INTRODUCTION

TThis policy sets out the framework and commitment of Positive Support for You to PBS. We understand the need to support people to lead the lives they choose with valued opportunities and maximum choice and control. As a provider of support to people with complex presentations PBS holds relevance. PBS aims to enhance our understanding of a person’s life not by providing subjective opinions but by gathering information in a systematic way, using good quality evidence from people the person knows best. As supporters of people with learning disabilities we have a duty to understand the function of certain behaviours and the impact of our own responses. PBS is a learning model based on psychological theory but has person centred values at its core. The re is nothing wrong with seeking attention, a preferred object or wanting to remove oneself from an environment or set of demands but too often the people we support are not able to communicate those wishes to us. Challenging behaviour then has served an important role and has a clear function for people to communicate their needs. It is our role as a support provider to aim to understand the complex circumstances at play which influence a person’s behaviour.

AIM

This policy will detail the PBS process in Positive Support for You and how both the commitment and values of maximising choice and control and understanding behaviours of concern are embedded in organisational structure, leadership, person centred planning and reviews, training of our support staff, supervisions and team meetings to ensure excellent outcomes for the people we support. In short, we aim …

• To ensure Positive Behaviour Support has  Lead Practitioners to provide support, training and leadership in PBS and ensure strong partnerships with multidisciplinary teams.

• To ensure we understand, prevent and manage behavioural incidences.

• To ensure we understand the possible meanings and function of the behaviours of concern.

• To ensure the least restrictive option is always pursued.

• To ensure support teams understand all aspects of the support plan.

• To ensure positive outcomes for the people we support.

Positive Behavioural Support

PBS is embedded in psychological theory and applied behaviour analysis and has a scientific basis. It’s a framework to help analyse behaviour and collect good quality information so we can understand the function of certain behaviours. It is a framework based on positives, not withdrawing items or having punitive results, but of life enhancing growth and development to achieve similar outcomes in more positive ways. As such the plan will involve the person or attempted involvement of the person, family, friends and advocates and paid carers supporting the person. It will also be conducted in a manner consistent with the Mental Capacity Act 2005.

No CHALLENGING BEHAVIOUR/BEHAVIOURS OF CONCERN

Much has been written over recent decades about challenging behaviour, it is very much a social construct, based on our expectations of behaviour. Behaving in ways outside the social norms may be due to an impoverished life, lack of meaningful activity, inability to express oneself and communicate choices, lack of social networks, traumatic events, physical pain and poor health outcomes. The building blocks of human growth often missing historically for the people we support. Cumulative exposure to negativity, constant changes of staffing outside the persons control, loneliness, boredom and possible mental health issues create a vulnerability to behave in ways which fall under the label of challenging or behaviours of concern. However,this does not explain why certain behaviours continue for a person, so they must serve some purpose or function whether it be stimulation, attention and interaction, access to preferred objects or avoidance of certain demands. There is rarely one single function, almost always it’s a complex of interactions with certain environments and people which varies from person to person and environment to environment. Emotions too are added to the complex mix with stress anger and fear creating a complex dynamic.

It is really important that it is only individuals who display challenging behaviour or at risk of displaying challenging behaviour or both who have a PBS plan.

SCOPE

PBS has much in common with person centred support and planning needs to be embedded in the organisation. PST has an organisational commitment to PBS. Strong Leadership from the CEO/ Operational Director and Senior Management Team will ensure it’s a cornerstone of the work of Positive Support for You. It is an agenda item at Senior Management Meetings, with regular reports for Board Meetings. Team Managers meetings, support worker team meetings and supervisions will ensure it has maximum impact for the people we support. A Lead Practitioner will ensure training events are timely and functional assessments and plans have maximum impact for the people we support. Training is embedded, specific around teams and a person’s needs but also ensuring all those with leadership responsibilities have PBS high on their agenda. Plans specify any necessary characteristics for those supporting the person (mediators) and team members are trained to reliably and consistently implement strategies. Positive Support has a lead practitioner and a second practitioner will complete their Level 7 Postgraduate training by the end of 2022. Both practitioners also hold psychology degrees and are well placed to develop strong partnerships and a comprehensive training plan.

Assessment

Before a PBS plan is completed a Comprehensive Assessment of a person’s support needs will involve significant people in the person’s life and may well be a multi-disciplinary document. Information will be reviewed from the person and those people who are important to the person, current records, social work assessments, risk assessments and daily records including ABC’s will be analysed. Training in PBS will ensure the support team understand what type of social interaction the person enjoys, how the person communicates and when the person is understood by those around them. They will understand the importance of consistent language and respect for personalised rituals, routines and visual cues to ensure the person understands what is happening and what is about to happen. Environments will assess sensory preferences but encourage independence and choice. Good physical health and appropriate screening will also be high on the agenda with pain management assessed and reviewed.

POSITIVE BEHAVIOUR SUPPORT PLAN

A good Positive Behaviour Support Plan ultimately is to help the person lead a fulfilling life by understanding the function of the behaviour’s and thereby reducing / replacing the behaviour’s with alternatives. The aim is to maximise safety, enhance coping strategies and enable those around the person, in our case staff teams, to understand the impact of their own behaviour and the function of the behaviours of the person they support. The development of a person’s plan is based on gathering systematic information from those people who know the person well. The approach is data driven to ensure that data informs the interventions rather than subjective opinion. The plan is based on a functional assessment and contains a range of strategies which includes ways for the person to access things that are important to them. It is crucial then that person-centred planning is also the cornerstone of practice. The strategies are referred to as Proactive or Reactive Strategies. The plan will aim to state how to avoid or prevent behaviours of concern by collecting quality data and evidence both directly and indirectly. Indirect data will be collated through records team interviews and group work. However, it is acknowledged that this data can be subjective. Direct data, usually more accurate, will involve direct observation recording frequency, duration and intensity of behaviours of concern.

Proactive Strategies

The proactive strategies are intended to ensure the person has what they need and what is important to them and should be comprehensive. A good plan should have detailed information on the person’s likes and motivators. As well as enhancing and learning new skills. It is the essence of person-centred planning, who is the person? What do they enjoy in life? Does the person need support to learn new life skills? Does the person need support around communication? How does the person relax and have down time? This part of the plan states how to avoid or prevent the behaviour of concern and will define ways for the person to influence what happens to them and to communicate without the need for behaviours of concern. These strategies comprehensively address the identified functions of the behaviour. Thus, ensuring the plan is focused on positive outcomes and life enhancing opportunities.

Person Centred Planning

This is key to all assessment processes, to ensure likes, dislikes, aspirations, learning and opportunities are the precursor to real understanding of the person’s behaviour and ensure a strength-based approach with behaviours not identifying the person. Positive Support has trained person centred planning facilitators and has a special interest group. Formal plans link to goals and outcomes monitoring and person-centred reviews and activity plans. Information compiled with the person and family ensure a strength-based support plan incorporating choice and preferences. This information is key when compiling proactive support strategies. Positive Behaviour Support then should enable the person to develop and achieve personal goals in life.

Communication

Effective communication is a key aspect of any quality support. Understanding how a person communicates whether it be verbally or non-verbally through their actions is a core support skill, as is active listening. PBS plans will describe the person’s unique character and the most effective means of communicating for successful interactions. The PBS plan incorporates a communication profile to ensure we are supporting the person to express their needs, emotions and choices.

Reactive Strategies and Data

These strategies are designed to keep the person safe and provide ways to act quickly if the person is distressed. The plan should give clear instruction to staff on how they should intervene in the early stages to prevent further escalation. The plan includes one or more non-restrictive strategies for responding to instances of behaviours of concern. Where physical intervention, managing of actual or potential aggression, disengagement, and medication are included these are not included without a clear rationale and are assessed as part of the multi-disciplinary process.  They are always the least restrictive option to keep the person and their teams safe. We adhere to the STOMP agenda and will always seek to understand the functions of behaviour, analyse data and manipulate antecedents to avoid conditions which the person finds difficult by developing a capable environment with well trained staff. Data is analysed by PBS practitioners and champions. Some of our staff hold a Level 4 in PBS. Team meetings play a crucial role in involving support teams and developing implementation plans. PBS has enabled a number of people from longstay hospital with complex presentations to have behavioural PRN removed completely. We have clear data of enhanced quality of life. We compare annual data on ABCs, use of PRN and safety interventions. It is rare that physical interventions are used as staff understand low level signs of arousal and are quick to respond using proactive strategies.

Safety Interventions and Least Restrictive Practice

We train in Safety Interventions to support Reactive Plans. We recognise that any model is not effective if it is not supported by experienced managers leading their staff teams. We use our safety and wellbeing assessments to support positive risk-taking tailored to individual’s needs –and these are informed by Positive Behavioural Support Plans. Person Centred Risk Assessments cover each identified area of positive behavioural support.  Our Positive Behavioural Support plans are supported by the British Institute of Learning Disability (BILD) accredited Safety Intervention training  and NAPPI, Non Abusive Psychological and Physical Intervention training. We train that this is a last resort action to maintain safety. We strongly believe that incidents of aggression should be managed with non-aversive techniques and with a strong focus on de-escalation. Withdrawal of staff in the home environment if possible is always a preferred option. A major aspect of the training is to outline levels of behaviour and appropriate responses to it. It reinforces PBS strategies by raising awareness of verbal and non-verbal communication and the affect this can have on both the individual displaying the behaviour and the supporting staff member. The importance of understanding that behaviours of concern are primarily socially constructed needs to be understood to reduce and positively manage potential instances of behaviours of concern. Staff learn techniques that involve active listening and how to respond to incidents in a way that deescalates the behaviour and potentially avoid a crisis. They will learn about offering choices but avoid sensory overload. Staff learn that appropriate limits in relation to behaviour are best received when a positive choice and consequence are stated as early as possible, at first signs of escalation, as this is when it is most effective. This is implemented in service user support on a person specific basis and used alongside techniques relating to interrupting an aspect of behaviour and redirecting the individual’s attention.. It is important we enable staff to understand how their behaviour and attitude can impact the behaviour of those they are supporting. An outcome for staff is not to be totally focused on the behaviour but to see the person’s qualities and individuality. The physical aspect of the course does not teach participants ‘self-defence’ techniques. It enables staff to protect themselves and others from injury if they encounter someone engaging in destructive behaviour. They are taught that physical interventions are a last resort after all other techniques have been unsuccessful. Risk of potential physical restraint and all the interventions within the course have been independently assessed as not to be high risk to service users or staff. Individual service user safety assessments are an import part of the positive behavioural support process to ensure that risk is managed on a person -centred basis. Staff are taught the importance of recording behavioural incidents on ABC (Antecedent, Behaviour and Consequence).Any instances of harm are recorded on an Accident and Incident Form and safety assessments are comprehensively reviewed by PBS Practitioners and Managers. These form part of a continual review process for updating support documents, analysing data and determining the functions of behaviour. In reality it is rare that we require any physical intervention across all our support services. Annual data is available.

Leadership and Learning and Development.

As such we hold a policy position of enhancing people’s lives with proactive strategies and collecting data to understand the function of the behaviours of concern. We train our teams in Positive behaviour support and focus on a Human Rights approach. As well as formal training we take a proactive approach to restrictive practice and use team meetings to deliver restrictive practice training pods which are relevant to the specific service. We emphasise quality of life and values training as building blocks to non-restrictive practice.

Restraint is an act carried out with the purpose of restricting an individual’s movement, liberty and/or freedom to act independently. This may or may not involve the use of force. Restraint does not require the use of physical force, or resistance by the person being restrained, and may include indirect acts of interference for example removing someones walking frame to prevent them moving around. ( EHRC, 2019)

We are committed to Positive Behaviour Support. Leading support in proactive strategies which work for the person whilst understanding that all behaviours of concern are a form of communication and happen for a reason. We complete functional assessments where necessary and involve whole teams in the development of non- restrictive strategies to minimize the need for behaviours of concern. Our teams understand the need for data so we can alter the antecedents to behavior and understand the impact of the consequences and how we can unintentionally maintain behaviours of concern. We work hard to understand the root causes to behaviour and avoid any physical interventions.

AUTISM and PEOPLE WITH LEARNING DISABILITIES

PBS is recognised as a valuable support tool for people with Autism Spectrum Conditions. All our support workers are trained in autism awareness. They are aware that autism is a spectrum condition and person-centred support is crucial to the person’s life enhancing opportunities. Every human being is unique. They learn that people with autism share a triad of impairments-social communication problems, both using and understanding verbal and non-verbal language. Social interaction issues, recognising and understanding other people’s feelings and managing their own. Social imagination impairments and difficulties in understanding and predicting other people’s intentions and imaginary situations outside their own routine. Any PBS plans developed, and any analysis need to be understood within the above context when developing strategies and routines to reduce arousal.

Review

As with all good practice, review should be an ongoing process but also needs to ascertain the effectiveness of strategies being used to address any behaviours of concern and to assess staff consistency. It is likely therefore that monitoring is intensive in the early stages with Team Managers analysing documentation along with the PBS Lead and assistant PBS practitioner. Strategies will be monitored and reviewed at team meetings, with the person, supporters and MDT on an ongoing basis.

Sue Paton

Bsc Psychology, M.A, PG Dip, PG Cert Dis  PBS, Social Work registration

Fran Macdonald

BSc Psychology, PG Cert PBS in process