We are The Behaviour and Communication Support Service. We work to support care home staff in Wandsworth to understand and manage behaviours that they find challenging in their residents. We work systemically with everyone involved in the resident’s care; including care home staff, families and other health and social care services. In our model behaviour that challenges is viewed as a way to communicate unmet needs and through understanding these behaviours we can tailor interventions to meet those needs. Behaviours are understood in the context of current and previous experiences. We believe that psychosocial interventions should be the first line of support for people experiencing distress.
What We Did
Our practice is guided by the National Institute of Clinical Excellence, the National Dementia Strategy, The National Service Framework for Older People and the Royal College of Psychiatry. In our model behaviour that challenges is viewed as a way to communicate unmet needs and through understanding these behaviours we can tailor interventions to meet those needs. Behaviours are understood in the context of current and previous experiences. We believe that psychosocial interventions should be the first line of support for people experiencing distress. When working with ‘Frank’ for example, we were able to understand his destructive behaviour in the context of his previous occupation as a handyman. We therefore devised interventions that would allow Frank to pursue his previous interests without causing damage to the care home environment. After the interventions the care staff were more empathetic and invested in understanding and spending time with Frank. As a result they felt more confident to support Frank and through better meeting his needs the incidences reduced.
As well as working directly with referrals for behaviour that challenges, our service has a variety of other roles. We deliver training to care home staff and we currently developing reflective practice groups for care home staff. We are committed to delivering evidence based practice and disseminating this to our stakeholders through a quarterly newsletter. We are also passionate about contributing to the evidence base for people with moderate/ severe dementia and the mental health professionals that work with them. We have completed a series of Cognitive Stimulation Therapy (CST) groups in care homes. This has shown a positive impact on the social engagement and quality of life of residents.
We have a information leaflet for care home staff to give to families of residents about behaviours that challenge. We are a friendly and open team. We follow an inter-disciplinary model and this encourages a non-hierarchical approach to working. This allows team members to seek support with cases and to feel confident and valued for the contribution they make to the development of the service.
Wider Active Support
We work with a network of complex systems. We work with care homes at all levels from care staff to relatives and management. ‘The Cracks in the Care Pathway’ highlighted our experience of the disjointed nature of services offered to residents. To address this, we have set up joint clinics with our GP colleagues. We also work closely with Continuing Health Care, Social Services and community therapy teams. Our experience has been that through a collaborative approach, all aspects of residents’ care are considered and this discourages duplication of services and miscommunication.
Due to a high amount of referrals from one specific care home we have set up a fortnightly clinic to help manage cases more effectively but to also help support and contain the care home staff’s anxiety.
Our model is person centred and we encourage staff teams to view behaviour in the context of the person and environment. One way this is endorsed is by gathering a detailed life history of residents through talking to them and their families and friends. We will then present this information at our case formulation sessions; which aim to encourage care staff to think more about behaviour that challenges in different contexts and to take a role in developing interventions.
This is in order to minimise the distress of residents and improve the confidence of staff in managing behaviours they find challenging. We have had positive feedback from our care homes that this is a novel approach to working for them and that the collaborative style is both supportive and empowering. All our interventions are tailored to the individual resident, with the help of their loved ones we are able to build a picture of who that person is. Following every formulation session we ask for written feedback from care staff, this enables us to reflect on our practice and be flexible to the needs of individual care homes.
Looking Back/Challenges Faced
Working with care homes and people living with chronic conditions including dementia can be emotionally challenging. To manage this we have introduced morning meetings to discuss plans for the day, cases of concern and to feed back any important information to the team. This has helped team cohesion and ensures that any risk or team concerns are identified and managed promptly. We also have regular supervision which provides an individual space to reflect on difficulties.
Another challenge for our service relates to the experience of high care staff turnover and frequent management changes in some of our homes. When there is instability within a staff team or reliance on a high proportion of agency staff, the incidence of behaviour that challenges and the number of urgent referrals we receive goes up significantly. We have recognised that when a new manager or staff team are in post, it is important to begin the process of embedding our service and rapport building again.
A more recent challenge has been the closure of two care homes. During this time we ensured that all our care plans and recommended interventions had been handed over to the staff in the new care home. We worked closely with relatives supporting them to adjust to a new care environment. We also worked closely with Social Services and Continuing Healthcare to ensure that residents were re-housed in appropriate care environments suited to their needs.
Our team members have a good understanding of the service ethos and well defined team roles. We have a joint leadership, which promotes continuity within the service and a shared approach to risk management. There are several systems in place including morning meetings and weekly MDT meetings; which encourages successful communication and a holistic way of working within the team. Having successfully become embedded in the care homes, the care staff have clear expectations about what our service can provide and know what support they can ask for.
All staff within the BACS team receive regular clinical supervision, helping staff to reflect on their practice and develop their skills. Many of the referrals to our team are worked jointly, ensuring that we utilise the different professions skills across the team for the benefit of the resident.
Evaluation (Peer or Academic)
We use the Challenging Behaviour Scale (CBS) to measure the frequency and severity of challenging behaviour and our results show that as referrals pass through the care pathway there is a reduction in CBS scores. We also use the Quality of Life in Late-Stage Dementia Scale (QUALID) to measure quality of life and our audit has demonstrated that following our interventions residents enjoy a better quality of life. Following a medication audit, we have also found a reduction in the use of anti-psychotic medication for our referrals. This is in line with NICE guidelines.
The team are looking to expand the data collected in the yearly audit by looking at specific types of behaviour that challenges that are referred to us. By looking at this in more detail we will be able to tailor different training packages to individual care homes based on the behaviours they find most challenging.
Our recent 2016/17 audit has demonstrated an increase in referrals and that we continue to reduce the frequency and severity of behaviours that challenge as captured through using the CBS.
We have had no admissions from care home to Psychiatric Hospital in the 2016/17 audit.
We continue to received positive feedback from care staff that we work with. We have recently implemented a feedback form that we use at discharge as a way of us capturing more formal feedback about the service to aid in service improvement.
We have recently been shortlisted for a Nursing Times Award in the Older Peoples Category.
We are committed to sharing positive practice within our team, with our stakeholders and with other healthcare professionals. We take it in turns to deliver training sessions to the wider team, which encourages good evidence based practice. Through training, our quarterly newsletter and facilitating therapeutic groups we encourage staff to deliver best practice and person centred care. We regularly present at professional healthcare forums and conferences. We have organised and delivered a training event for local GP’s around behaviour that challenges, associated physical health conditions and the importance of introducing psycho-social interventions alongside pharmacological treatment for best outcomes. We think it would be a great opportunity to host a learning event to share our experiences for developing a service to our and other NHS Trusts.
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Openness, honesty and collaboration are cornerstones of our service and have helped us model a new way of working. We have seen empowered care staff being experts in delivering effective interventions and witnessed the resilience, humour and capacity of staff and residents to cope with the challenges dementia brings. Our clinical expertise has taught us there is no ‘one size fits all’ approach to dementia care or people! Please see the film we produced showcasing the work we do: https://www.youtube.com/watch?v=6Y06kPafKPY