Learning from safeguarding adult reviews on self-neglect: addressing the challenge of change

Abstract   Purpose – One purpose is to update the core data set of self-neglect safeguarding adult reviews and accompanying thematic analysis. A second purpose is to address the challenge of change, exploring the necessary components beyond an action plan to ensure that findings and recommendations are embedded in policy and practice.   Design/methodology/approach – Further published reviews are added to the core data set from the web sites of Safeguarding Adults Boards. Thematic analysis is updated using the four domains employed previously. The repetitive nature of the findings prompts questions about how to embed policy and practice change, to ensure impactful use of learning from SARs. A framework for taking forward an action plan derived from SAR findings and recommendations is presented.   Findings – Familiar, even repetitive findings emerge once again from the thematic analysis. This level of analysis enables an understanding of both local geography and the national legal, policy and financial climate within which it sits. Such learning is valuable in itself, contributing to the evidence-base of what good practice with adults who self-neglect looks like. However, to avoid the accusation that lessons are not learned, something more than a straightforward action plan to implement the recommendations is necessary. A framework is conceptualised for a strategic and longer-term approach to embedding policy and practice change.   Research limitations/implications – There is still no national database of reviews commissioned by SABs so the data set reported here might be incomplete. The Care Act 2014 does not require publication of reports but only a summary of findings and recommendations in SAB annual reports. This makes learning for service improvement challenging. Reading the reviews reported here enables conclusions to be reached about issues to address locally and nationally to transform adult safeguarding policy and practice.   Practical implications – Answering the question “how to create sustainable change” is a significant challenge for safeguarding adult reviews. A framework is presented here, drawn from research on change management and learning from the review process itself. The critique of serious case reviews challenges those now engaged in safeguarding adult reviews to reflect on how transformational change can be achieved to improve the quality of adult safeguarding policy and practice.   Originality/value – The paper extends the thematic analysis of available reviews that focus on work with adults who self-neglect, further building on the evidence base for practice. The paper also contributes new perspectives to the process of following up safeguarding adult reviews by using the findings and recommendations systematically within a framework designed to embed change in policy and practice.     Keywords: Safeguarding adult reviews, change, self-neglect, action plans   Paper type: Research pape

The neural correlates of childhood maltreatment and the ability to understand mental states of others

$\textbf{Background}$: Emotional abuse and emotional neglect are related to impaired interpersonal functioning. One underlying mechanism could be a developmental delay in mentalizing, the ability to understand other people’s thoughts and emotions. $\textbf{Objective}$: This study investigates the neural correlates of mentalizing and the specific relationship with emotional abuse and neglect whilst taking into account the level of sexual abuse, physical abuse and physical neglect. $\textbf{Method}$: The RMET was performed in an fMRI scanner by 46 adolescents (Age: $\textit{M}$ = 18.70, $\textit{SD}$ = 1.46) who reported a large range of emotional abuse and/or emotional neglect. CM was measured using a self-report questionnaire (CTQ). $\textbf{Results}$: Neither severity of emotional abuse nor neglect related to RMET accuracy or reaction time. The severity of sexual abuse was related to an increased activation of the left IFG during mentalization even when controlled for psychopathology and other important covariates. This increased activation was only found in a group reporting both sexual abuse and emotional maltreatment and not when reporting isolated emotional abuse or neglect or no maltreatment. Functional connectivity analysis showed that activation in the left IFG was associated with increased activation in the right insula and right STG, indicating that the IFG activation occurs in a network relevant for mentalizing. $\textbf{Conclusions}$: Being sexually abused in the context of emotional abuse and neglect is related to an increase in activation of the left IFG, which may indicate a delayed development of mirroring other people’s thoughts and emotions. Even though thoughts and emotions were correctly decoded from faces, the heightened activity of the left IFG could be an underlying mechanism for impaired interpersonal functioning when social situations are more complex or more related to maltreatment experiences.This work was supported by The Netherlands Organisation for Scientific Research (NWO)-E.A.C., VICI-grant [453-14- 001], B.M.E., VIDI-grant [016-085-353], A.L.v.H., Rubicon grant [446-13-006] and by the Royal Society-A.L.v.H., Dorothy Hodgkin Fellowship [DH150176]

Peer advocacy in a personalized landscape:The role of peer support in a context of individualized support and austerity

Whilst personalization offers the promise of more choice and control and wider participation in the community, the reality in the United Kingdom has been hampered by local council cuts and a decline in formal services. This has left many people with intellectual disabilities feeling dislocated from collective forms of support (Needham, 2015). What fills this gap and does peer advocacy have a role to play? Drawing on a co-researched study undertaken with and by persons with intellectual disabilities, we examined what role peer advocacy can play in a context of reduced day services, austerity and individualized support. The findings reveal that peer advocacy can help people reconnect in the face of declining services, problem-solve issues and informally learn knowledge and skills needed to participate in the community. We argue that peer advocacy thus offers a vital role in enabling people to take up many of the opportunities afforded by personalization

An evaluation of the Cygnet parenting support programme for parents of children with autism spectrum conditions

Parents of children on the autistic spectrum often struggle to understand the condition and, related to this, manage their child’s behaviour. Cygnet is a parenting intervention which aims to help parents address these difficulties, consequently improving parenting confidence. It is widely used in the United Kingdom (UK). Despite this, there have been few evaluations. This paper reports a small-scale pragmatic evaluation of Cygnet as it was routinely delivered in two English cities. A non-randomised controlled study of outcomes for parents (and their children) was conducted. Data regarding intervention fidelity and delivery costs were also collected. Parents either attending, or waiting to attend, Cygnet were recruited (intervention group: IG, n=35; comparator group: CG, n=32). Parents completed standardised measures of child behaviour and parenting sense of competence pre- and post-intervention, and at three-month follow-up (matched time points for CG). Longer-term outcomes were measured for the IG. IG parents also set specific child behaviour goals. Typically, the programme was delivered as specified by the manual. Attending Cygnet was associated with significant improvements in parenting satisfaction and the specific child behaviour goals. Findings regarding other outcomes were equivocal and further evaluation is required. We conclude that Cygnet is a promising intervention for parents of children with autism in terms of, at least, some outcomes

Using mobile devices and apps to support reflective learning about older people with dementia

There has been little research to develop computing technologies to support the care of people with dementia, in spite of the growing challenges that the condition poses for society. To design such technologies, an existing model of computer-support reflective learning was instantiated with findings from a pre-design study in one residential home. The result was a mobile device running an adapted enterprise social media app to support person-centred care. Evaluations of the device and app in two residential homes revealed that use of the app both motivated and increased different styles of care note recording, but little reflective learning was identified or reported. The results suggest the need for more comprehensive and flexible computer-based support for reflective learning about residents in their care – and new designs of this more comprehensive support are also introduced

The development and use of the Assessment of Dementia Awareness and Person-centred Care Training (ADAPT) tool in long-term care

Policy and practice guidelines recommend person-centred care (PCC) to support people to live well with dementia in long-term care (LTC). Therefore, staff working in LTC settings need to be trained in dementia awareness and PCC. However, the access to, content of and reach of training across LTC settings can be varied. Data on current and ongoing access to PCC training can form and important component of data gathered on usual care (UC) in research studies, in particular clinical trials within LTC. However, no suitable assessment tools are available to measure dementia awareness and PCC training availability, content and reach. This paper describes the development of a training audit tool to meet this need for a UC measure of dementia awareness and PCC training. The ‘Assessment of Dementia Awareness and Person-centred care Training’ (ADAPT) tool was based on a review of published PCC literature and consultation with dementia and aged care experts. The ADAPT tool was piloted in 13 LTC facilities the UK and Australia, before being used to assess the content of dementia and PCC awareness training in 50 UK settings in a randomized controlled trial (RCT) as part of a UC recording. Following pilot testing, modifications to the ADAPT tool’s wording were made to enhance item clarity. When implemented in the RCT, pre-baseline training assessment data showed that the ADAPT tool was able to differentiate between LTC and identify settings where further dementia awareness training was required. ADAPT was then used as a method of recording data on dementia awareness and PCC training as part of UC data collection. The ADAPT tool is suitable for use by researchers to establish the availability, content and reach of dementia and PCC awareness training to staff within research studies

Values, virtues and initiatives-time for a conversation

Editoria

Programmers manual FlexGripPlus SASS SM 1.0

This document describes the op-code of the assembly language SASS of the G80 architecture used in the FlexGripPlus model. Every instruction is compatible with the CUDA Programming environment under the SM_1.

On self-neglect and safeguarding adult reviews: diminishing returns or adding value?

Purpose: One purpose is to update the core data set of self-neglect serious case reviews and safeguarding adult reviews, and accompanying thematic analysis. A second purpose is to respond to the critique in the Wood Report of serious case reviews commissioned by Local Safeguarding Children Boards by exploring the degree to which the reviews scrutinised here can transform and improve the quality of adult safeguarding practice. Design/Methodology/approach: Further published reviews are added to the core data set from the web sites of Safeguarding Adults Boards and from contacts with SAB Independent Chairs and Business Managers. Thematic analysis is updated using the four domains employed previously. The findings are then further used to respond to the critique in the Wood Report of serious case reviews commissioned by Local Safeguarding Children Boards, with implications discussed for Safeguarding Adult Boards. Findings: Thematic analysis within and recommendations from reviews have tended to focus on the micro context, namely what takes place between individual practitioners, their teams and adults who self-neglect. This level of analysis enables an understanding of local geography. However, there are other wider systems that impact on and influence this work. If review findings and recommendations are to fully answer the question “why”, systemic analysis should appreciate the influence of national geography. Review findings and recommendations may also be used to contest the critique of reviews, namely that they fail to engage practitioners, are insufficiently systemic and of variable quality, and generate repetitive findings from which lessons are not learned. Research limitations/implications: There is still no national database of reviews commissioned by SABs so the data set reported here might be incomplete. The Care Act 2014 does not require publication of reports but only a summary of findings and recommendations in SAB annual reports. This makes learning for service improvement challenging. Reading the reviews reported here against the strands in the critique of serious case reviews enables conclusions to be reached about their potential to transform adult safeguarding policy and practice. Practical implications: Answering the question “why” is a significant challenge for safeguarding adult reviews. Different approaches have been recommended, some rooted in systems theory. The critique of serious case reviews challenges those now engaged in safeguarding adult reviews to reflect on how transformational change can be achieved to improve the quality of adult safeguarding policy and practice. Social implications: Originality/value: The paper extends the thematic analysis of available reviews that focus on work with adults who self-neglect, further building on the evidence base for practice. The paper also contributes new perspectives to the process of conducting safeguarding adult reviews by using the analysis of themes and recommendations within this data set to evaluate the critique that reviews are insufficiently systemic, fail to engage those involved in reviewed cases and in their repetitive conclusions demonstrate that lessons are not being learned

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes:Development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Background: Dementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB. Objectives: To study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers. Review methods: Cochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies. Design: ResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants. Settings: ResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England. Participants: ResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews. Intervention: An online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools. Main outcome measures: ResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications. Results: ResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings. Limitations: Functionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals. Conclusions: A Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care. Future work: There is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts