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'Closer to Home': Proactively commissioning PBS solutions

 

Page-1-closer-to-home.JPGCloser to Home (C2H) is an innovative collaboration between Health, LA Social Services and the third sector in South Wales that has successfully provided people with learning disabilities who have behaviours that challenge with their own homes and assisted providers to implement Positive Behavioural Support (PBS). The C2H partners were initially inspired by the recommendations of the Mansell reports and have been working together for over four years. Their achievements provide a practical demonstration that more recent, similar policy initiatives (e.g. Bubb Report, Welsh Government, DOH, etc) are not only feasible but can deliver better outcomes.

 

What supports best practice?

The main aim is to develop enhanced supported living services with ‘ordinary’ houses provided and adapted by registered social landlords; the ‘enhancement’ is PBS provided by experienced third sector, values led ‘not for profit’ agencies. Proactive joint commissioning to develop a local infrastructure of services competent in PBS, driven by the needs of people and their families is key to this success. Supported living brings the benefits of security of tenure and the houses are personalised and homely, providing an environment rich in easily accessible typical activities, located in people’s own communities. Supported living is more cost effective compared to ‘residential placement’, as capital costs are carried by registered social landlords and recouped from rents paid by tenants via housing benefit. Commissioners informally pool budgets and carefully plan staffing with support providers and families so that revenue funding can be used more effectively. Social services care management teams and health counterparts regularly review and strategically plan for individuals. 

Whilst ordinary housing, in the right location provides the best foundation for service quality, how staff support people is crucial. C2H providers are contractually required to implement PBS, and demonstrate a commitment to enhance staff skills by enabling them to gain PBS qualifications. Staff use Active Support as a core ‘PBS primary prevention’ strategy. People participate in the typical activities of daily life such as shopping, cooking, community leisure and employment opportunities etc. Providers work together to develop organisational PBS competencies, with a particular emphasis on practice leadership, and co- produce service standards and outcome measures. NHS specialist staff provide PBS expertise regarding, for example:

  • Functional assessments
  • Co-production of PBS plans
  • Bespoke staff training
  • Positive monitoring
  • Periodic Service Review

Health behavioural specialists also coach staff in situ to implement each person centred PBS plan. Initially, this is often intensive then gradually tapers, as support teams become competent and people ‘settle in’. 

 

The impact of 'Closer to Home'

The most important outcomes are improvements in people’s quality of life. Generally these include increased participation in a wide range of activities at home and in the community and the development of personal interests, skills and relationships. The following examples provided by people, their families and staff illustrate these.

 

‘Mervyn’ a gentleman in his 50’s had always loved dogs but had previously lived for most of his life in hospital settings where he had very limited opportunities to have anything to do with ‘a man’s best friend’. Within a few weeks of moving into his own C2H home, he became a regular volunteer dog walker, in a local dog rescue centre. He greatly enjoys the dogs and is also getting to know the staff and other volunteers who share his interests.

 

‘Bryn’ used to live a very sedentary, almost nocturnal life in a residential home, where he was very anxious, agitated and there were mounting concerns regarding the way he was supported and the increase in his hyperventilation, destructive and disruptive behaviours. In his new C2H home, staff supported him to communicate more effectively, and participate in a much greater range of activities, develop a consistent sleep pattern and establish his own self-help routines. Skilled consistent support made things more predictable, reducing Bryn’s anxiety. 

 

Within a few months of moving from an assessment and treatment unit Dan a young man who was described as ‘aggressive and disruptive’ now sings in a local choir. Cathleen a middle aged lady with a harrowing history of traumatic abuse used to ‘repetitively pester’ staff and become very demanding in previous ‘placements’. Now she actively participates in running her own home, and also represents her co tenants at the provider agencies management committee meetings.

 

There are other countless other examples of small but significant personal achievements, that range from going on a first date, using public transport, to maintaining eye contact for more than a few seconds.

In line with PBS these often dramatic improvements in quality of life have been associated with reductions in the frequency and intensity of people’s behaviours that challenge, such as aggression, destruction, self injury etc.

Families have expressed greater satisfaction and have commented on how much easier it is for them spend more time and be involved now that their relative is ‘closer to home’. One mum said ‘marvellous’ when asked to sum up her own experience of her daughter moving to a C2H house and added ‘she’s happier, more confident and her self esteem has increased, I’m particularly pleased that she has more freedom at home, in her last placement everything was always locked’. Another mum said her son’s epilepsy was now much better managed and he’s doing many more things that he enjoys, she’s really pleased that the staff support him to take photos and tell her about all the things he does

In conclusion the C2H collaboration has successfully provided 24 tenancies, with a similar number in development or planned. The situation is not perfect, for two people things did not work out, due mainly to problems in getting accurate assessment data, from existing providers. Learning lessons and improving our understanding of people’s individual needs is a continual process. It is apparent that all partners must continue to develop skills in PBS, and develop a better infrastructure so everyone with behaviours that challenge can receive a local competent and resilient service.

Getting on with the local actions in partnership such as exemplified by C2H generates shared learning. Using this to inform work with national governments and other agencies is the best way of promoting good practice nationally.

 

 

Dr Edwin Jones

Service Development Consultant

Directorate of Learning Disabilities

 

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