I want to share the feedback that we recently received in connection with an overall “outstanding” CQC rating for a service within an organisation we work with. It really illustrates that when you implement PBS practices across an organisation rather than just as an add on or a job title, it can really impact on the quality of your service, the rating that CQC give and essentially the support provided to people.
The following quotes are from the registered manager who is also the lead for a specialist team within the service;
“Using organisational behaviour management (OBM) to imbed a management culture focused on positive reinforcement, introducing us to a functional living skills assessment, supporting the development of the Periodic Service Review, pushing for practice leads, tracking the engagement of the people we support and ultimately collecting and using data that support decision making, I believe have contributed to the improvement in the quality of life of the people supported and better working conditions for the staff teams.”
‘I just wanted to say thank you so much for the support Redstone has given the service as your supervision has made this remarkable achievement attainable.’
Let’s unpack what the manager is referring to here and why, for Redstone, PBS isn’t just about doing a functional assessment or some staff training.
OBM and Positive Feedback for Staff
The value base in PBS is clear, we use primarily positive practices avoiding aversive approaches and any punishment strategies. Most of the time we apply this to adults and children 
supported, but not to staff teams providing the support and middle managers. The initiative referred to by the manager and CQC is an application of applied behaviour analysis called Organisational Behaviour Management. In this initiative team leaders and middle managers were trained to provide a greater frequency of positive feedback to their direct reports. The aim here is to shape and increase desired work behaviours, however this also had a positive impact on staff morale.
The following quote is from the CQC report;
“The provider had worked with external positive behaviour consultants to extend the principles of positive behaviour support (PBS) into leadership and management. An evaluation completed into the project demonstrated how there had been a significant cultural change within the organisation and a shift from negative messaging to one that was wholly positive.
Comments from managers involved in the evaluation included, “The general atmosphere and esteem of staff seems to be better. Even during tougher days with sickness and stuff, morale has stayed high and I think this has been because of the positive feedback and making it an environment where staff are being praised for doing a hard job.”
Functional Living Skills Assessment
Throughout our work with organisations we have found that one of the biggest challenges is ensuring that staff teams support people to have maximum engagement in their lives, to develop new skills and be supported to be as independent as possible. We also know that if we can crack this then the person has more opportunities for social interaction, they have greater independence and their days are full and not spent ‘waiting’ for the next leisure activity or meal. As a result, they are less likely to present with behaviours that challenge as their needs are being met and they have an increased quality of life. However, it’s a challenge for staff members to know how to do this as generally it’s not part of their training and if they are supporting people with little verbal communication or who currently appear to have few independent skills it’s not easy to know where to start.
We trained key staff to use a comprehensive structured assessment which is used to identify an initial number of target skills to work on. We then train staff teams in how to support the development of these skills for people using different levels of prompting and show them how to fade those prompts out so the person becomes as independent as possible.
Periodic Service Review (PSR)
The PSR was pioneered by Gary LaVigna and the IABA. If anyone reading this has been to the series of workshops the IABA regularly run over in the UK, and has been lucky enough to catch one with Gary presenting, you’ll know how inspiring his talk is about this. It is made very clear that having standards for a service is key to making sure that service runs well. After all, if a team doesn’t know what they need to be doing, when and where, there’s a big chance it won’t get done. It’s essentially an audit, with a big difference. The team set their own standards and the team check whether they are meeting them on a monthly basis. Standards are defined clearly and a rating of the standard as either met or not met is made. There is a focus on opportunities to improve rather than a telling off for not meeting a standard.
“The service had well established and comprehensive systems in place for quality assurance and audit. An innovative approach was taken through Periodic Service Review (PSR). The primary aim of the PSR was to enhance and maintain high quality service delivery and was both a tool for prompting actions and a system of measurement. The PSR was a set of agreed standards and accompanying operational definitions by which the service would measure themselves against. These standards covered areas from administrative duties, quality of life, support documentation, support & supervision, health & medication and health & safety. There was an easy to follow score sheet and a system to provide monitoring and feedback to ensure desired quality is maintained.” (Quote from CQC report)
Practice leadership
We know that having people to lead the practice is key to getting PBS practices established. Having a central team which get more and more stretched as a service develops is not enough. There also needs to be key people within services. Redstone provided additional training both covering behavioural theory and hands on practice skills.
“A key development since our last inspection was the introduction of support worker practice lead roles. Practice leads were recruited from experienced staff who demonstrated a thorough understanding of people living with autism and/or a learning disability. Newly recruited practice leads were supported by a mentor and were required to provide practice based evidence through a competency framework. Key areas of responsibility for the practice leads included frontline implementation of positive behaviour support (PBS), assessment, planning, coordination and implementation of bespoke packages of support and activities according to a supported persons individual needs, and to implement any changes identified through a person’s review.” (Quote from CQC report)
Tracking Engagement and Using Data
Use of data is key to positive behaviour support in a number of different areas. In terms of individual interventions, 
relaying on verbal reports from staff teams, although helpful, is not sufficient to track whether a plan is being implemented, being implemented correctly and having the impact you are looking for in terms of behaviour changes. So, use of data is really essential here. In terms of tracking engagement one of the key initiatives that staff teams have really liked is being able to see visually the impact of their support on the levels of participation and engagement for people they support.
Supervision
As practising professionals at Redstone, we know the importance of supervision. We provide it for each other and we also access external supervision ourselves. Getting the right level of support for key staff in an organisation is essential, both for the development of that staff member but also so that they can complete assessments and interventions as well as service wide initiatives with competence. There is no PBS course out there, regardless of academic level, that alone will lead to practical competence. This can only be gained through regular supervised practice. Seeing supervision for your key staff as an additional cost rather than part of their training can mean that you risk wasting a lot of money on courses and you don’t see the impact in your service.
You might be thinking ‘well none of this is rocket science’…and this is often the case with some elements of PBS. The ideas are not complex. The challenge is in implementation, sustaining initiatives and following through. That’s why it is so very satisfying for me to this recognised in a CQC report. If you are going to embrace PBS, thinking of it as a job title or training sessions won’t be sufficient to get the results that are possible. Applying these PBS initiatives systemically can make all the difference.
© Redstone PBS 2017
If you’re interested in finding out how an organisational approach to implementing PBS might be able to add value and quality to your support organisation get in touch for a free, no commitment consultation. Email info@redstonepbs.co.uk or check out further information here
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Author- Kate Strutt Director of Redstone PBS and clinical psychologist with over 19 years’ experience of working in intellectual disability and autism services, both within statutory services and the independent sector. Kate is a member of the British Psychological Society and is registered with the Health and Care Professions Council. Bsc Psychology, D.Clin Psyc, PG Certificate Applied Behaviour Analysis.
Contact: kate.strutt@redstonepbs.co.uk
