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Layout, design and behaviour

29 Mar 2016

We speak with Precious Homes’, Chief Operating Officer, Greg Lapham, on how the layout and design of a service plays an important role in de-escalating behaviour that may be described as challenging and ensuring placement success.

1. What role does the living environment play in supporting adults who exhibit behaviour that may be described as challenging?

The living environment is critical to the success of a placement and unfortunately this is not focused on enough by providers. If a service is designed poorly it increases the chance that service users and staff can get hurt. If a service user experiences an episode of behaviour that may be described as challenging and consequently is injured, for example by falling and hitting their head on the corner of a wall or in a bathroom, it is likely that they will need to receive hospital treatment. This can create unnecessary additional trauma and can set them back with their independence development.

Simple improvements within the environment like taking the corners off walls and changing the layout prevents that additional trauma, and you stop an already negative situation from escalating into something much more complex.

It’s important to try to keep episodes of behaviour that may be described as challenging as short as possible, so that both the service user and the staff can move on more quickly, preventing the need for ongoing medical care and additional support. For example, a behaviour presented by some adults with autism is that they pick at the stitches on a wound and this increases the chance of infection. An injury or time spent in hospital can be very disruptive to their routine and development because wounds do not heal properly and treatment needs to be ongoing.

A little bit more effort at the start of a placement can avoid prolonged periods of behaviour that may be described as challenging. For example, one of our service users has a tendency to bang his head a number of different items within his living environment, walls, taps, sinks etc. Before he moved into our service, the manager went through a thorough assessment of his needs and behaviours, and we then made a number of changes to his flat so now it is a bespoke living environment for him.

The taps in the bathroom have been recessed and no longer protrude, so he now puts his hands into the wall to wash them. The basin is also half recessed so there is less danger of him hitting his head and we have amended the bath so that it fills up through an additional hole (much like the overflow hole) rather than protruding taps. We also removed the radiators, as in the past he had ripped them off the wall, so we took away that risk and put in an air conditioning system that meets his needs. When you remove furniture or room features it does leave the room quite sparse which means there is an echo, the echo then provided further stimulation for the service user which triggered challenging behaviour so we put in acoustic sound absorbing materials to reduce the echo and created a much calmer environment.

So far the placement has been a success. The changes we made, based on the service users needs and behaviours, have helped him continue to live more independently and so far he has avoided a return to hospital.

2. What’s the most important aspect of the design or layout to help people with behaviour that may be described as challenging?

The first test is to ask yourself the question, would I allow my kids or members of my family to live in this environment, is it acceptable? You should answer immediately ‘Yes’ and if there is any doubt at all then you need to go back to the drawing board. You need to rethink the layout and the design and make sure that it is somewhere that you would be happy having members of your family live in.

If we, as the providers, don’t believe in it, how’s that going to come across to our service users and their families? We need to be committed and believe in what we are providing. Layout has a dramatic effect on behaviour and if not suitable for service users it can escalate behaviour causing placement breakdowns, so we must be confident that the design of our services is suitable for the people who use them.

Secondly, its hugely important to reduce the pinch points within the layout of a building that increase the chance of behaviour escalating. For example, avoid long corridors, keep them to a max of 2-3 metres. Have a central communal space with short corridors branching off it so that you reduce the number of service users walking up and down the corridors, walking past each other and potentially causing conflict.

Also remove all blind corners in corridors, make sure they are straight so that there is a clear line of sight up and down them. Service users can bump into each other if they can’t see around the corner and they can get hurt.

3. What feedback have you had from service users living in these new environments?

All our feedback has been hugely positive. Our non-verbal service user who has his own bespoke flat responded with a double thumbs up when I asked him what he thought of his new home and for me that’s the best feedback you can get. Those who had known him in previous placements have commented on how well he is doing. This is his longest placement to date (1.5 yrs) without going back into hospital so we are very proud of his achievement. The less time he spends in hospital the more support he can receive to further his independence and he can make real progress.

4. Why do you think these facilities have been missing in the sector so far?

There’s a number of different factors but the main one is cost. It requires upfront investment from the provider and that’s expensive. Often there are pressures to fill vacant beds so placements are sometimes rushed and service users are housed in inappropriate environments. But this is a short-term view because when the placement breaks down and the service users returns to hospital or has to be moved on elsewhere, money is lost for the provider and also it costs the NHS and local authorities further money. When you rush placements it means there is a compromise from day one, and you might as well just stop the process right then because there is much less chance that the placement will be successful.

Adults with complex needs do not fit into standard living environments, it’s like trying to fit a square peg into a round hole. Providers should think long-term, invest the money up front and ensure that service users can access the personalised support that they deserve.

5. What feed back have you had from staff?

We’ve had excellent feedback from our staff. The working environment makes a huge difference to them. They are committed to providing first class personalised support and by investing in their working environment it demonstrates that we share that commitment. If staff feel proud of where they work, they take more care and the quality of the environment lasts longer – if you like where you work, you look after it.

The staff are more motivated, they want to come to work and this means that we are improving staff retention and we retain our managers who provide consistency for the service.

6. What are you looking forward to for Precious Homes over the next 12 months?

I want more of the same great work, innovation and fantastic dedication for the next 12 months. With the same attitude and same approach, I want us to keep building on our successes and to keep getting better.

People work in the social care sector because they want to make a difference and they want to be proud of where they work, so we are going to continue to make improvements across our services, upgrading and redeveloping them. These small but significant steps actually have real long-term benefit for the company, for example, a better working environment, can help reduce staff turnover means we are able to train our staff more and develop their professional skills in more depth. This knowledge means they are better equipped to deal with behaviour that may be described as challenging which then prevents placements from failing because our teams have the skills to handle difficult situations.

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