Broad Category of Care Provision

Moving from an Assessment and Treatment Unit (ATU) to the community

Number of people care provided for

One

Overview / Description of the type of care

• A has autism and a severe learning disability. The history of institutional care means that he finds it difficult to communicate what he wants and needs. He can physically ‘handle’ others in a way which can seem aggressive. He communicates using a combination of a few words and gestures, Makaton sign language and pictures developed for him by the support team.
• A is supported by Dimensions, a large not-for-profit organisation that provides supported living services for people with autism and learning disability. A lives alone in his own bungalow with a large garden situated on a suburban street. 
• Support is provided in shifts and by a team consisting of a manager and Lead support workers. A has three support team members with him in the daytime and one at night. Support is provided with every aspect of daily living with a focus on increasing A’s independence and improving communication.
• A has support from Dimensions’ Positive Behaviour Support practitioners who help the team understand his behaviour and make plans to improve his quality of life, communication, and independence.
• The team is currently focussed on consolidating their relationship with A, built up over a year, supporting A to tolerate being out in the community for longer periods of time, building a range of stimulating activities and communicating with greater precision about what he needs and wants.
• There will be a planned reduction in support hours as A develops greater independence.
• A loves time exercising on gym equipment, music, playing ball games and spicy food. A often prefers to be alone but has developed good relationships with the support team and he enjoys interacting with them on his own terms.

What makes this type of care unique? What are its strengths?

• This is the first community placement that has been able successful. Prior to this, A lived in a low level secure hospital for 20 years and in a residential specialist school before this.
• A’s behaviour was seen as ‘too challenging’ or ‘too dangerous’ for community placements to manage. The last year has proved that this is not the case.
• The bespoke physical environment which is an adapted two-bedroom bungalow with a good-sized garden.
• Some of the team members supporting A have a personal understanding of his culture and they have been able to build rapport with his family.  This makes both long-term planning and day-to-day decision making easier and ensures it is in A’s best interest.
• The intensive management presence (one dedicated manager for A’s service and three lead support workers to allow for ‘lead’ coverage on every shift).
• The provider and the local authority Community Learning Disability Team have worked well together and shared the risk. Commissioning has an impact on the success of community support and the shared role that the Community Learning Disability Team has in supporting the person. It isn’t helpful for commissioners to delegate sole responsibility to the support provider.

• The team supporting A is resilient and they enjoy being around him despite the risk posed by his physically aggressive behaviour. One of the reasons that this team have matched well with A is the experience they have gained from supporting other people to move away from similar institutional settings.
• There is support to understand A’s behaviour from the Dimensions’ Positive Behaviour Support Practitioners who have extensive professional experience and training (MSc and BTEC) in Positive Behaviour Support. The assessment carried out by the PBS team was especially important in the initial specification, training, and the development of support practices which remains an important part of the development and delivery of care for A.
• The team benefits from regular reviews from a Dimensions’ Oversight Team which includes the clinical director (registered psychologist), the regional managing director, operations director, and a family consultant who is an expert by experience.
• The placement is well resourced with the right number of team members, access to a specially adapted Motability vehicle, and there are safety adaptions to his home.

What can the care sector learn from this type of care?

• There is a group of people who have remained in institutional care for the last 20 years because their needs are complex and there are not enough community support for them. 
• This work, by its very nature, includes substantial risk and there is a further risk of service breakdown, injury, and loss of reputation for all involved. The sector needs to learn to share risk-taking between providers, families, and commissioners. This will increase service providers’ appetite to bid to support those with complex needs.
• The three most important resources for the care sector to establish are: trained and resilient staff teams, robust adapted environments and long-term clinical support for individuals.
• Creating a good working relationship with an individual’s family is vital to their successful support. Historically families have been side-lined by professionals and service providers.
• An established team is often better at supporting someone with challenging behaviour, rather than recruiting from scratch. Providing enough management supervision and specialist support is vital.
• Housing stock needs to be fit for purpose. We have experienced placement breakdowns in the past arising from problems caused by a lack of space or suitable adaptations to a property.
• Enabling people to leave institutional care and live in the community takes time. If a community placement is going to fail, it will do so in the first year with the first few weeks being the most challenging.  Often the first year ‘out’ is spent consolidating and preventing service breakdown. We often find that much more development and growth for the person and the team happens in the second, because it does so founded on the stable base established in the first year.

Supportive quote from someone who draws on this form of care and support

Email received from an Occupational Therapist who supported A through the discharge from ATU to the community:

I wanted to give Dimensions, XXX and XXX a plaudit for all their hard work and creativity in supporting A over the last year to have a successful discharge from hospital. A’s visual care and support plan is excellent and clear. Great to see the video footage of him enjoying his home. “

Discharge summary from Community Disability Team November 2022:

“The team at Dimensions has been dedicated to supporting A to successfully transition into a local placement in the community from an out of area specialist hospital.  It has been a pleasure working with them.  “

Comments from family members during an internal quality assurance review:

         “(name of person) no longer has to wait for someone to open the door so he can go out into the garden, like where he was before, and he is free to roam around his home and can go to his bedroom when he’s had enough of people. I am very happy with this.”    

         “I am happy with his diet and seen an improvement in how his diet has changed for the better.”

What are the current challenges that face this type of care

• Although A has been supported safely and with no staff turnover during the last year, several risks have arisen during the placement.  To communicate with support team members “go away” or “I need something” A will sometimes rip the t-shirts and tops from members of staff’s torso, strike people forcibly on the head, grasp and pull at other’s arms and hands with considerable force. One member required hospital treatment for a dislocated shoulder which was caused by A forcibly pulling at the support team member’s arm.
• Despite the adaptations to the property there have been times where A has been able to bypass these and cause some minor damage, including removing large rocks from walls and throwing them over the fence, destructing the wall surfaces in the bathroom and engaging in faecal smearing, destructing window fitments requiring replacement.
• The legacy of institutional care remains and progress can seem slow. A requires time to trust those around him, because of his history in hospital created a low tolerance of the support team around him. 
• The positive side of this is the observable increase in A’s tolerance of his current team and his enjoyment of activities at home.  The team is working on increasing the amount of time A feels comfortable with them in the same room and on the duration of trips into the community using his adapted vehicle.
• There are limits to the reduction in staff that are likely to be required to support A in the community. Although reductions have been made already, A is likely to always need at least two people to accompany him in the community due to the risk he poses to the public.

How can the UK Government support this type of care?

• There needs to be investment so that positive behaviour support can be provided for those leaving hospital care or to prevent admission to emergency ATU placements.
• Individual providers are often not commissioned to provide specialist clinical support but are expected to do so by deploying PBS specialists with MSc degrees and practitioners with BTEC qualifications in PBS but the costs of this are not met through the support package.

• Create standards and specifications for the design, build or adaptation of living environments for people moving on from institutional care.
• Living environments require significant bespoke design and adaption. Non specialist builders frequently guess at the adaptations required which are soon rendered unworkable through use. Important factors are the high durability of surfaces, having safe exits and escape routes to enable staff to give people enough space to calm down without restriction and sufficient outdoor space.
• Work in partnership with contractors experienced in ‘behavioural healthcare’ building projects and providers of community-based support for people with Learning disabilities and behaviours of distress.

• A commitment to a better pay for social care staff. This would enable providers to pay for more experienced and specialist support work and make these roles more attractive to the most motivated and capable staff.
• Improve training in how to support an individual with behaviours of distress. This could be a BTEC Level 4 or 5 in Positive Behaviour Support. Currently most support workers receive one awareness training which is not enough to support more people to move from hospitals into the community.