View scandal looks at how such abusive environments can be prevented and good care promoted for people with learning disabilities and complex needs.
It comes from Sharon Paley, development manager for behaviour support at the British Institute of Learning Disabilities (BILD).
BILD has developed a code of practice on the use of physical intervention with people with learning disabilities and autism and accredits training in this area.
Finding, developing and keeping the right staff to provide good support for people whose behaviour is seen as challenging is a complex activity to manage and get right. It involves a range of interrelated workforce areas including recruitment and induction, learning and qualifications, continuous professional development, regular supervision and appraisal, and, crucially, effective leadership and management. Getting some or all of these areas wrong can result in the kind of abuse that we witnessed so shockingly in Panorama's Undercover Care: the Abuse Exposed.
The investigations into institutional abuse at Sutton and Merton and Cornwall showed NHS organisations with considerable systemic weaknesses in the development of their workforce and it seems evident that similar failings might have happened in the Castlebeck service in Bristol.
At Winterbourne View we saw a situation where staff felt intimidated by some colleagues, where there was a lack of purposeful engagement and activity and where both the people with learning disabilities and the staff were bored. Winterbourne View appears to have been an archetypal 'toxic working culture' as described by Dr Michael Nunno of Cornell University. He says this is an environment that shows:
- A lack of a clear mission or therapeutic approach.
- A lack of leadership and where management and supervision are poor.
- A culture of interpersonal aggression - between staff as well as aimed at service users.
- An absence of active support or positive engagement with service users.
- A lack of appropriate assessment or risk management systems.
- A lack of quality assurance processes and internal or external review.
So what do we need to do to get the support right? Not by simply having another review and trying to 'ensure this never happens again'. The issue need instead to be approached from several angles.
First, the implementation of
best practice and current policies should be the top priority for the
Department of Health, the Care Quality Commission (CQC), commissioners
and providers. There is a strong evidence and policy base to support the
development of local specialist community-based services for people who have
learning disabilities who have challenging behaviour or mental health needs in Professor Jim Mansell's 2007 report for government and the 2009 Valuing People Now strategy.
Second, providers must respond by developing a proactive, whole-service approach in which human rights-based aims and values permeate throughout the organisation and support the delivery of person-centred, individually-tailored, flexible and responsive support. They should ensure that each person is treated as a valued member of their local community with dignity, respect and the same rights as everyone else. Services should understand and respect people's culture, ethnicity and religion.
To make sure this is implemented, providers need strong governance, leadership and management, underpinned by up-to-date policies and procedures, a commitment to government policies and best practice and a striving for continual improvement. Those responsible for governance need to show how they engage with and learn from those being supported and their families.
As well, providers need to establish a learning and development programme for all staff that focuses on the needs of the people who use the service and is in line with the Skills for Care and CQC requirements on the induction of support workers and their ongoing development using the new health and social care qualifications.
Finally, and most importantly, the people who need support and their families must be fully involved in the planning, delivery and review of their support. Their ideas and concerns should be sought and valued and responses should be proactive, not based on crisis management. This means everyone having an up-to-date and regularly reviewed person-centred plan, access to independent advocacy and an accessible complaints process.
We know what makes a good service and we know how to prevent abuse, now as a society we - government, regulators, commissioners, monitoring authorities, providers and those engaged in delivering support - have to take responsibility for taking clear, practical and measurable steps that ensure that all vulnerable people live the best life possible.
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