Achieving quality outcomes in supported

accommodation:

NDS forum October 2013

Professor Christine Bigby

Living with Disability Research Group

La Trobe University

C.Bigby@latrobe.edu.au

What makes a difference

Good quality of life outcomes when...... Complex interactions 6 main elements

Necessary but not

sufficient conditions

• Adequate resources

•Design - Size & Type

Coherence of organisational values

and policies & a mission that puts quality of life

of service-users at the core of all its actions

• Organisational leadership policies and procedures

• Service characteristics

• Staff training

• Staff characteristics

An informal culture that is

congruent with and supports

the formal mission of the

organisation

Service user characteristics

Organisational and staff

practices that compensate

as far as possible for

inherently disadvantageous

characteristics of residents

An external environment that is

congruent and reinforces the

mission and values of the

organisation

Staff and managerial

working practices that

reflect organisational

values and policies and

the principles of active support

3

Outcomes and Staff Practice High and Lower Performing

Organisations Sample average and people with higher support needs

Whole Sample Org 1 Org 2

UK study

Good active

support

(Ashman, Beadle-

brown, 2006)

Engagement in

meaningful activity

and relationships

47% (31) 64% (54) 25% (16) 60% (54)

Percentage of time

spent in Social

Activity

15% (24) 23% (19) 9% (5)

Percentage of time

spent in Non-social

Activity

35% (31) 45% (38) 16% (11)

Active support 49 (38) 67 (64) 28 (12) 79 (79)

Time spent receiving

assistance and

contact from staff

12 mins (11) 18 mins (15.5) 7.5 mins (6) 23 (25)

0

20

40

60

80

100

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Pe

rce

nta

ge s

core

on

ASM

Active Support: People with More Severe Disabilities vs.

People with Less Severe Disabilities

Target 66%

• More able people experience better active support - exception Org 6 (& Org 7)

• Only 3 orgs provide consistent good active support for more able people

Sig difference

Relationship between ability, active support, engagement, &

assistance

Higher engagement related to higher active support & more assistance

More able people get more assistance, better Active Support and are

engaged more.

With good implementation of active support should see:

lower, non-significant relationship between active support and level of

ability

weaker relationship between level of ability and engagement.

a slight negative relationship between Assistance and level of ability –

those who are more severely disabled should be getting the most help.

Engagement Active Support Assistance

Level of ability .689** .624** .199**

Engagement .614** .247**

Active Support .423**

Support for communication

• Only 6% of non verbal residents received any adaptive communication that

appeared to be effective.

• Increase for 3 of the 4 Vic orgs since 2012

All O1 O2 O3 O4 O5 O6 O7 O8 09

N/n 63 2 12 3 0 8 6 23 3 6

Number receiving good adapted communication

4 1 0 2 N/A 0 0 0 1 0

What affects practice - Practice Leadership * Relationship between Practice Leadership Scores, Engagement & ASM Score

• Evidence of relationship between Practice Leadership and Active Support and

Engagement

• Significant relationship between Active Support and overall PL score on three

domains

• Allocating staff - Team meetings - Manager focus

• Practice leadership generally poor – only one organisation had higher scores

• Big discrepancy between observational measures and staff ratings of PL (and practice)

• Staff clearly felt that managers prioritised more admin related tasks than user enabling

tasks *note all figures are from work in progress – see reference list for published studies

Allocating Staff

Coaching Supervision Team

Meeting Manager

Focus Average PL

Score

Any Engagement .245** -.116 .029 .180* .088 .094

ASM Score .257** .143 .105 .265** .225** .234**

Practice Leadership Components

Allocating and organising staff to deliver support when and how service

users need and want it

Coaching staff to deliver better support by watching how staff support

people, telling them what they are doing well and what needs to be

improved and showing people how to provide better support.

Reviewing the quality of support provided by individual staff in regular

one-to-one supervision and finding ways to help staff improve their

support

Reviewing how well the staff team is enabling people to engage in

meaningful activity and relationships in regular team meetings and

finding ways to improve it.

Focusing, in all aspects of their work as manager, on the quality of life

of service users and how well staff support this

9

Producing and Reproducing Positive regard (and Active

Support practice

Supportive organisational processes

HR policies

Core of long term staff – more than 10 years – deep knowledge and strong bonds

Rosters and Recruitment

• new staff rostered along side more experienced ones

• good practice modelled and new staff exposed to knowledge

• close scrutiny of casual and prospective staff

• only employment via casual pool

Even if they [casual] are a bit messy, we think, 'Ooh, we can work on that

person' because they’re fantastic with relating to everyone who lives

here, they’re great. We think, 'Alright, you’re a little bit messy, we’ll fix you

up, (laugh), we’ll neaten you up’.... you can, just follow instructions ‘til you

know what to do yourself. (I/LC/102811)

• induction separated from orientation - practice same weight as

procedures

10

Translation of values – no doubt what’s expected

‘What we expect of you: We expect you to treat ALL individuals with respect, dignity,

empathy, sensitivity, and to listen, learn and act on individuals needs, wants and desires,

which encourages participation in THEIR life. We expect that you value all individuals for

their individuality regardless of YOUR own opinions, morals and values’. (D109

PowerPoint slide)

‘each person is inherently valuable; people can grow and develop; people have dignity

and respect’ (D71, Quality measures/Shared values around people/indicators)

Reinforced through language and communication policies

Expectation that staff will, ‘use language that reinforces the individuality and humanity of

those people [who access our services] and emphasizes the fact that they are, like the

rest of us, a valued, member of the community in which we live’. (D/MSS/180507), D11)

First person language plans, communication books

Artefacts – pictures with family - on holiday

Above the sideboard with the fish-tank are photographs of the residents, some

taken at a fun-park, others are family pictures. In the pile of CDs, the top one is

Funhouse by Pink and the top DVD is I Robot starring Will Smith. On the

coffee table are some flowers and more photographs. (F/A/051411)

11

Reinforced by other dimensions of culture

Alignment of power holder values

• strong practice leadership in line with organisational values

• no sub culture counter to expectations

If I had to discipline somebody or talk to them about something, my approach to each

person would be different. I feel that a good manager, a really good manager is a leader

and leads by example I like to build trust and respect between all staff and with myself,

but also know that a manager has to wear the manager’s hat when it’s needed.

There was some real issues…..They felt that that it was a babysitting service, basically,

and I knew that when I left, things weren’t done the way we needed to do things for

people…... And they did everything to try and undermine me. There was a couple of

investigations going on. ….the organisation assisted me to have some sessions with a

personal development trainer type person. I was ready to ask for a demotion, because I

felt that I couldn’t manage that place the way I needed to manage and lead. And after

having sessions with this man.......I decided that I had a lot of good qualities. I knew that I

could manage a team of staff in a way that they would have respect for me, but also give

the best of themselves, but I knew that there was a couple of people that had to go.

12

Conclusions – Achieving quality outcomes

Attention to practice - Upward trend in 5 Vic organisations

Whole organisation commitment to a practice framework that includes Active

Support

Create and support conditions for good staff practices

Strong practice leadership

Organisational processes staff recruitment -gaining entry – screen for

values

Explicit translation of values to expectations / action avoids front line

interpretation

Space for reflection on practice avoid imposing own values

Depth of knowledge of people supported – prolonged engagement or

passed on - mechanisms to do this

Creation and re-creation of cultural norms of regard for people by staff

assumptions/values/thinking, seen in talk and action

Staff over estimate outcomes and quality of their own practice

Observation not paperwork a better way to make judgments - reinforce good

practice

13

References

Mansell., J., Beadle-Brown, J., & Bigby, C. (2013) Implementation of active

support in Victoria, Australia: an exploratory study. Journal of Intellectual and

Developmental Disabilities 38(1), 48–58 (download from

http://hdl.handle.net/1959.9/206149 )

Bigby, C., Knox, M., Beadle-Brown, J., Clement, T., Mansell., J (2012). Uncovering

dimensions of informal culture in underperforming group homes for people with

severe intellectual disabilities. Intellectual and Developmental Disabilities 50,

6, 452–467 (download from http://hdl.handle.net/1959.9/206141 )

Bigby, C., Cooper, B., & Reid, K. (2012). Making life good in the community:

Measures of resident outcomes and staff perceptions of the move from an

institution. Melbourne: Department of Human Services:

(http://hdl.handle.net/1959.9/200242 other Making life good reports also)

Bigby, C. (2013). Tackling the crisis in disability group homes. Opinion on line,

http://apo.org.au/commentary/tackling-crisis-group-homes-people-intellectual-

disability

Clement, T. & Bigby, C. (2010). Group homes for people with intellectual

disabilities:Encouraging inclusion and participation. London, Jessica Kingsley.