Dimensions is one of the country’s largest not-for-profit organisations supporting people with learning disabilities, autism, challenging behaviour and complex needs. It applies research-based, outcomes-focused best practice to its services.
Dimensions creates and applies initiatives that improve outcomes for the people it supports, including developing Positive Behaviour Support and using one page profiles throughout the organisation for everyone from management to staff and clients. To keep driving best practice, it has now developed and launched a whole new model of support.
The Dimensions Activate support model is for people with learning disabilities and autism and is being rolled out across the organisation. It focuses on improving the quality of support provided to its clients in a personalised way, keeping the people that Dimensions’ supports at its heart.
It has been developed from research, funded by NIHR School for Social Care Research and conducted by Dimensions with Peter McGill from the University of Kent’s Tizard Centre and the Challenging Behaviour Foundation. It identifies eight domains of social care, using them to shape the support on offer. These eight domains, which are known to affect a person’s quality of life, are: health, activities and skills development, physical environment, service staff, wider organisation, service management, relationships and families, and communication/ social interaction.
The name Dimensions Activate was inspired by these domains and the commitment to helping staff to use Active Support, and for the people being supported to be actively involved in their communities. The aim is for clients to be happy, build meaningful relationships and be an integral part of society. Dimensions Activate aims to help them achieve this and their goals in life.
Exploring the model
The model has several components. Firstly, the support is co-produced and designed in partnership with the people receiving services, their families and their support teams. This means that the services are centred around the individual and in their best interests, with full support from their family and the team around them. Once the support has been identified, challenging goals are set in the eight domains.
With all the preparation complete and everyone having had input, support teams then work with the individual to achieve their goals using two techniques: Active Support (AS) and Positive Behaviour Support (PBS). AS is a way of providing assistance to people that focuses on making sure they are engaged and participating in all areas of their life. PBS is based on the principle that if you can teach someone a more effective and acceptable behaviour than the challenging one, the challenging behaviour will reduce.
Periodic Service Reviews are then used to set standards, monitor everyone’s progress and provide performance feedback to the organisation. These reviews aim to improve quality in the locality and help to determine whether the individuals being supported are achieving the outcomes they want. They also provide an evidence base for continuous improvement and identify where further gains can be made.
Ensuring it works
As Activate is a research-based model, Dimensions tested it with a control group and an experimental group of its clients. Trialling it over 12 months, in 24 Dimensions services supporting over 80 people and employing 270 staff, the research team randomly allocated different settings to either the experimental or control groups. All clients consented to participate.
On all measures of quality of life, those who were in the experimental group, supported according to the Dimensions Activate model, improved more than those in the control group who received Dimensions’ usual, person-centred support methods. Also, the standards set for each experimental service were largely achieved.
Dimensions and the researchers also found that the way staff worked changed substantially. The Active Support they offered, including providing more choice, more activities and presenting demands more carefully, went up from 45% to 60% in the experimental group, whereas the control group showed a marginal fall. Much greater improvements were also observed in meaningful activity in the experimental group compared to the control group.
The approach also saw a dramatic fall in the ABC (Aberrant Behaviour Checklist) score, from 42 to 15 in the experimental group. Observed challenging behaviour also fell, from 25% to 10%.
The support model requires different behaviours and ways of thinking from frontline staff who are responsible for ensuring its successful implementation. This, clearly, requires extensive retraining of all support teams.
However, despite this, during the research, staff in the experimental group settings showed significant increases in their job satisfaction and reductions in stress when compared with staff in control group settings.
Researchers found that the approach was greeted positively by everyone involved in the Dimensions Activate settings, including staff, the families of people being supported and the professionals engaged there. Over time it is hoped that this job satisfaction will be reflected in staff retention, which enables long-term relationships to develop between staff and the person they support.
Evidencing the benefits
Improved quality of life, engagement, meaningful activity and satisfaction for individuals being supported is known to reduce challenging behaviour. As such, with further analysis, Dimensions hopes that the model can evidence these benefits to commissioners and achieve an associated reduction in costs of placements.
Over to the experts
Is Dimensions’ new Activate model an approach for all learning disability support providers to adopt? Are there any barriers to implementing such a model? With impressive results and research-based evidence, will it lead to commissioners expecting providers to follow Dimensions Activate? What do the experts think?
Some positive early results
Dimensions must be commended for investing in the important and essential research that has been undertaken to validate Activate.
We believe any innovations that deliver improved quality of life for people should be regarded as valuable, not least because they help to foster a culture of continuous improvement.
The team at Dimensions has clearly achieved some positive early results, which everyone should welcome. Indeed, their rigorous outcomes-focused approach is a great example of the commitment that all responsible providers are making to raising standards. We agree wholeheartedly with the central focus of the methodology; co-production between individuals, their circles of support and providers, to identify goals and sustain improvements to quality of life.
The ability to measure integrated outcomes underpins the sector-wide response to the many initiatives and changes post-Winterbourne. Whilst it may not be appropriate for commissioners to mandate Activate, we believe all providers have a responsibility to deliver and evidence person-centred models of support and it is a drum we’ve been beating for a number of years.
If Activate is to be adopted more widely across the sector, it would be helpful to understand how the existing good and effective practices of both individual services and larger providers, like ourselves, could be incorporated into the framework to build on the positive early outcomes witnessed by Dimensions.
We would welcome being part of any future discussions regarding the role the Activate principles have in creating ‘Outstanding’ services which truly place the people being supported and their goals and aspirations front and centre.
Amanda Griffiths Director of Quality, Voyage Care
Could be part of the answer for others
I often feel that in focusing on a particular method of supporting people, we can become over-fixated in methods and toolkits. This means we forget to just be with the people we support, listen and work out together what to do.
However, with the Dimensions Activate model, I was immediately taken with the results of the pilot. Clearly, it is an holistic approach that gives support staff a very clear framework, based in rights and humanity, as well as a set of skills from which to work. This will be one of the reasons that the independent evaluation showed such positive results.
We often impose models of working on support staff that do not make sense to them and are seen as yet another thing they ‘have to do with the people they support’. It can cause them more stress. The fact that support staff reported greater job satisfaction also interested me.
I think that most of us know what kind of lives people with learning disabilities want to lead. However, the gap between that aspiration and what is needed to help people achieve this is still huge. This approach to supporting people could be part of the answer for other organisations in changing how they support people, but just a part.
Dimensions is also an organisation that invests in thinking about where people live, who they live with, family involvement and shifting power towards the people they support and families. If an organisation does not have a commitment to a fundamental shift in power and giving the people they support and their families real control over their lives, then this method alone will not be the answer in driving up quality and giving people with learning disabilities the lives they want.
Alicia Wood Chief Executive, Housing & Support Alliance
Innovative thinking and proactive working
This model embodies the innovative thinking and proactive working that we need to improve services. It is coproduced with people with learning disabilities and/or autism, and their families. It uses Positive Behavioural Support as a framework to create positive environments, which do not rely on reactive strategies, and it rests on research led by experts.
Workforce development will be a key area for the national Transforming Care programme as it works to build up resilient, community-based teams. Moving people out of inappropriate hospital settings, and preventing admissions to them in the first place, relies on providers ensuring, and commissioners enabling, quality training across organisations.
Encouraging different behaviours and new ways of thinking is perhaps a challenge in the short-term, but the long-term sustainability of services in the community requires just this sort of action. Indeed, it requires transformation. The Transforming Care programme wants to reduce the number of hospital-based beds for people with learning disabilities and/or autism by up to 50% across the country by 2019. But it cannot do this without significant development of community-based care. This does not just mean a different setting – it means integrated, person-centred support which is at the heart of health and social care’s overall vision.
Activate demonstrates what this could look like for people with learning disabilities and/or autism, and their families. All providers and commissioners should be thinking proactively about the support they offer and how it showcases those core elements. Elements which we know lead to meaningful outcomes – co-production, flexibility and a culture that is not averse to thinking widely about how best to improve the quality of life of the people it supports.
Kate Brittain Senior Policy Adviser, Association of Chief Executives of Voluntary Organisations