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Residential staff working in the first two staffed homes of a local service for adults with mental handicaps were interviewed in-depth at regular intervals over several years about their experiences, as part of a “formative evaluation” of the service overall. Certain key issues

“AN ORDINARY LIFE”: the early views and experiences of residential staff in the Wells Road Service

Linda Ward

“Staff who are in direct contact with service users are the most valuable resource of any service for people with learning disabilities.” (Porterfield, 1987). How staff work - their performance, attitudes, and

behaviour towards service users - largely determines the quality of the service in which they are employed and thus, to a considerable extent, the quality of service users’ lives; hence the importance of recent research exploring the activities of staff at work in the community services that are now mushrooming in the drive towards “community care” (Felce, de Kock, and Repp, 1986; Evans, Blewitt, and Blunden, 1983; Evans, Todd, and Blunden, 1984; Evans et af., 1985).

Staff can also be a vital means of improving or sustaining service quality in another important way. As individuals they have direct, day-to-day, personal experience of services as they are in practice, rather than as they are in plans or in theory, and how they impinge on service users’ lives. Through staff and their “hands on” experience a good deal can be learned about the practical problems and dilemmas that arise in “Ordinary life” type services and how these may best be addressed.

The Wells Road Service Soliciting, and then utilising, staff views in order to

improve service quality is not common practice in the UK, although mechanisms for routinely doing so have been developed (Porterfield, Evans and Blunden, 1983; IDC, 1986; Porterfield, 1987). A focus on staff views, however, was seen to be an important feature of the “formative

evaluation” * conducted into the Wells Road Service, a developing community service for adults with mental handicaps in South Bristol.

When the service was established in 1982, there was little knowledge or experience in this country of how to translate the innovative ideas of An Ordinary Life (Kings Fund Centre, 1980) into practice. It was decided therefore, to mount a study of different aspects of the service as it evolved, for the benefit of others embarking on the same road. The research was funded by the Joseph Rowntree Memorial Trust and the South Western Regional Health Authority, and was conducted from 1982 to 1987. The key areas of study were: the evolution of the service overall (Ward, 1986a, b; 1987b); the quality of life and social integration of service users; the cost effectiveness of the service in comparison to other residential options (Davies, 1987; 1989 in press); and staffing issues (Ward, 1984, 1985, 1987a).

Staffing The Wells Road Service was established by Bristol and

Western Health Authority, for adults with mental handicaps from a small geographical patch of South Bristol (three square miles in area; population - 35,000). It had two components: a residential service, providing housing and residential support; and a community service, offering new opportunities and help to adults living at home with their families.

The residential service (initially two houses, each home to three people) at first employed six staff and one manager (home leader), with part-time, back-up relief available at times of illness and holidays. (The staff complement has since been increased in order to service additional homes and to support an adult with profound and multiple handicaps who now lives in one of the original houses.) The community service was staffed by two full-time community support workers. (The community support service has now been replaced by a more conventional community mental handicap team (Ward, 1987b)).

Both parts of the Wells Road Service were managed by a coordinator. Specialist advice, for example from a psychologist ,ipsychiatrist ,\occupational Itherapist, and speech therapist, was available as required. All staff posts were located on NHS Administrative and Clinical grades to permit the recruitment of people from a wide range of backgrounds and experience. The staff appointed had backgrounds in teaching, adult training centre, nursing, and residential

* Formative evaluation involves collecting and feeding back information in order to improve a programme or servicel(Herman, Morris, and Fitz-Gibbon, 1988).

LINDA WARD is a Research Fellow at the Norah Fry Research Centre, University of Bristol, 32 Tyndall’s Park Road, Bristol BS8 IPY.

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MENTAL HANDICAP VOL. 17 MARCH 1989

work. Their experience in the field of mental handicap ranged from considerable to none at all. They were aged from 18 to 52 years and, until 1987, were predominantly women.

Conscious efforts were made from the outset to promote positive working conditions for staff. These included:

0 detailed job descriptions, subject to regular review in the light of experience;

0 weekly staff meetings, for residential and community staff separately;

0 monthly service meetings for all staff; 0 individual staff supervision; 0 staff support sessions; 0 intensive initial training particularly for the original

0 ongoing in-service training, both in-house and

0 involvement in reviews of service progress and

residential staff (Ward, 1985);

external (Ward, 1987a); and

forward planning.

Study method Interviews were conducted with staff individually on a

regular basis: at the point of recruitment; mid-way through and on completion of their initial training; and at six-monthly intervals thereafter until July 1984. The purpose of the study was to obtain detailed information from staff about their early experiences of working within this “model” service. Staff have since been interviewed in connection with a number of separate studies, the material from which is not reported here.

Each round of interviews was conducted on an in-depth, semi-structured basis, using a questionnaire drawn up for the purpose. Topics of focus varied at different stages of the evaluation, according to service developments at the time and different staff members’ roles and responsibilities. Some issues, however, were consistently explored: staff support, supervision, and in-service training; staff views on positive and negative developments in the service to date; and staff ideas for service improvements in the future. Material from the individual interviews was collated, summarised (to ensure confidentiality for individual staff members and their views), and fed back to staff on a group or individual basis as appropriate. With staff agreement, key issues were then passed on to other relevant points in the service hierarchy, namely the home leader, service coordinator, or unit administrator, for consideration and hopefully action.

Results So how did staff find working in this “model” service in

which they were employed? Constraints of space preclude a detailed view here of all aspects of staff experiences and ideas. What follows is a distillation of the key issues and themes that emerged from staff of the residential service, particularly during the first few years. The first six months

Looking back over the first six months of the service, certain clear areas of concern emerged.

First, there had been particular difficulties in coping with some people’s aggression and other “problematic” behaviour, towards staff, fellows, and other people. What could be done by colleagues and other staff in the service to give more support to residential staff experiencing these

problems? How could the service ensure something was done sooner, when problems first developed (for example, when aggression was threatened or at the onset of “disturbed” behaviour arising through illness)? What could be done to help staff feel more confident about handling such behaviour in the future? Staff ideas here included: in-service training; self-defence classes, especially for women staff; a telephone in the staff bedroom; and help in setting up a group in the house to work through difficult issues.

Second, there were several problems in connection with goal planning and helping people to learn new skills. Some staff felt that more should be happening in this area. How could they ensure it did? There was uncertainty about appropriate “goals” for “more able” individuals. Staff were not sure if they should work on goals in people’s leisure time (that is, evenings and weekends). Should there be a more structured programme for people on days when they did not attend the adult training centre? A subsequent in-service training day helped address some of these fundamental issues in detail.

Th i rd , some obvious weaknesses in the initial establishment of the first two staffed houses had become clear. It was decided that, in future: people who were to share a house should be selected with a view to them being more compatible, if possible; they should know exactly which bedroom they would be moving into in advance; all household equipment should be present before they moved in; systems and routines for working on goals and household chores should be sorted out before, or immediately after, they moved in, so that residents and staff alike would know what was expected of them and could act accordingly.

Other, more minor dilemmas had emerged. For example, staff were uncertain about how they should handle household tasks. Which chores were staff responsible for? Which should the residents do? Should staff do the jobs that the residents did not do, not through lack of skill, but through lack of time or inclination? Inevitably there were mundane, but important, issues for staff over rotas. Should late shifts be followed by “earlies” when staff were not sleeping in overnight? It was agreed that this should be avoided whenever possible. What could be done about the seeming impossibility of taking theoretical meal and coffee breaks in a residential situation? Very little, it appeared.

Finally, there was the question of how to strike a balance between setting up interesting activities with and for the adults with mental handicaps at home, for example, learning carpentry, as opposed to outside, for instance at adult education classes. Clearly, more links with the local community needed to be forged. It was felt that if volunteers or other people from the community became involved with the adults on a one-to-one basis, and friendships developed, individual adults would be able to go out more often and experience a wider range of activities

After a year Six months later, after the houses had been open for nearly

a year there had been some major changes. The home leader had resigned in order to return to a career

in mental illness nursing. For a variety of reasons his successor was not appointed for several months, which left residential staff without an immediate line manager. Support, supervision, and managerial activities were undertaken by the overall service coordinator, and individual staff members took on particular aspects of the home leaders’

~~ ~ ~~

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MENTAL HANDICAP VOL. 17 MARCH 1989

role, such as responsibility for ensuring the books balanced financially and organising staff rotas. One member of the original support staff team had left and been replaced. A clinical psychologist had been appointed with special responsibility for the service. The original, somewhat incompatible, household groups had been rearranged so that three “fairly able” adults were now living together, with less intensive staff support than before.

How had all these changes affected the views of staff about their work? In interviews, a number of themes emerged.

As far as helping adults learn new skills and enjoy new opportunities was concerned, things were going better now that individual key workers (residential staff members), rather than the home leader, were responsible for drawing up goal plans. Staff had found the new clinical psychologist particularly helpful both in assisting them with structuring individual reviews, filling in checklists, and drawing up goal plans, and in organising weekly skill teaching sessions. Even so, some concerns remained. For example, what should staff do if they thought a particular goal plan (drawn up by a colleague) was inappropriate? How could staff ensure everyone knew about new goal plans as they were drawn up? More importantly, how could staff ensure that everyone worked on them? It was hoped that the arrival of a new home leader would resolve these issues.

There were some tensions and problems of division within the staff group regarding, for example, consistency of approach and ideas about appropriate activities and organisation in the houses. The situation was exacerbated by the absence of a home leader who could ease such problems by making rulings so that staff would know what do do. The divisions meant that some individual staff felt quite isolated at times. On the whole, however, staff had felt support was available when needed: from the service coordinator, pending the arrival of a new home leader; from fellow staff; and from the fortnightly group support sessions established for residential staff following the previous round of interviews. Led by a clinical assistant with counselling experience, these sessions were generally appreciated.

As far as other recent changes in the service and its plans for the future were concerned, staff were positive about the flexibility and potential for change. Apart from niggles over details, such as the speed with which some decisions about change had been taken, most staff were: happy to be offering less intensive but more structured support to one household; keen to help two adults move out together into a new, permanent home; excited at the possibility of working in other homes nearby as they were established; and looking forward to meeting the challenges of working alongside people with profound and multiple handicaps in the future.

Six months later Six months later, 18 months after the houses were opened,

staff optimism had been tempered somewhat. Interviews

First, staff had been deeply distressed by persistent attempts at self-harm by one of the people living in one of the houses. Although grateful for the excellent support they had received during this period, they had felt ill-trained and ill-equipped to handle this person’s mental illness problems, and the difficulties caused by the mental health problems experienced by several of the residents. A series of three in-service training days were organised to address this problem.

’ revealed three particular areas of concern.

Second, staff were aware that familiar problems regarding skill-teaching and goal planning had re-emerged as a result of these crises, coupled with the disruption to routine caused by two people moving together into a new home and the departure of the clinical psychologist. Staff often did not know what goals were being set for whom, or whether goals were being worked on. Some were anxious about the effect on some people of inconsistent approaches, and wanted a more structured organisation of time in the houses.

Third, staff were frustrated by the slow progress in establishing additional homes in the area which was due to events outside the control of the service. They were also worried that the original ideas behind the “core and cluster” model on which the service was initially based were proving ill-founded. Experience had shown that moving the adults on to other permanent homes after a period of time in one of the original staffed houses was disruptive and counterproductive for all concerned. Staff were extremely heartened when this view was endorsed at an in-service day held at around this time to consider future plans for the service.

Conclusions The interviews reported here highlight some recurring

themes in the establishment of “ordinary” staffed homes for adults with mental handicaps.

First, tensions will inevitably arise when supporting people with mental handicaps in leading “ordinary lives” at home while helping them, in a systematic way, to learn new skills as they do so. There are phiIosophical and ethical issues here, but also practical ones about the organisation of daily activities, skill teaching, goal planning, and the maintenance of consistency of approach and momentum in these areas.

Second, even with extensive initial and in-service training, certain issues will remain difficult for staff to handle. The early experiences described, relating to aggression and mental health problems, stand out as particularly taxing for staff. The availability of good individual and group support and supervision are of fundamental importance, alongside whatever practical action, help, or other back-up is needed.

Third, the involvement of staff in regular reviews of progress and plans is crucial if services are to learn from experience and really develop around the needs of individual service users. In addition, staff feel happier and more valued in their work if they know their views count. In the early years of the Wells Road Service, their views were deliberately sought, both from within the service itself and through interviews with the researcher, and this proved to be greatly appreciated by staff. Staff also valued regular opportunities to come together for staff meetings, support sessions, and in-service training days; both for the intrinsic benefits of support and discussion and the resulting feeling of being “part of a team”.

More recently, other issues have emerged. In addition to management changes, most members of the original staff team have now left and new, and additional, staff have been recruited. Induction training for these staff has, for various reasons, been minimal in comparison with what was provided from the original team; in-service training likewise.

Experience at Wells Road, and from other similar services, indicates that the quality of life of many adults living in staffed houses falls short of the ideal. In particular, the lack of close personal relationships within the local community is emerging as a vital issue to be addressed; one in which staff

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MENTAL HANDICAP VOL. 17 MARCH 1989

may have a crucial and previously unrecognised role as “bridges” or facilitators (McConkey and McCormack, 1983).

Ironically, as pressure to close hospitals and open more houses grows, it may become less, rather than more, easy to develop “high quality”, model services. It may become harder to generate the sense of optimism, excitement, and commitment that was engendered by the first trailblazing services amongst staff and management alike. It may become all too easy for things to slip and stagnate, as new projects become either old or commonplace.

The widespread adoption of mechanisms like positive monitoring and quality action groups, designed to involve staff, service users, families, and managers alike in improving service quality, may help to avoid this eventuality. Positive monitoring (Porterfield, 1987) means specifying clearly to staff what they should be doing, teaching them how they should do it, regularly checking out how things are going, and giving constructive and positive feedback to individual staff members on their work. Regular, positive feedback of this kind is not common currently in mental handicap services. Quality action groups are a still newer development. Key “stakeholders” in a service, such as staff, manager, service users, family, and friends, form a group which meets regularly to review the quality of that particular service in practice, and to take appropriate action to improve it on an ongoing basis. Early accounts of this approach (Blunden and Beyer, 1987; Beyer, 1987) suggest it has much

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to recommend it, not least because of its emphasis on practical accomplishments of services in users’ lives and its welcome emphasis away from a “top down” approach to monitoring for quality. Without such an approach it may become difficult for residential staff in the future to say (as they did of Wells Road), “It’s a really good service and a really good staff team”.

Acknowledgements Thanks to the Joseph Rowntree Memorial Trust for funding the

research on which this article is based, and to the staff of the Wells Road Service for sharing their ideas and experiences with me.

REFERENCES Beyer, S. Pursuing quality through a Quality Action Group:

experiences in the CUSS Home Support Service. In Ward, L. (Ed.). Getting better all the time: issues and strategies for ensuring quality in community services for people with mental handicap. London: King’s Fund Centre, 1987.

Blunden, R., Beyer, S. Pursuing quality: a practical approach. In Ward, L. (Ed.). Getting better all the time: issues and strategies for ensuring quality in community services for people with mental handicap. London: King’s Fund Centre, 1987.

Davies, L. Cost evaluation ofresiden tial services for people with learning difficulties. Birmingham: Health Services Management Centre, 1989 (in press).

Davies, L. Quality, costs and “An Ordinary Life. ” Comparing the costs and quality of different residential services for people with mentalhandicap. London: King’s Fund Centre, 1987.

Evans, G., Blewitt, E., Blunden, R. A preliminary study of problem behaviours within a staffed house for severely mentally handicapped people. Cardiff: Mental Handicap in Wales - Applied Research Unit, 1983.

Evans, G., Todd, S. Blunden, R., Porterfield, J., Ager, A. A new style oflife. Theimpact ofmovinginto an ordinaryhouse on thelives ofpeople with amentalhandicap. Cardiff Mental Handicap in Wales - Applied Research Unit, 1984.

Evans, G., Todd, S. Blunden, R. Working in a comprehensive community based service for men tally handicapped people. A survey of the staff of the NIMROD service. Cardiff Mental Handicap in Wales - Applied Research Unit, 1984.

Felce, D., de Kock, U., Repp, A. An eco-behavioral analysis of small community based houses and traditional large hospitals for severely and profoundly mentally handicapped adults. AppliedResearch in Mental Retardation,l986; 7:4,393-408.

Herman, J . L., Morris, L. L., Fitz-Gibbon, C. T. Evaluator’s Handbook. London: Sage, 1988.

Independent Development Council. Pursuing Quality. How good are your local services for people with mental handicap? London: IDC, 1986.

King’s Fund Centre. An Ordinary Life. Comprehensive locally- based residential services for mentally handicapped people. London: King’s Fund Centre, 1980.

McConkey, R., Mdonnack, M. Breaking barriers. Educating people about disability. London: Souvenir Press, 1983.

Porterfield, J., Evans, G., Blunden, R. Working together for change. A service manager’s guide to involving staff and f d e s in servjce improvement. Cardiff Mental Handicap in Wales - Applied Research Unit, 1983.

Porterfield, J. Positive monitoring. Kidderminster: BIMH Publications, 1987.

Ward, L. After induction then what? Providing on-going staff training for “An Ordinary Life”. British Journal of Mental subnormality, 1987(a); XXXIII Pt 2: 65, 131-142.

Ward, L. Alternatives to community mental handicap teams. Developing a community support service in South Bristol. In Grant, G., Humphreys, S. , McGrath, M. (Eds.). Community menral handicap teams: theory and practice. Kidderminster: BIMH, 1986(a).

Ward L. Changing services for changing needs. Community Care, 1986(b); May 22, 21-23.

Ward, L. Planning for People: developing a local service for people with menral handicap. I. Recruitingand trainingstaff. London: King’s Fund Centre, 1984.

Ward, L. Pursuing quality in community support services. Lessons from the Wells Road experience. In Ward, L. (Ed.). Getting better all the time? Issues and strategies for ensuring quality in community services for people with mental handicap. London: King’s Fund Centre, 1987(b).

Ward, L. Training staff for “An Ordinary Life”: experiences in a community service in South Bristol. British Journal of Mental Subnormality, 1985; XXXII Pt 2: 61, 94-102.

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