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This paper reviews progress in deinstitutionalisation and community living for people with learning disabilities. The effects of replacing institutional care on residents are summarised and some emerging problems identified.

ABSTRACTA training course was provided to disseminate good practice in the provision of staffed housing for people with mental handicaps in South East Thames Regional Health Authority. A follow‐up questionnaire of people who attended two years after the course showed that respondents rated the course as a major contributor to their practice. A survey of four London health regions showed much greater development of staffed housing in South East Thames Regional Health Authority, including development in districts which were not committed to this model before the course, than in the other three regions.

AbstractObservational measures of client engagement and staff‐client contact were taken of 33 people attending a day centre for adults with mental handicap. A low ability group were engaged in constructive activity for 22%, a middle ability group for 46% and a high ability group for 66% of the observations. Assuming a notional 5‐hour 'working' day in the centre, people in the low ability group were engaged for, on average, 66 minutes; people in the middle group for 2 hours 18 minutes; and people in the high ability group for 3 hours 18 minutes. The most common disengagement code for the highest ability group (53% of disengaged observations) was 'inactivity' ‐ people were either spectating or doing nothing although they had materials available. For the middle and low ability groups the most common codes were 'waiting' (e.g. for staff, client, materials to work with) and 'not allowed or enabled to participate in activity by member(s) of staff (e.g. not included in a team game, not given necessary materials with which to participate, not given anything to do). Together these accounted for over half of the 'disengaged' time of the middle and low ability groups: i.e. the low ability group spent, on average, 2 hours and 18 minutes waiting or not enabled to participate out of a notional 5 hour 'working' day. The implications of these results are discussed.

Active Support is a proven model of care that enables and empowers people with intellectual disabilities to participate fully in all aspects of their lives. This evidence-based approach is particularly effective for working with people with more severe disabilities, and is of growing interest to those responsible for providing support and services. The authors provide a comprehensive overview of Active Support and how it can be used in practice, based on the theory and research underpinning the methods involved. They describe how to engage people with intellectual disabilities in meaningful ac

This paper responds to four commentaries on our original paper in this issue. We respond to issues raised under three headings addressing the scale of the task envisaged in the 2001 White Paper Valuing People, the feasibility and effectiveness of individual planning and how to achieve person‐centred action. We conclude that there is substantial agreement about the goals of intellectual disability services and the processes that need to take place around individuals to help them get what they need and want. We disagree about whether person‐centred planning will deliver this, and about whether it will provide a robust basis for claiming and defending the resources people with intellectual disabilities will need in the future.

This book paints a picture of life in group homes today. The authors propose a framework for increasing community presence and participation, and consider the barriers to be overcome in achieving these key goals. Topics include the notion of 'homeliness', maintaining a balance between individual and group needs and practice leadership.

Background  As institutions for people with intellectual disabilities have been replaced with community services, health care provision has developed to provide assessment and treatment, low and medium secure units for people with challenging behaviour or mental health problems. These include both public and private sector provision. Little is known about these services. The aim of this study was to describe the characteristics of the services studied and to compare the different types of service.Methods  A survey was carried out of National Health Service (NHS) and independent sector (IH) health settings providing specialist inpatient services for people with intellectual disabilities. Data were collected on setting and patient characteristics, staffing and management and care processes and outcomes.Results  Services were very unevenly distributed across England. There were differences between NHS and IH settings. IH assessment and treatment units were bigger, had higher occupancy and lower staff ratio. In all three types of unit, IH units had fewer visits to patients, used more seclusion, physical restraint and had more locked areas. They had more complaints in more services from users and (for assessment and treatment units and low secure units only) from relatives. In low secure units, they had more adult protection referrals. On the other hand, IH units used fewer agency staff in assessment and treatment units (though more in medium secure units) and provided more appraisals, more visits from commissioners, more consultations with GPs and dentists and more use of whistleblowing procedures by staff. A quarter of people in NHS assessment and treatment units had finished treatment but had no plan for discharge.Conclusions  Further research is required to determine the reasons for differences observed between IH and NHS units. The large number of people who have finished treatment emphasizes the importance of developing housing in the community with sufficiently skilled support. The large number of patients in low secure services raises the question whether this type of service is recreating the intellectual disability institutions which government policy intends to close.

ABSTRACTVerbal interactions involving direct care staff in a group home for people with moderate and severe mental handicaps were observed. The total amount of interaction staff had with residents and with each other was compared. The existence of interaction under different configurations of staff and residents was also examined. Overall, the care staff were involved in interactions across 71.1 per cent of observed intervals. They were almost twice as likely to be involved in interactions to or from residents (47.3 per cent) than to or from other staff (25.9 per cent). However, when compared across different configurations, interactions with residents were less frequent when other staff were present, suggesting that interactions with staff were preferred. Examination of staff‐staff interactions suggested that these were largely work‐related, so to dismiss them as detrimental to people's work is premature. Ways in which staff‐staff interaction may be important are discussed.

ABSTRACTStructured diaries describing the activity of three people with mental handicaps were kept by direct‐care staff and compared with results of simultaneous direct observation using five‐second momentary time‐sampling. Item‐by‐item agreement on main activity in five‐minute time blocks ranged from 41 to 72 per cent. Even averaged across three‐hour sessions substantial inaccuracy remained. These results suggest great caution is needed in using diaries as a source of evaluative data.

Background  National minimum standards for residential care homes were introduced following the Care Standards Act 2000 in response to concern about the lack of consistency and poor quality services. These standards are intended to reflect outcomes for service users and to be comprehensive in scope.Method  This study compared ratings made by care standards inspectors with research measures for 52 homes for people with intellectual disabilities serving 299 people. The research measures focused on the lived experience of residential care, including engagement in meaningful activity, choice and participation in activities of daily living. They also included measures of related care practices and organizational arrangements.Results  The research measures were in general significantly correlated with each other. Most of the care standards ratings were also correlated with each other. However, only two of 108 correlations between care standards and research measures were significant. Possible reasons for this are discussed.Conclusions  This study confirms that the review of national minimum standards and modernization of inspection methods recently announced by the Department of Health and the Commission for Social Care Inspection are timely and appropriate.

Background  Determining the relative importance of variables including client characteristics, setting features, staffing and care practices on the lives of people with learning disabilities in residential care continues to be a relevant topic for research.Methods  Measurements were made of the adaptive and problem behaviour of 343 adults with intellectual disabilities living in 76 residential homes and of various aspects of staffing, care practices (extent of active support) and resident engagement in meaningful activity. Ordinal and logistic regression was used to identify variables best predicting engagement and care practices.Results  Only adaptive behaviour and care practices predicted resident engagement in meaningful activity; only age and adaptive behaviour predicted care practices.Conclusions  Given the limited scope for changing resident adaptive behaviour, attention should be given to improve active support in residential homes in order to promote greater engagement in meaningful activity by people with learning disabilities.

A handbook was written to instruct researchers and health and social services staff how to carry out sensitive yet quick, simple, and inexpensive measures of engagement in activity by old people in residential care. The handbook was tested experimentally to demonstrate that researchers and staff could observe engagement reliably, using only the written instructions. High levels of the interobserver agreement were attained by subjects with little or no previous experience in direct observation, showing that the handbook was sufficient for training researchers and staff in the use of the measure. Some limitations of the handbook are discussed.