Bigby et al qualty of staff practice in group homes for people with intellectual disability. What makes a differnce -findings from year 1 of a 5 year study of the implementation of active support. Presented asid confernce nov 2014

1. latrobe.edu.au
Quality of life for people with
intellectual disability who live in small
group homes: What makes a difference
Professor Christine Bigby
Dr Emma Bould
Dr Julie Beadle-Brown
Living with Disability Research Centre
c.bigby@latrobe.edu.au
CRICOS
Provider
00115M

2. Outcomes for people with intellectual disabilities in
supported accommodation
§ Half disability expenditure is on accommodation services – most
on group homes
§ Policy aims improving quality of life
§ Outcomes are very variable
§ 2 factors reliably predict:
̶ active support
̶ adaptive behaviour
§ Consistent use of active support increases engagement, growth
in skills, more choice and control and reduces challenging
behavior (see Mansell and Beadle-Brown 2012 for a review)
§ Does not require more staff nor cost significantly more – uses
available resources more efficiently in services (Beadle-Brown et al, in
press)

3. Person-centred active support
§ Providing enough help to enable people to participate
successfully in meaningful activities and relationships (an
enabling relationship),
§ So that people gain more control over their lives, gain more
independence and become more included as a valued member
of their community,
§ Irrespective of degree of intellectual disability or presence of
extra problems (Mansell and Beadle-Brown, 2012)
§ One of a family of person centred approaches
§ But research evidence for the impact of the other approaches on
quality of life is currently very weak

4. Implementing active support - Australia
§ For over 10 years – organisations in Australia have been adopting
active support - led by Victoria in 2003/04
§ Active support figures as method of staff practice in Qld and Vic state
policy
§ But has proved difficult to embed in organisations
§ Largest study to date in Australia 6 organisations – implementing A/S for
1-8 years (Mansell, Beadle Brown, Bigby, 2013)
§ Less than 1/3 people received consistently good support
§ Only consistent high levels of active support in one organisation
§ Substantial variation within and between homes
Research Question
§ What organisational factors are associated with high levels of active
support and improvements over time?

5. Conceptual Framework
Organisa6onal
Systems,
Structures
&
Processes
Prac6ce
Leadership
Quality
of
Ac6ve
Support
Assistance
Other Staff
Contact
Engagement
and
quality
of
life

6. Embedding active support in accommodation
services
§ Linkage study 9 industry partners
§ Implementing Active Support for varying periods*
̶ Golden City Support Services (2003,10 yrs)
̶ Jewish Care (2004, 9 yrs )
̶ DHS Eastern Region (2004, 9 yrs)
̶ Yooralla (2005, 8 yrs)
̶ Sunshine (2006, 7 yrs)
̶ annecto (2009, 4 yrs)
̶ Endeavour (3 years)
̶ Karingal (18 months)
̶ Greystanes (2012, 1 yr)
*correct
at
.me
of
data
collec.on

7. Method
§ Measures of resident outcomes [engagement] and staff practices [active
support, contact & assistance] and leadership
§ Structured observations for 2 hours, 4 - 6pm
§ Resident engagement
§ Challenging behaviour
§ Frequency of contact and assistance from staff
§ Active Support Measure (quality of support)
§ Observed Measure of Practice Leadership - interview and observe
§ Resident needs and characteristics completed by keyworker
§ Staff surveys - training, qualifications, satisfaction, knowledge and
attitudes
§ Annual data collection for 5 years
§ longitudinal same houses alternate years [plus existing data]
§ representative sample from audit
§ Annual reports – feedback and development

8. Settings and participants year 1 2012/2013
§ 58 group homes (9 organisations), average 4 people (1 – 9)
§ 189 residents observed
§ 36 - 76 yrs, mean age 42
§ Relatively able group - wide range - org 7 exception
§ Each organisation supporting at least one person with more
severe disabilities
§ 153 staff surveys (52%).
§ 46 front line leaders interviewed and 38 returned the practice leader
survey (82%).
§ 20 (77%) Managers of practice leaders survey (77%)

9. Quality of support and outcomes
Mean Range
Active support score (%) 50% 2 – 97%
Percentage of time receiving
assistance 3% 0 – 28%
Percentage receiving no
assistance to be engaged 65%
Percentage of time engaged 47% 0 – 100%
Relatively low on all indicators

10. Summary results and what it is possible to achieve
LaTrobe Study Year 1
Skilled support study
Good active support
Whole
sample > 151 <151 >151 < 151
Those with
PIMD
ABS Average 139 198 88 197 78 56
Engagement 47 68 31 67 53 49
• Social activity 15 49 24 20 21 23
• Non social activity 35 68 31 55 39 33
Active Support 49 64 38 84 80 78
Staff Assistance % 3 4 2 15 10 5
Staff Contact % 17 17 17 16 37 51
Staff Assistance + Contact % 20 21 19 31 47 56
Time spent receiving
assistance + contact Mins 12 13 11 19 28 34
§ Relatively poor active support compared to what has been shown to be
possible
§ Good active support = score greater than 66%
§ Assistance over 10% is possible and necessary
§ Poorer outcomes for people with more severe impairment except contact

11. § High and Lower Performing Organisations
§ Sample average and people with higher support needs – variability
across and within services
Whole Sample
Org 1
Org 2
UK study
Good active
support
(Ashman, Beadle-brown,
2006)
Engagement in
meaningful activity
and relationships
47% (31%)
64% (54%)
25% (16%)
60%(54%)
Quality of Support
(Person Centred
Active Support)
49% (38%)
67% (64%)
28% (12%)
79% (79%)
Time spent receiving
assistance and
contact from staff
12 mins (11)
18 mins (15.5)
7.5 mins (6)
23 mins (25)
Variability - outcomes and staff practice
Work in progress Bigby et al.,

12. Active Support: people with more severe disabilities do
much worse than people with less severe disabilities
100
80
60
40
20
§ More able people experience better active support - except Orgs 6 & 7
§ Only 3 orgs provide consistent good active support for more able people
Sig
difference
0
Org1
<151
Org
1
151
+
Org2
<151
Org
2
151
+
Org3
<151
Org3
151
+
Org4
<151
Org4
151
+
Org5
<151
Org5
151
+
Org6
<151
Org6
151
+
Org7
<151
Org7
151
+
Org8
<151
Org8
151
+
Org9
<151
Org9
151
+
Whole
<151
Whole
151
+
Percentage
score
on
ASM
Target
66%

13. Observed opportunities and support for choice
28%
63%
12%
53%
32%
9%
52%
41%
28%
36%
28%
13%
76%
27%
37%
45%
0%
28%
40%
31%
100%
80%
60%
40%
20%
0%
-­‐20%
-­‐40%
-­‐60%
-­‐80%
-­‐100%
Not
offered
any
choice
Supported
well
to
make
choices
Org
1
n=20
Org
2
n=16
Org
3
n=17
§ Discrepancy staff rated and observed choice.
§ Only 1/3 residents observed as supported well to make choices - much higher
staff rated scores (51%).
Org
4
n=17
Org
5
n=23
Org
6
n=13
Org
7
n=25
Org
8
n=31
Org
9
n=27
All
N=189

14. Observed support for communication
All
O1
O2
O3
O4
O5
O6
O7
O8
09
N/n
63
2
12
3
0
8
6
23
3
6
Number
receiving
good
adapted
communica.on
4
1
0
2
N/A
0
0
0
1
0
§ 32% of sample no verbal communication
§ Only 6% of non verbal residents received any adaptive communication
that appeared to be effective.

15. Practice leadership - defined
§ Focusing, in all aspects of the front-line manager’s work,
on the quality of life of service users and how well staff
support this.
§ Allocating and organising staff to deliver support when and
how service users need and want it, providing consistency
and predictability.
§ Coaching staff to deliver better support by spending time
with them providing feedback and modelling good practice.
§ Reviewing the quality of support provided by individual
staff in
̶ regular one-to-one supervision and;
̶ in team meetings

16. Quality of practice leadership
Mean Range Median Percentage of services good or
excellent (score of 4 or 5)
Allocating staff 2.43 1-5 2 17%
Coaching staff 2.33 1-5 2 11%
Supervision 2.30 1-5 2 11%
Team meetings 2.80 1-5 3 22%
Focus on QoL 2.61 1-5 3 20%
Mean score 2.50 1-5 2.4 11%
Total score 12.2 5-25
Percentage score 36% 0 – 100
§ Practice leadership generally poor
§ Only one organisation (3) had high scores
§ Discrepancy between observational measures and staff ratings of PL,

17. Correlations between practice leadership and
quality of support
Any
engagement
Active
Support
measure
Assistance
from staff
Other
Contact
from staff
At service level (n=43)
Allocating Staff 0.192 0.36* 0.176 0.355*
Coaching 0.127 0.504** 0.215 0.375*
Supervision 0.117 0.332* 0.139 0.317*
Team meetings 0.255 0.411** 0.192 0.175
Focus on QOL 0.178 0.474** 0.242 0.243
Mean PL score 0.201 0.484** 0.224 0.345*
* = p< 0.05 ** = p< 0.01
§ First evidence of relationship between PL and Active Support
§ Significant correlations between A/S and PL – overall and each domain
§ Strongest correlation A/S and – coaching domain
§ Correlation other staff contact, overall score, allocation of staff,
coaching and supervision
§ PL too low for very strong relationships

18. Same picture at service user level
Any
engagement
Active
Support
measure
Assistance
from staff
Other
Contact
from staff
At service user level (n=166)
Allocating Staff 0.208** 0.222** 0.01 0.229**
Coaching 0.100 0.363** 0.055 0.203**
Supervision 0.157* 0.214** 0.017 0.175*
Team meetings 0.245** 0.315** 0.046 0.115
Focus on QOL 0.197** 0.336** 0.044 0.131
Mean PL score 0.212** 0.338** 0.039 0.201**
§ But also shows correction between PL and Engagement on 4 of 5
domains.

19. Comparing weak and strong practice
leadership
Mean scores
when PL weak
(below 3)
n=143
Mean scores PL
higher (3 and
above)
n = 46
Significance
Active Support % score 46% 63% t(171) =3.88 ***
% time receiving Assistance 3% 4% Not. Sig.
% time receiving other contact from staff 16% 20% Not. Sig.
% time Social activity 13% 20% z = -2.159 *
% time Non- social activity 33% 44% z = -2.001 *
Any engagement 44% 59% t(169) =2.63 **
* = p< 0.05 ** = p< 0.01 *** = p< 0.001
§ Active support significantly better in services where practice leadership
overall was better and service users more engaged (Mann-Whitney U
Tests)

20. Individual PL items
Allocating staff Coaching Supervision Team meetings Manager focus
Weak PL
Better PL
Weak PL
Better PL
Weak PL
Better PL
Weak PL
Better PL
Weak PL
N=121
N=68
N=115
N=74
N=107
N=82
N=85
N=104
N=89
Better PL
N=100
% score on Active
support
44 58 49 50 47 53 42 56 45 54
% time receiving
assistance
3 3 3 3 3 3 2 4 3 3
% time with other
contact
16 19 15 20 15 20 16 18 15 19
% time Any
engagement
39 61 52 39 45 50 41 53 46 49
Total score on ABS
Part 1
129 157 156 113 141 136 137 141 145 134
Mean Age 42 43 43 42 43 41 42 42 43 41
Mean score on ABC 14 17 15 16 16 14 14 16 14 16

21. Main story is……..
§ Active support is significantly better for people who are living in
services where the score on allocation of staff , team meetings and
front-line manager overall focus on quality of life is higher.
§ However for allocating staff, there is an interaction with level of
ability – services users in services where better systems exist for
allocation of staff to meet needs and maximise engagement were
generally more able. This probably at least partially explains the
significantly higher levels of engagement too.
§ For the domain of coaching, services users in a service where
coaching is better tend to be engaged less but this is likely to be
explained by significantly lower levels of adaptive behaviour for
these individuals. When team meetings are in place and at least
used to review service user needs and quality of life, levels of
engagement are higher.

22. Staff Support: Active support - People Observed
with PL Absent vs. People Observed with PL
Present
2
2
2
4
3
4
1
1
3
3
3
2
2
2
2
3
2
3
2
3
Target
66%
§ Staff support better when the PL present in the house during the
observation
Sig
difference
100
80
60
40
20
0
Percentage
score
on
ASM
Mean
PL
Score:

23. Summary
§ Outcomes and staff practice well below what is possible - for
same cost
§ Substantial variability within and between organisations
§ People with more severe disabilities get poorer outcomes and
support
§ Change can happen - with a focussed attention
̶ Improvement in most of the organisations over 3 years
§ First evidence that practice leadership is important in
determining quality of support and engagement
§ Practice leadership is fairly poor
§ Staff and Practice Leaders overestimate quality of their
practice

24. Conclusions and Implications
§ Importance of PL skills and support for PLs
§ Articulate and build staff and front line leader competencies
in active support and PL
§ Power of Observation to make judgements about service
quality – should at least be part of QA
§ Funding bodies and NDIS should not fund poor outcomes
and poor staff support
§ Set benchmark expectations for outcomes such as
engagement – demonstrable use of active support
§ Future data will help to understand other organisational
structures and processes

25. References
Beadle-Brown, J et al., (in press) Outcomes and Costs of skilled support for people with severe intellectual disability and complex needs
Mansell, Jim and Beadle-Brown, Julie (2012)Active support: enabling and empowering people with intellectual disabilities. Jessica Kingsley Publishers,
London
Mansell, Jim and Beadle-Brown, Julie and Macdonald, Susan et al. (2003)
Functional grouping in residential homes for people with intellectual disabilities. Research in Developmental Disabilities, 24 (3). pp. 170-182. ISSN
0891-4222
Schalock, R., Brown, I., Brown, R., Cummins, R. A., Felce, D., Matikka, L., et al. (2002). Conceptualization, measurement, and application of quality of
life for persons with intellectual disabilities: Report of an international panel of experts. Mental Retardation, 40(6), 457-470.
Mansell., J., Beadle-Brown, J., & Bigby, C. (2013) Implementation of active support in Victoria, Australia: an exploratory study. Journal of Intellectual and
Developmental Disabilities 38(1), 48–58 (download from http://hdl.handle.net/1959.9/206149 )
Bigby, C., Knox, M., Beadle-Brown, J., Clement, T., Mansell., J (2012). Uncovering dimensions of informal culture in underperforming group homes for
people with severe intellectual disabilities. Intellectual and Developmental Disabilities 50, 6, 452–467 (download from
http://hdl.handle.net/1959.9/206141 )
Bigby, C., Cooper, B., & Reid, K. (2012). Making life good in the community: Measures of resident outcomes and staff perceptions of the move from an
institution. Melbourne: Department of Human Services: (http://hdl.handle.net/1959.9/200242 other Making life good reports also)
Bigby, C. (2013). Tackling the crisis in disability group homes. Opinion on line,
http://apo.org.au/commentary/tackling-crisis-group-homes-people-intellectual-disability
Clement, T. & Bigby, C. (2010). Group homes for people with intellectual disabilities: Encouraging inclusion and participation. London, Jessica Kingsley.
Bigby,
C.
Knox,
M.,
Beadle
Brown,
J.,
Bould,
E.
(2014)
Iden6fying
good
group
homes
for
people
with
severe
intellectual
disability:
Qualita6ve
indicators
using
a
quality
of
life
framework.
Intellectual
and
Developmental
Disability
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52,
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348-­‐366
Bigby, C., Knox, M., Beadle-Brown, J., & Clement. T., (in press) ‘We just call them people’: Positive regard for people with severe intellectual disability
who live in of group homes. Journal of Applied Research in Intellectual Disability.

26. Thank you
Contact
c.bigby@latrobe.edu.au
e.bould@latrobe.edu.au
j.d.beadle-­‐brown@kent.ac.uk