Quality of life tool for inspecting specialist services for people with a learning disability and autistic people

Positive indicators

• Appealing physical environment for all, reflecting sensory needs
• Reasonable adjustments made where applicable
• Empathetic and dignified social and interactive environment
• Staff, the person and carers speak positively about the physical environment and culture or are able to indicate it meets their needs, including sensory.

Red flags

• Poorly maintained or dirty fixtures and fittings
• Bright lights
• Noisy
• No attempt to meet individual sensory needs
• Inflexible or limited access to outside space
• Blanket measures
• Limited access to or use of communication support tools or plans.

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c), 9(3)(1)(a)(b)(h)
• Regulation 10: Dignity and respect
  10(1)
• Regulation 11: Need for consent
  11(1)
• Regulation 12: Safe care and treatment
  12(1), 12(2)(a)(b)(d)
• Regulation 13: Safeguarding service users from abuse and improper treatment
  13(4)(d)
• Regulation 15: Premises and equipment
  15(1)(a)(b)(c)(d)(e)(f)
• Regulation 17: Good governance
  17(1), 17(2)(a)

Human Rights Act

• Article 8: Right to private and family life
• Article 1: Protocol 1 - Right to peaceful enjoyment of possessions

Key questions

• Effective
• Caring
• Responsive

Positive indicators

• The staff team support people consistently and understand their communication needs
• People enjoying activities that they like to do including in the evening, opportunities to try different activities
• Activities are tailored for individuals
• Staff actively promote equality and diversity in their support to people, are respectful of diversity and protected characteristics, including how activities are offered
• People have an active role in maintaining their own health and wellbeing, including annual health checks, access to screening and primary care services
• People have a communication plan in place which meets their needs, which staff are aware of, understand and use.

Red flags

• No access to external health professionals or visiting from them
• People have limited access to or engagement with their community
• Wellbeing plans provided by health professionals are not followed

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c), 9(3)(a)(b)(c)(d)(e)(f)
• Regulation 10: Dignity and respect
  10(1), 10(2)(b)
• Regulation 12: Safe care and treatment
  12(1), 12(2)(a)(b)(c)
• Regulation 17: Good governance
  17(1), 17(2)(a)(b)

Human Rights Act

• Article 2: Right to life (failure to support health and wellbeing)
• Article 3: Inhuman or degrading treatment (failure to support health and wellbeing leads to pain or emotional distress)
• Article 8: Right to private and family life (treatment without adequate consent re: bodily integrity)

Key questions

• Safe
• Effective
• Responsive

Positive indicators

• People choose and communicate when they'll next see family or carers
• Staff, people and their carers talk about activities done and future plans
• Staff support people to actively engage and try new activities, not just participate
• Records and support plans evidence family and carer contact and activity choice.

Red flags

• No records of outside activities or evidence of day to day choice
• No records of carers visits, phone calls or video calls
• Staff unenthusiastic and fail to encourage people's independence
• Staff dismiss requests for activity or food choices out of hand, including those relevant to protective characteristics - for example, due to cultural or religious preferences.

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c), 9(3)(d)(e)(i)
• Regulation 10: Dignity and respect
  10(1), 10(2)(b)
• Regulation 13: Safeguarding service users from abuse and improper treatment
  13(1), 13(4)(c)(d)
• Regulation 14: Meeting nutritional and hydration needs
  14(1)
• Regulation 17: Good governance
  17(1), 17(2)(a)(c)
• Regulation 18: Staffing
  18(2)(a)

Human Rights Act

• Article 8: Right to private and family life

Key questions

• Caring
• Responsive

Positive indicators

• Staff offer choices tailored to the individual using open questions
• People exercise control over activities and staff enable flexibility
• People have choice over personalising room and carer visit times
• Behaviour support plans record preferences including communication
• Support plans are accessible to people including language used, symbols, photographs, etc
• There is an at-a-glance or one-page profile with the essential information and dos and don'ts. This is to ensure new or temporary staff can reduce the likelihood of someone having a bad day by following how best to support them.

Red flags

• No record of choice in how people's day unfolds
• Staff do not encourage engagement in tasks or activities
• Overprotective care even if well-intentioned
• Avoidance of involving people in activities due to perceived risk.

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c), 9(3)(d)(e)(f)(g)
• Regulation 13: Safeguarding service users from abuse and improper treatment
  13(4)(d)
• Regulation 17: Good governance
  17(1), 17(2)(a)(b)(c)
• Regulation 18: Staffing
  18(2)(a)

Human Rights Act

• Article 8: Right to private and family life

Key questions

• Safe
• Effective

• Caring

Positive indicators

• Individualised support - for example, tailored visual schedules are used to support understanding
• Staff support people's independence in planning their day or week
• Staff support unplanned changes and assess risks continuously
• Plans show evidence of positive risk-taking approach.

Red flags

• No evidence of risk assessments for building or environment
• No evidence of risk assessment for activity participation
• No evidence of positive risk taking
• No structure to a person's day and person left uncertain.

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c), 9(3)(a)(b)
• Regulation 12: Safe care and treatment
  12(1), 12(2)(a)(b)(c)(d)
• Regulation 15: Premises and equipment
  15(1)(a)(b)(c)(d)(e)(f)
• Regulation 17: Good governance
  17(1), 17(2)(a)(b)(c)

Human Rights Act

• Article 8: Right to private and family life

Key questions

• Safe
• Effective
• Responsive
• Well-led

Positive indicators

• Staff are skilled and proactive in reducing challenging behaviour using plans personalised for each person rather than a single approach
• Staff are alert to emotional communication and address signs of distress, frustration, etc
• Staff support the person after an occurrence of behaviour that challenges, following the protocol detailed in each person's behaviour support plan
• Functional assessments are co-produced with person and carers
• Behaviour support plans are clear, detailed and used by all staff.

Red flags

• Staff use same strategy for every person
• Failure to recognise less obvious risky behaviours - for example, freezing
• Behaviour support plans do not include teaching skills targets
• Staff offset responsibility or ownership of challenge to others
• Use of positive behaviour support plans from previous settings with no or little attempt to modify or update
• Staff use inappropriate language such as “kicking off”.

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c); 9(3)(a)(b)
• Regulation 10: Dignity and respect
  10(1)
• Regulation 12: Safe care and treatment
  12(1); 12(2)(a)(b)(c)
• Regulation 13: Safeguarding service users from abuse and improper treatment
  13(4)(c)(d)
• Regulation 17: Good governance
  17(1); 17(2)(a)(b)

Human Rights Act

• Dependent on outcomes - consider if failure to support people's distress leads to excessive restraint (see question 7 red flags)

Key questions

• Safe
• Effective
• Responsive

Positive indicators

• Unplanned use of restrictive strategies triggers review of support plan
• Evidence that staff and the people who were subject to restrictive interventions are de-briefed and carers informed
• Staff discuss techniques that promote reducing restrictive practice
• Staff can give examples of post-debrief updates to support plans.

Red flags

• Poor or absent record of monitoring use of restrictive interventions
• No evidence of clear reducing restrictive intervention plan in place
• Staff say no alternative and adopt restrictive interventions first
• No evidence of reflective practice or debriefs post incident.

Regulations

• Regulation 10: Dignity and respect
  10(1)
• Regulation 12: Safe care and treatment
  12(1), 12(2)(a)(b)(c)
• Regulation 13: Safeguarding service users from abuse and improper treatment
  13(1), 13(2); 13(4)(b)(c)(d)
• Regulation 17: Good governance
  17(1), 17(2)(a)(b)
• Regulation 18: Staffing
  18(2)(a)

Human Rights Act

• Article 3: Inhuman or degrading treatment (failure to minimise use of restraint leads to pain or emotional distress)
• Article 5: Right to liberty or security (does use of restrictive practices reach the threshold for a deprivation of liberty that is avoidable or may not be authorised through, for example, the Deprivation of Liberty Safeguards?)

Key questions

• Safe
• Effective
• Well-led

Positive indicators

• Arrangements for staffing including skills and numbers to reflect people's needs
• Managers work directly with people and take a coaching approach with other staff
• Managers set a culture that values reflection and learning
• Staff say they can raise concerns with managers and feel safe.

Red flags

• Staff say or indicate that they do not feel safe at work
• Staff say or indicate that they cannot raise concerns
• There is a high turnover or use of agency staff
• Supervision, appraisal or staff meeting records with the same content for all staff.

Regulations

• Regulation 13: Safeguarding service users from abuse and improper treatment
  13(2), 13(3)
• Regulation 17: Good governance
  17(1), 17(2)(a)(b)(e)
• Regulation 18: Staffing
  18(1), 18(2)(a)

Human Rights Act

• Dependent on outcomes

Key questions

• Safe
• Effective
• Well-led

Positive indicators

• Evidence of ongoing supervision and recognition of good practice
• Evidence of understanding and compliance with legal requirements including human rights
• Quality training to meet people's needs - for example, autism, learning disability, trauma-informed care, all of which includes relevant human rights issues
• Workforce development plan in place.

Red flags

• No or poor records of staff training or CPD
• Staff not able to talk about training and how it relates to the people they support
• No clear procedures for supporting team working or peer support
• Poor or no supervision records.

Regulations

• Regulation 12: Safe care and treatment
  12(1), 12(2)(c)
• Regulation 17: Good governance
  17(1), 17(2)(a)(b)(e)
• Regulation 18: Staffing
  18(1), 18(2)(a)(b)

Human Rights Act

• Dependent on outcomes

Key questions

• Safe
• Effective
• Well-led

Positive indicators

• Up-to-date assessments including medical, psychological, functional, preferences and skills
• Programmes include details and methods of communication needs
• Contributed to by person and family - and feedback that it is actioned
• Includes autonomy-enhancing strategies, and supported by staff
• Sets out current needs and pathway to future goals, including skills teaching
• Staff discuss ways of ensuring targets are meaningful to person.

Red flags

• There is no evidence of future planning or consideration for the longer-term aspirations of each person.

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c), 9(2), 9(3)(a)(b)(c)(d)(f)
• Regulation 10: Dignity and respect
  10(1), 10(2)(b)
• Regulation 12: Safe care and treatment
  12(1), 12(2)(a)(b)

Human Rights Act

• Dependent on outcomes

Key questions

• Safe
• Effective
• Responsive
• Well-led

Positive indicators

• Relevant information and progress collected and used to update support plans
• Continuously recording outcomes - for example, skills, behaviour challenges
• Staff provide feedback on support provided, which updates plans
• Staff talk positively about progress and ensure support evolves.

Red flags

• No data is collected about how people are progressing or struggling with activities and tasks, or data is rarely collected and does not inform current behaviour protocols or support plans
• There is no evidence of support plans having been updated - or if they have, they include the same protocols or targets as previous versions.

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c), 9(2), 9(3)(a)(b)
• Regulation 12: Safe care and treatment
  12(1), 12(2)(a)(b)(c)
• Regulation 17: Good governance
  17(1), 17(2)(a)(b)

Human Rights Act

• Dependent on outcomes

Key questions

• Effective
• Responsive
• Well-led

Positive indicators

• Families or carers involved in developing support plan and updates
• Multidisciplinary team members sighted and involved in care plans where appropriate
• Families and carers involved - for example, in provider policy review and development, and recruitment
• There is information about independent advocacy and support
• Staff empower people's decision making and evidence use of the Mental Capacity Act
• Stakeholders describe how they've contributed and records back this up
• Stakeholders speak positively about opportunities to feedback.

Red flags

• No involvement of multiple stakeholders in the development of people's support plans or behaviour support plans
• No involvement of family members, guardians or carers in the continuous development of the service (for example, staffing and recruitment)
• Supporting the emotional wellbeing of stakeholders (and in particular family and carers) is not within the remit of the service, or is not considered by the service.

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c), 9(2), 9(3)(a)(d)(e)(f)(g)
• Regulation 17: Good governance
  17(1), 17(2)(a)(b)(e)

Human Rights Act

• Article 5: Right to liberty or security (does use of restrictive practices reach the threshold for a deprivation of liberty that is avoidable or may not be authorised through, for example, the Mental Capacity Act Deprivation of Liberty Safeguards?)

Key questions

• Effective
• Responsive

Positive indicators

• People learn new skills appropriate to their needs and that promote stretch
• Plans evidence targets that build on people's existing skills
• New skills taught regularly, consistently and at right frequency
• Evidence of exact process of skill teaching - for example activity scripts used
• Skills taught in line with person's individual preferences
• People engaged consistently throughout the day in all activities
• Staff speak knowledgeably about tailoring level of support
• Person and family or carers talk about skills they've learnt and skills they want to learn.

Red flags

• Skills teaching rarely occurs
• No evidence of continuous learning or skills teaching conducted by staff
• Rather than teaching a skill, staff are doing the task for the person
• Staff are inconsistent in how they teach specific skills to a person, increasing the likelihood of failure to learn the skill. This potentially results in frustration and behaviour that challenges.

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c), 9(3)(d)(e)
• Regulation 12: Safe care and treatment
  12(1), 12(2)(a)(b)(c)
• Regulation 17: Good governance
  17(1), 17(2)(b)

Human Rights Act

• Dependent on outcomes

Key questions

• Caring
• Responsive

Positive indicators

• Staff confident in applying support plan - for example, behaviour and teaching
• Staff deliver support consistently
• Staff can explain their role without needing to refer to documents
• Staff explanation of their role matches with observation and support plan
• Staff speak confidently to protocols for behaviour that challenges
• Staff explanation of protocols matches the person's behaviour support plan
• Staff support roles are detailed in each person's support plan.

Red flags

• Staff do not know their roles within each person's support plan or the person-specific protocols for addressing behaviours that challenge
• Staff are not consistent in the way they support people to manage behaviours, approach teaching targets or teach people skills.

Regulations

• Regulation 12: Safe care and treatment
  12(1),12(2)(a)(b)(c)
• Regulation 17: Good governance
  17(1), 17(2)(b)
• Regulation 18: Staffing
  18(2)(a)

Human Rights Act

• Dependent on outcomes

Key questions

• Safe
• Effective
• Responsive
• Well-led

Positive indicators

• Activities and support apportioned according to plan areas
• Activity planning maps to aspirations and promotes quality of life
• Staff speak about how multiple programmes work together
• Support plans work together across areas - for example, behaviour plan and speech and language therapy plan
• Programmes include advice or methods to promote sense of belonging
• Programmes and plans line up with information from clinicians.

Red flags

• Daily activities for each person do not match up with the programmes for that person
• A disproportionate amount of time is focused on just one or two aspects of the support (for example, spending more time on occupational therapy exercises than skills building).

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c), 9(3)(b)(c)
• Regulation 17: Good governance
  17(1), 17(2)(a)

Human Rights Act

• Dependent on outcomes

Key questions

• Effective
• Responsive
• Well-led

Positive indicators

• Staff and others work within positive behaviour support framework
• Staff and others offer choice, show kindness, respect and nurture people
• Staff and others consistently offer same high-quality level support
• Staff and others speak knowledgeably about each person
• Staff speak knowledgeably about support provided by others
• People and families talk positively about support across all aspects
• Multi-disciplinary assessments work together - for example, medical needs in PBS.

Red flags

• Difference in the quality of support provided by the service, staff and professionals
• Support is organised around the service's needs, rather than the person's - for example, arranging rotas in a way most convenient for staff or activities offered based on staff availability.

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c); 9(3)(b)(c)
• Regulation 12: Safe care and treatment
  12(1), 12(2)(i)
• Regulation 13: Safeguarding service users from abuse and improper treatment
  13(4)(d)
• Regulation 17: Good governance
  17(1), 17(2)(a)(b)

Human Rights Act

• Article 3: Inhuman or degrading treatment (failure to treat people with kindness and respect may lead to pain or emotional distress)
• Article 8: Right to private and family life

Key questions

• Effective
• Caring
• Well-led

Positive indicators

• Service updates programme with stakeholder input as person evolves
• Support given over time adjusts as natural changes occur for people
• Activities and learning in daily routines build skills for longer-term goals
• Staff speak about life development with insight into life goals
• People and family talk optimistically about the future including goals
• Programme sets out desired end goals agreed with stakeholders and people.

Red flags

• No evidence or consideration for the desired aspirations or end-goals for each person
• Little or no continuity across the lifespan for each person reflected in their support plan.

Regulations

• Regulation 9: Person-centred care
  9(1)(a)(b)(c), 9(2), 9(3)(a)(b)(c)(d)(f)
• Regulation 10: Dignity and respect
  10(1), 10(2)(b)
• Regulation 12: Safe care and treatment
  12(1), 12(2)(a)(b)
• Regulation 13: Safeguarding service users from abuse and improper treatment
  13(4)(d), 13(5)
• Regulation 17: Good governance
  17(1), 17(2)(a)(b)

Human Rights Act

• Dependent on outcomes

Key questions

• Effective
• Responsive