He can’t live with others

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