INTRODUCTION

This 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 if we are supporting the person to increase their quality of life. 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 information from the person and people the person knows best. As supporters of people with learning disabilities and their human rights we aim to understand why distress is evident, and how the impact of our own responses impact when people need support by a team of people in their own homes. PBS is a learning model based on psychological theory and has person centred values at its core. There 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 cannot easily communicate those wishes to us. Distress behaviours then have served an important role and have a 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, so we can reduce distress.  We do not see the person as ‘challenging’ rather we see people as distressed because we have been unable to understand the person’s needs. We understand that by making adjustments to the persons environment we can help the person to avoid distress. PBS is about having a well-trained team around the person to support and ensure that the person has a group of strong supporters who understand their distress and can create strong trust accounts to enhance lives.

We have seen PBS produce great outcomes which have enabled people with the greatest need to enjoy better life outcomes and increased quality of life. By investing in well trained, dedicated, and experienced teams we can ensure we meet the needs of the people we support. We always ensure we are working to high ethical standards enhancing and supporting people to live their best lives. Our strong value base in human rights, self-determination and equality can be evidenced in our support. We do however recognise that for some PBS is a controversial approach and attracts criticism from some self-advocates, families and professionals who are opposed to its use on ethical grounds. We acknowledge that given lack of certification and regulation there is poor practice in systems. Positive Support for You will always seek to listen to the views and choices of people we support, family members and significant others. To further strengthen this, we have arrangements in place independent advocates to support people with their choices. We are strong supporters of neurodiversity as a social movement, influencing many spheres of the disability movement and creating understanding of human diversity. This is highly conducive to the social model of disability. To equality and self-determination, very much the core tenets of Positive Support for you, to support vulnerable people to lead their best lives and combat the systemic failures which have created so many difficulties and trauma for the people we support. The fact that PBS has incorporated systems change has been a positive. To understand how the human condition can be impacted by unmet need, multiple placements, sectioning and multiple traumatic events can bond staff to understand the person better. To create teams around the person to achieve consistency in the minutiae of life, so the person understands now and next and feels safe. To create trusting environments where teams understand how to support the person both in and after a difficult situation without pathologizing and blaming the individual. To have a good understanding of the role of motivation to support people to navigate their day. All of which can be evidenced as life changing and of value to human growth. To understand the need to escape a difficult situation and to realise with genuine self-determination we all avoid stressful situations, but most of the people we support have not had this opportunity. To understand antecedents and consequences to avoid distress. These are all huge in our understanding of the human condition and increasing awareness to support. We are not proponents of the medical model, do not seek to cure or change but to find ways to develop human understanding and for people to navigate their own life with the support they need. Our commitment is not one of behaviour modification but understanding when we work with people who find it difficult to share their internal environment, describing their thoughts and feelings that we listen and observe and be guided by the person in a truly person-centred way. Our families describe their loved ones as being so settled, and we hope these people too have a voice in future debates.

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 distress.

• 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.

For people to live their best lives, actively in the way they wish.

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. Much of our work s about planning with the person to help them feel safe with a focus on the environment and what the person finds over stimulating, understanding fears from their personal historical traumas so people feel safe. There is no room for pathology or deficits, we do not seek to change the person.

NOT CHALLENGING … BUT DISTRESS

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  important that only individuals who display distress behaviours or are at risk of displaying such behaviours have a PBS plan, but we train all our staff in PBS so they understand human behaviour, the impact of trauma and how proactive strategies can reduce anxiety and maximise choice and control.

SCOPE

PBS is about person centred support and planning needs to be embedded in the organisation. Positive Support for You has an organisational commitment to quality of life and self-determination and we can evidence this. 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. 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 two Level 7 practitioners. 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 how the behaviour (function) is useful to the person. 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 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 and self-determination leads any support. 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 avoiding difficult situations and helping the person navigate their life.

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 for autonomy and choice. It is the essence of person-centred planning. 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 best practice, 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. 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. 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 person, analyse data and focus on environmental 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 managers. Some of our staff have completed level 4 competencies in PBS. Team meetings play a crucial role in involving support teams and developing implementation plans. PBS has enabled a number of people from long stay 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 extremely 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

 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)

Safety Intervention is extremely rare across our services and only used as a last resort. It has only ever been used to reduce further risk to the person and is monitored with annual data collated.

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. We train that this is a last resort action to maintain safety and all our individualised intervention plans are approved annually through the Restraint Reduction Network. 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 is always a preferred option. The training reinforces PBS strategies by raising awareness of verbal and non-verbal communication and the affect this can have on both the distressed person 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 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 in distress and at risk.

Leadership and Learning and Development.

 Our support is entirely focused to support people to live their best lives. Enhancing people’s lives with proactive strategies and understanding why some people become distressed is dependent on the needs of the person. Not everyone needs such assessments. We train our teams in Positive Behaviour Support and focus on person-centred planning focus on a Human Rights approach for all the people we support, but the development of behaviour support plans are dependent on need and only used to reduce distress. As well as formal training, we support learning through practice, leadership and competency-based learning which are relevant to the specific needs of the person. In this way, we emphasise modelling and coaching from a first line manager who, as part of the person’s team, can support consistency and structure. Quality of life and values training are building blocks to non-restrictive practice from day one of recruitment.

Review

As with all good practice, review should be an ongoing process, but it also needs to ascertain the effectiveness of strategies being used to minimise distress. It is likely, therefore, that monitoring is intensive in the early stages with Team Managers analysing documentation along with the PBS Leads. 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