Community living support: staffing, staff performance & matching support to service user needs

1. Community living support:staffing, staff performance & matching support to service user needs David Felce Welsh Centre for Learning Disabilities Cardiff University, Wales, UK

2. Poor quality institutional care • Major causes of concern: • low staff presence • low rates of staff attention to service users • low stimulation • absence of meaningful or constructive activity (Burg et al., 1979; Duker et al., 1989, Felce et al., 1980, 1986; Moores & Grant, 1976; Rawlings, 1985)

3. Too little attention Poor quality attention Wright et al. (1974) 16 children in 5 wards 4 hours observation each Received attention for 13 minutes (5.6% of time) No attention for 227 minutes (94.4% of time) 0.4% positive 5.1% negative 94.5% neutral Poor quality institutional care

4. Poor quality institutional care • Under-investment • Difficulties in staff recruitment • Poor staff-to-service user ratios • Medical/custodial models • Low expectations/poor attitudes • Lack of support/stimulation • Institutional environment

5. Reversal of institutional conditions • Deinsitutionalisation in UK associated with increased resource investment…& • Improved staff-to-service user ratios • Social care, ‘ordinary life’ model • Normalisation ideology … inclusion • Community integration, normative buildings/locations/furnishings • Trend towards smaller, more staff intensive settings over time (Felce & Perry, 2004)

6. Community housing & supported living • Given the extent of reform, how has the situation changed? • How well matched is staffing and staff performance to the needs of service users? • Does variation in staff input reflect service user characteristics?

7. Variation in costs in relation to service user characteristics • 23% of costs related to skills, challenging behaviour and size of residence (Knapp et al., 1992) • 42% of costs related to skills and behaviour in hospital (Cambridge et al., 1994) • 65% of costs related to 7 variables including age and skills (Raynes et al., 1994) • 51% of costs related to 10 variables including age and skills (Hallam et al., 2002) (Note: staff costs = 60-80% of costs)

8. Variation in staff input in relation to service user characteristics • Felce et al. (2003) found 26% of variation in staffing related to service user challenging behaviour … but… • Stancliffe (2004) found no significant association with adaptive/maladaptive behaviour but did find association with age and psychiatric status

9. Other factors associated with variation in staff input • Size - number of residents (Knapp et al., 1992; Hallam et al., 2002; Felce et al., 2003; Stancliffe, 2004) • Provision sector/service model (Knapp et al., 1992; Raynes et al., 1994; Felce et al., 2003; Stancliffe, 2004) • Date of opening(i.e., how old/recent) (Felce et al., 2003) • Quality of process/outcome (Raynes et al., 1994 … but not … Felce et al., 2003)

10. Conclusion:Variation in staff input • A minority of variation in staffing per service user related to service user characteristics • Other aspects of the design of services influence staff input per service user

11. Staff performance in relation to service user needs • (a) has reform been accompanied by improved staff performance? • extent of attention • quality of attention • balance of staff activities • differentiation according to needs for support

12. Emerson & Hatton (1996) review of staff attention to service users • % of time attention received by service users: • 4.2% (3%-16%) in hospitals • 9.3% (2%-17%) in community units/ hostels • 14.8% (5%-31%) in houses

13. Extent and quality of attention(% of time per service user)

14. Staff activity (% time per staff)

15. Other staff contact per person Staff assistance per person Relation-ship to service user needs(Felce & Perry, 1995) 60 ABS score 255

16. Relationship to service user needs (Felce & Perry, 2004)

17. Predictive relationship between service user characteristics & extent of attention or assistance received • Generally no/low association • Sometimes direction of association is positive (more able getting more support) (Hatton et al., 1996; Felce et al., 2002; Felce et al., 2003)

18. Conclusion:Staff performance • Levels of attention have gone up • Still largely “neutral” - low levels of support (assistance, encouragement) • Staff in community housing not that different to staff in hospital (1/3 time directly related to supporting service users) • Staff performance does not relate to needs for support - people with lower skills do not receive significantly more assistance or encouragement

19. Impact of staff input on staff performance • Evidence of a positive relationship (i.e., higher staff-to-service user ratios leading to service users receiving more attention) (Felce et al., 2002, 2003) … but … • Evidence of a negative relationship between higher ratios and extent to which each member of staff attends to service users (i.e. diminishing marginal returns from adding staff) (Mansell et al., 19882; Felce et al., 2002)

20. Relationship between costs and staff attention to service users (Hatton et al, 1996)

21. Impact of resource or staff input on service user outcomes • there were "no links between costs and outcomes”(Cambridge et al., 1994) • no association between service costs and any indicator of quality (Hatton et al., 1996) • association between costs and outcome weak (Emerson et al., 2004)- some indication that may promote greater community activities

22. Impact of resource or staff input on service user outcomes • Engagement in activity is associated with extent of attention or assistance, but not directly related to staff-to-service user ratios (Felce et al., 2002; 2003; Perry & Felce, in press) • Some evidence that more choice and greater involvement in household management are related to lower staff:service user ratios (Felce et al., 2000; 2002, Stancliffe & Keane, 2000) … or independent of them (Perry & Felce, in press)

23. Impact of resource or staff input on service user outcomes • Some evidence that more frequent community activity is related to higher staff:resident ratios (Felce et al., 2002) … but … • Stancliffe & Keane (2000) found the opposite (Note: May differ depending on ability of service users)

24. Conclusion:Impact of resource or staff input • Clearly, having sufficient staff is important • But limited evidence that there is a straightforward relationship between more resource intensive services and quality of outcome • Certainly, resource input should not be viewed as a proxy for outcome • Better to view it as getting the balance right between too few and too many staff

25. Support and quality of life • Occupation is important to wellbeing • …and we do not expect people to be moved by what is not unusual. That element of tragedy which lies in the very fact of frequency, has not yet wrought itself into the coarse emotion of mankind; and perhaps our frames could hardly bear much of it. If we had a keen vision and feeling for all ordinary human life, it would be like hearing the grass grow and the squirrel’s heart beat, and we should die of that roar which lies on the other side of silence. • George Eliot, Middlemarch

26. The problem of under-occupation • the extent to which people are constructively engaged in activity is related to their measured adaptive behaviour • people with lower adaptive behaviour have consistently been found to spend substantial periods of the day unoccupied

27. The problem in support • staff availability does not necessarily translate to people receiving more support • people with lower adaptive behaviour do not receive differentially more support from staff • staff attention is typically conversation • too little from the perspective of someone with severe intellectual disabilities is assistance to do activities (particularly non-verbal assistance)

28. Training staff to provide ‘Active Support’

29. Conclusions: Training staff to provide support • the 2 studies had consistent results: • service users received more assistance • people with greater disabilities received more assistance • service users were more constructively engaged • increases in engagement were related to increases in assistance • people with lower adaptive behaviour scores derived most benefit

30. Conclusion • No longer a resource input problem • Problem of low attention resolved • However, still questions about quality of support and matching support to need • In the UK, ‘ordinary life’ model did not stress need for staff to learn how to give effective support • ‘Active Support’ illustrates potential for improvement from this and other approaches to training carers • Staff training may be the ‘missing link’ between resource input and quality of outcome