Over the last five years we have been working on a project to review 1-1 care for people in care settings. Most of the people we have assessed have experienced cognitive impairment, mental health and acquired brain injuries. They have also demonstrated behaviours that have put them at a high risk of causing harm/injury to themselves or others.
In that time we have reviewed around fifty 1-1 packages in a bid to make 1-1 care more person centred, therapeutic, cost effective but also based upon sound clinical reasons.
Whilst there are no actual set of guidelines in place for 1-1 provision within care home settings, much observation strategy is taken from a NICE document entitled: ‘The short term management of disturbed/violent behaviour in psychiatric inpatient settings and emergency departments’. (NICE, 2005, revised in 2015) and Standing Nursing and Midwifery Advisory Committee (SNMAC, 1999). The Mental Health Act codes of practice for England and Wales (2015 & 2016 respectively) make clear that use of observation for reducing harm to self and others within inpatient settings.
Defining adequately what 1-1 interventions are for is fraught with difficulties. The definition below by Wood et al (2018) is a sound description, by also recognising the hazard of falling, which is one of the major reasons for requests for 1-1 funding within care homes.
‘One to one specialling is a type of care which is provided to ensure the safety of patients who may be suffering from cognitive impairment, exhibit challenging behaviour, or may be at risk of falls or of causing harm to themselves or others. Care such as this, often referred to as ‘specialling’ or ‘sitting’ is common practice in most hospitals around the world…’.
These guidelines are designed mainly for mental health or acute hospital settings and also for those people who express behaviours that challenge in the form of violence. There is a need for a more set of bespoke guidelines for care homes.
One to one care has been a recognised and an accepted feature of support within care homes throughout the UK. Often however it is sought as a defensive, restrictive aspect of care and rarely a therapeutic, wellbeing enhancing intervention.
Furthermore, there is often a lack of recognition that 1-1 interventions are a restriction on the person’s liberty and there have been several care providers who have not recognised their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (2009).
One of our endeavours has been to establish the ten (10) core behaviours that may warrant 1-1 support. These are:
- Violence towards others
- Destructive behaviour towards property
- Deliberate Self Harm
- Suicide Risk
- Sexually inappropriate behaviour
- Absconding behaviour (putting the person at risk of harm)
- Prolonged overactivity likely to lead to physical exhaustion
- Falls* After a Falls team involvement and exhaustion of Multifactorial risk assessment and multifactorial care plan
- Disruptive behaviour that may put a person in another person’s property/space
- Pica- attempts to eat inedible objects
Complicating the issue, is when it (1-1) is sought for reasons that will not be ameliorated by having 1-1 care, such as shouting or being agitated, or non descriptive terms such as ‘challenging’ or ‘difficult’ or being ‘upset’.
Two questions that arose early on in this work, was: If a person was receiving 1-1 care for 24 hours a day, what care/interventions would they be receiving if there was no 1-1 in place?
Secondly if a client is sleeping for six hours, what is the function and value of 1-1 care during that time period?
The fact is, all clients within a care setting with needs around dressing, feeding and personal care will receive at least four to six hours of individualised care by the core staffing compliment – whether they are receiving 1-1 care or not.
With this fact in mind it is reasonable to consider it as a factor when prescribing 1-1 support by Local Authorities and Integrated Care Boards (ICBs).
Therefore it will be a core consideration that all 1-1 requests put to the ICBm (unless exceptional in nature) will be based upon a 18-20 hour period.
There is also an urgent need to develop a policy, procedure and guidelines to ensure that 1-1 care is administered therapeutically, cost effectively, ethically and legally.
This will be achieved by:
- Ensuring that such a policy is applied consistently
- 1-1 support is enhanced observation and by its very nature is a restrictive intervention.
- Encouraging 1-1 applications to be in accordance with agreed criteria and guidelines including flow chart
- Supporting care providers to explore alternative options such as Assisted Technology
- Provide training and guidance for carers and agencies to ensure 1-1 strives to be therapeutic and less restrictive
- Promoting good documentation and accurate record keeping
- Working in partnerships with care providers to promote evidence based practice with sound data gathering
- Support compliance with Human Rights Act, Equality Act, Mental Capacity Act, DoLS and best practice related to falls reduction
- Help to develop centres of excellence for care providers when dealing with behaviours that challenge by using Positive Behavioural Support as a core learning stream
copyright Shirley Brennan and Walter Brennan 2023
References & Further Reading
- National Institute for Clinical Excellence (2005), Violence: managing disturbed/violent behaviour (clinical guideline 25)”, National Institute for Clinical Excellence, London.
- National Institute for Clinical Excellence (2015), Violence and aggression: short-term management in mental health, health and community settings (guidance/ng10), available at: https://www.nice.org.uk/guidance/ng10/resources/violence-and- aggression-shortterm-management-in-mental-health-health-and-community-settings- 1837264712389 (accessed 10th November 2021).
- Wood V, Vindrola – Padros C, Swart N, McIntosh M, Crowe S, Morris S, Fulop N, (2018) One to One Specialling and sitters in acute care hospitals: A scoping review. International Journal of Nursing Studies. 84 pp. 61-77.
- Standing Nursing and Midwifery Advisory Committee (1999), “Practice guidance. Safe and Supportive Observation of Patients at Risk. Mental health
nursing: addressing acute concerns”, Department of Health, London, available at: https://webarchive.na tiona larc hives .gov.uk/20100604194331/http://www.d h.go v.uk/p r od_consum_dh/groups/dh_digitalassets /@d h/@e n/documents/digitalasset/d h_4066 779.pdf (Accessed 10th November 2021)
- Department of Health (2015), Mental Health Act 1983: Code of Practice, TSO (The Stationery Office), Norwich.
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