outcomes of ordinary housing services in wales: objective indicators

OUTCOMES OF ORDINARY HOUSING SERVICES IN WALES: OBJECTIVE

INDICATORS

Jonathan Perry and David Felce Welsh Centre for Learning Disabilities Applied Research Unit, University

of Wales College of Medicine, 55 Park Place, Cardif” CFI 3A T

Paper accepted June I994

Abstract Outcome data were collected on fourteen, recently provided staffed houses for people with mild, moderate, severe or profound learning disabilities in order to assess the quality of service provided. Quality indicators reflected the quality of the housing provision, social and community integration, social relationships within the houses, resident engagement in activity, developmental progress over time and opportunities for autonomy and choice. The data show that the quality of the houses investigated was broadly similar to that reported for other housing services in British research which has accompanied deinstitutionalisation. Quality levels on many indicators were related to the ability of residents and the data illustrate the difficulty in providing services for people with more severe or profound learning disabilities, which are capable of achieving outcomes comparable with those attained in services for more able residents. This research provides further evidence that the extent of staff support for resident activity is critical to how much residents are able to participate fully in the everyday activities which arise in the conduct of their lives.

Ordinary housing in the community has increasingly been seen as the most appropriate residential context and should, therefore, be the basis of provision for people with learning disabilities when the time comes for them to leave the parental or family home (e.g. Welsh Office, 1983). This study looks at the nature of domestic and community living in fourteen, recently established staffed houses in South Wales. Such outcomes are reflected by a range of indicators each relevant to a particular aspect of a person’s quality of life (Felce 8z Perry, in press).

The effect on people with learning disabilities of the shift in emphasis from institutional to community residence has been the subject of considerable research (see Allen, 1989). Lowe 8z de Pavia (1991) assessed the impact of the

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0 1994 J. Perry and D. Felce Vol. 7, No. 4, 1994

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ORDINARY HOUSING: OUTCOMES FOR RESIDENTS 287

introduction of the NIMROD service on residents’ development and their community and social contacts, and found broadly beneficial results. In similar vein, Felce et al. (1986a), Felce el af. (1986b), and de Kock et al. (1988) showed that groups of adults with severe or profound learning disabilities living in two staffed houses in Andover received higher levels of interaction and assistance from staff, spent more time in purposeful activity, experienced greater developmental progress and enjoyed greater community and social contact than when in hospital or when compared to matched groups in large community units. Felce & Repp (1992) concluded that the project established that local community living was preferable to large hospital care on a number of indices of quality, given that housing services were set up with a certain ethos and attention to working methods and staff training.

Bratt & Johnston (1988) have referred to these initial community housing services and others, such as the Wells Road project in Bristol (Ward, 1986) and the housing services established to resettle children from the Northgate Hospital in Northumberland (Thomas, 1985), as ‘first generation’ projects. As the first ordinary housing schemes for people with severe or profound learning disabilities in Britain, first generation projects according to Bratt & Johnston, may well have benefited from generous time allocation from line managers, clinical specialists and administrative staff and ‘pioneer spirit’ manifested in extra staff commitment and motivation. Instrumental in creating this spirit were the innovators, professionals or researchers who designed and led the projects. The early stage of development meant that the first reforms were planned in considerable detail. Moreover, those planning first generation projects may well have had particular expertise to make success more likely. In contrast, they contend that later developments, ‘second generation’ projects, may typically be developed under more limited time constraints as pressure for hospital closure has increased. The number of ordinary houses now estabkished or being planned means, they suggest, that the majority of services will have been developed by less experienced and less research oriented service planners.

For these reasons, Bratt & Johnston (1988) advocated the evaluation of second generation projects. They themselves looked at five adults with learning disabilities before and after a move from hospital to a second generation community residence. They found improved quality of life in terms of residents going out more, visiting a more varied range of places, having more social interaction and engaging in less inappropriate behaviour. However, closer scrutiny of the data revealed a lack of real community integration in that trips out were generally leisure excursions rather than use of ordinary community facilities such as shops and pubs. They also found

288 MENTAL HANDICAP RESEARCH

that residents were not being supported to gain the domestic skills required for greater independence. Fleming & Stenfert Kroese (1990) similarly looked at changes in indices of the quality of life of people who moved from hospital to what could also be defined as second generation housing. They reported that residents’ competence did not increase when they moved to community- based group homes unless structured staff procedures were implemented; that residents had few meaningful relationships after their move and that residents had little community presence. In similar vein, having looked at the effects of resettlement on adaptive behaviour, Beswick (1992) found that moving to community settings did not lead to increased skill acquisition. In a recent review, Emerson & Hatton (in press) report that no statistically significant improvement in resident skills was apparent in 42% of evaluations concerned with moving from hospital to staffed housing in Britain.

Jahoda el af. (1990) assessed the social activity and social networks of people moving from family homes and longstay hospitals to community residences and found that the move led to more community-based activities but very few opportunities to meet people without learning disabilities. Donegan & Potts (1988) assessed the relationships of nine people with learning disabilities living in the community in terms of the frequency of visits to and by friends and relatives and the type of contact with neighbours experienced. They concluded that ‘ . . . most of the participants live on the fringes of society . . . although they live in their own homes independently within the community, the majority do not take part in many community activities’. The majority of comparisons reveal that the range and frequency of community activities increases on moving to the community (Emerson & Hatton, in press), although about a third showed that this was not the case. However, in keeping with Donegan & Potts (1988), even those studies showing increased social contact following deinstitutionalisation have commented on the persistence of the extremely limited social networks which people with learning disabilities have (e.g. Firth & Short, 1987; de Kock el al., 1988; Todd et al., 1990).

Emerson & Hatton (in press) also show that, while increased resident engagement in activity generally followed moving to less restrictive settings, 27% of the comparisons between hospitals and community housing services included in their review of the British deinstitutionalisation literature reported no significant change. Even where increased activity has been found, such a result may depend on the precise internal organisation of the setting rather than being a general consequence of the change in environment. For example, Conneally, Boyle & Smyth (1992) provided data on resident engagement and stafflresident interaction in two houses which


showed that engagement levels improved within one home over time as staff gave more assistance to residents as a result of ongoing staff training. However, the overall level of staff/resident interaction was no higher in either house than previously.

The South Welsh community residences evaluated in the current study are second generation in the terms discussed above. However, it is possible that standard setting through the AN Wales Strategy for the Development of Services for Mentally Handicapped People (Welsh Office, 1983) may have helped to counteract some of the reasons why second generation service outcomes may be less positive. The purpose of this study was to evaluate the quality of residential life in a reasonably large number of ordinary housing services using a broad range of evaluation indicators in order to assess the state of what is currently being provided.

Method

Settings and residents

Fourteen houses from four counties in South Wales participated in the study over two years. All were small, staffed community residences (ranging in size from between one and seven places), all were recent developments (provided between 1987 and 1990) and all but one had been in operation for at least a year. The services were recruited by approaching service managers in the four counties who were asked to nominate services which would span a range of support needs. Ten of the 14 houses were managed by local authorities, two by voluntary agencies, one by a health authority and one was privately operated. Four houses were located in cities or large towns, nine were in or on the edge of small towns and one was on the edge of a village.

At the outset, the houses catered for a total or 55 residents of whom 29 were male and 26 were female. Ages ranged from 19 to 67 years with the mean age being 37 years. Residents were assessed using the ‘Adaptive Behaviour Scale Part One’ (ABS) (Nihira et al., 1974). In all that follows, houses are ordered by ascending ABS score. Residents in Houses 1 - 3 had raw ABS scores which were typical for the lowest quartile of people in the sample from which the reference norms were derived. Residents in Houses 11 - 14 had raw ABS scores which were only achieved by the upper quartile of the reference sample. The raw scores of the other houses were more or less evenly spread across the second and third quartiles. During the course of the study, one resident died and three residents moved to alternative accommodation. Staffing levels in the 14 houses were, on the whole, related


to the ability of the residents and varied from staff/resident ratios of 1 : 1 or greater throughout the day, to 1:6 or less.

Measurement

Data were collected to reflect six quality of life concerns: quality of housing, social and community integration, social interactions, activity, personal development and autonomy/choice. Data were collected in each of these areas on more measures than are presented. High correlation has been found between related measures (Perry & Felce, in press) and, therefore, only representative examples are presented here.

Quality of housing

The ‘Characteristics of the Physical Environment Scale’ (CPE) (Rotegard et al., 1983) was used to measure the homeliness of the living room, dining room, bedrooms, bathroom and garden of each residence. It is arranged as a series of Likert scales and examples of what constitutes each pole of the scale are given for guidance. The measure was completed by the first author during a tour of the facility. The ‘Physical Quality Scale’ (PQS) (Conroy & Bradley, 1985) was also used. It is a measure of the physical quality of the environment similarly derived from a rater (the first author) touring the facility. Three items refer to the building’s exterior and the neighbourhood. Two items rate bedrooms in terms of personalisation and individualisation and the remaining items are concerned with cleanliness, amount of light, odours, orderliness and state of furniture in other rooms.

Social and community integration

The ‘Index of Community Involvement - Form 2’ (ICI) (Raynes el al., 1989) was used to reflect the range of resident involvement in social activities and their use of community-based facilities. Staff respondents were asked whether or not each resident had participated in 14 listed activities in the previous four weeks. They were also asked if the person had been on holiday in the last year. The percentage of items scored as occurring for each resident in each house was averaged to give an overall percentage for each house. No reliability data were collected. The ICI is simple, can be administered without training and Raynes (1988) has reported high inter-rater and internal consistency coefficients for the scale.

Staff were also asked to record the frequency and nature of social contacts and community activities for each resident over two four-week periods to provide a tally of the frequency of integrative events. Staff were initially


asked to complete recording forms and return them to the researchers after the month was completed. This resulted in low compliance in the first round with only six houses providing a complete record. Services were subsequently asked to return completed forms weekly and were given telephone reminders to fill in the records. Two services still failed to return the forms so results on this indicator are only presented for twelve residences. Reliability and validity of the data were not checked.

An evaluation of all of the houses using ‘Programme Analysis of Service Systems 3’ (PASS 3) (Wolfensberger & Glenn, 1975) was also conducted. A team of trained raters in a PASS 3 assessment evaluates the service on 50 ratings. Each rating is accompanied by an explanation of its rationale to provide scoring guidelines. The majority of ratings are weighted to reflect the importance of the aspect of service being evaluated according to the normalisation principle. In this study, teams of three raters were assembled for each house to be assessed from the body of individuals who have presented or provided team leadership within PASS 3 workshops held in Britain. Teams visited services for a full day. The social integration rating cluster subscore was calculated as relevant to this section. In this and all subsequent use of PASS ratings, consistent with Williams (1992), scores were expressed as percentages of the totals possible rather than preserving the negative to positive scoring spectrum of the original measure. The social integration cluster comprises one rating concerned with the occurrence of socially integrative social activities and nine to do with positive or negative image associations concerned with residents, staff, and the setting which may promote or inhibit integration.

Social interactions

The ‘Group Home Management Schedule’ (GHMS) (Pratt et a/., 1980) was used to measure the extent to which management practices were institutionally or individually oriented. The GHMS operationalises the extent of four negative factors: block treatment, depersonalisation, social distance and rigidity of routine. The scale contains 37 items, each scored on a 3-point rating scale. Higher scores signify institutionally oriented practices. Extensiveness of interactions are inversely reflected by the social distance items on the scale. In this study, scores were expressed as a percentage of the total possible score. Administration of the GHMS was by interview with staff members. No reliability data were collected in this study but high construct reliability has been found previously (see Raynes, 1988).

In addition, interactions which staff had with residents and the social initiatives or responses of residents were also observed using a 20 second


momentary time sample, encoding observations into a handheld portable computer (a Psion organiser), using software developed by Beasley et al. (1989). The observer was prompted by the computer to observe the behaviour of a particular resident and any contact received from staff every 20 seconds. The observer then pressed pre-coded keys to input data. The observational definitions used followed those given by Beasley et al. (1989): residents’ social activity comprised clear social activity, unclear social activity and no social activity; social interaction from staff comprised positive, negative and neutral contact, contact in the form of assistance and contact from other residents (this code was used in conjunction with one or more of the other four codes to distinguish contact between residents from contact from staff). The data were automatically saved onto datapacks and subsequently uploaded to an IBM compatible computer and analysed. Provision is made in the software for groups to be observed by observing individuals in rotation. Residents were observed in rotation in this study for blocks of ten minutes at a time.

Each house was observed for eleven hours a day for three days over the two year period. Individuals were not observed in personal situations or when out of the house. The number of observations made therefore varied according to when people got up, when they retired and the extent of their activity outside of the house. A second observer collected data simul- taneously with the main observer for 5% of the time in order to check the reliability of the data. Percentage occurrence agreement for each code was calculated by dividing the total number of agreements of occurrence by the total agreements plus disagreements for that code and multiplying by 100. Percentage non-occurrence agreement on each code was calculated by dividing the total number of agreements on non-occurrence by the totai number of agreements and disagreements for that code and multiplying by 100. Occurrence agreement was 98070, 6670, 96% and 64% for no social activity, clear or unclear social activity, no contact from others and contact from others respectively. Analogous non-occurrence agreements were 73%, 97%, 76% and 99%.

The average percentage of time residents in each house received social contact was calculated distinguishing contact from staff and from other residents. In addition, the average percentage of time residents in each house spent engaged in two-way interaction was calculated. This was defined as clear or unclear social activity on the part of the resident occurring in conjunction with positive, negative or neutral contact from staff or another resident.


Activity

The quality and quantity of activity was reflected by two measures. The general quality of activity in relation to age and cultural norms was reflected by the combined scores of the age and culture appropriate activities, routines and rhythms ratings from PASS 3 , expressed as a percentage of the total possible.

The extent of resident activity was measured by direct observation at the same time as staff/resident interactions were observed using a 20 second momentary time sample, handheld Psion computers and the observational definitions put forward by Beasley et al. (1989) as described above. Residents’ non-social activity comprised leisure, personaUself care, domestic/practical tasks, education and no activity. Residents’ social activity was as set out above. Other observational details are also as described earlier, including the manner of calculating reliability. Occurrence agreement was 77%, 85%, and 82% for leisure, personaVself care and domestic activities respectively. Analogous non-occurrence agreements were 97%, 98%, and 99%. Summing across individuals and observation sessions within each house, means for the following were calculated: engagement in leisure, personal and domestic activities (collectively, non-social activities) and total engagement in activity. The latter is defined by the occurrence of either non-social engagement or two-way social interaction or both.

Personal development

Change in score on the ABS (Nihira et al., 1974) over time was used to assess developmental progress. The ABS consists of 66 items spanning 10 domains of adaptive behaviour. It was administered by interview with a member of staff who knew the person well on three occasions each one year apart. A total ABS raw score was calcultated by combining the domain scores with the exception of vocationalactivity. This was omitted because the items relate to work outside the home and this was considered irrelevant to the quality of the residential service. An indicator of development was obtained by averaging the change in score for each resident between the first and second assessment and the second and third and then averaging across all residents in each house.

Inter-respondent reliability of the ABS was checked by obtaining independent assessments from two members of staff for 13% of residents. Reliability on each dorrain was calculated by dividing the number of times staff agreed on an item within the domain by the total number of domain items and multiplying by 100. An overall reliability of 81% was obtained, calculated by a weighted average of domain reliabilities. Domain reliabilities ranged from 58% to 89% exact agreement.


The developmental growth orientation rating cluster subscore from PASS 3 was also used to reflect the degree of focus on developmental issues within service structures and processes. This explores the extent of physical or social overprotection and the intensity and relevance of individual programming pursued.

Autonomy and choice

Autonomy and choice were reflected by three indicators: a combination of the age appropriate autonomy and rights and individuaitsafion ratings from PASS 3 , a combination of the depersonalisation, block treatment and rigidity of routine items from the GHMS described earlier and the ‘Choice Making Scale’ (CMS) (Conroy & Feinstein, 1986). This estimates the extent to which staff encourage residents to make choices. It is a self completion questionnaire with four items in each of six sections covering choice related to food, house/room, clothes, sleeping/waking, recreation and other issues and it has high construct reliability. The scale was completed by a single member of staff in each house. Scores on all measures are presented as percentages of the totals possible.

Results

Quality of housing

Housing quality was fairly high as reflected in scores on both scales being generally in the upper half. None of the houses scored less than half of the total possible PQS score (range 54% -72%) (Figure 1) while only two (Houses 1 and 3) scored less than 50% on the CPE (range 36% - 82%). PQS scores were not related to the ability level of the residents served, showing that such issues as the personalisation of the bedrooms and the general upkeep and pleasantness of the environment was as good in services for people with greater disabilities as in general. CPE scores were significantly related to ability (Spearman rank correlation coefficient = 0.81 , p<O.Ol) showing that services for more independent residents were generally better able to maintain an air of homeliness (the main feature of the CPE not reflected in the PQS).

Social and community integration

All residents participated in social and community activities to some extent (Figure 2). However, integration was variable. The ICI ranged from 20% of


Figure 1 Percentage scores on the Physical Quality Scale (PQS) and the Characteristics of the Physical Environment Scale (CPE) for the fourteen houses and the overall means

possible score to 73% with a mean of 55%. On average, therefore, residents experienced only about half of the community or social opportunities included within the scope of the scale. Residents in two houses (1 and 3) engaged in a particularly restricted range of activities. However, overall ICI scores were not related to ability with the highest levels of social integration indicated for those in the mid range. The PASS social integration subscores were generally lower although they had a similar range (mean 41 To, range 20% - 75%). Only three houses (4, 13 and 14) scored above 50%. As with the ICI, scores were unrelated to resident ability. The profiles of PASS social integration and ICI scores across the houses were, however, not similar to each other.

The average frequency of communtiy activities varied from 10-45 per person per month (mean 18). On the whole, settings with less able residents had lower frequencies than those with more able residents although this pattern was skewed by the data from House 4. The high frequency in this setting resulted from the fact that the sole resident received an individualised community-oriented day service. This typically involved daily trips to local amenities from the house. Otherwise, individuals tended to visit community amenities somewhere between once and twice every three days. Social activities were less frequent than community activities for residents in all houses bar House 14, who were the most able and independent. They ranged


Figure 2 Social and community integration: (a) the percentage of the total possible scores on the Index of Community Integration (ICI) and Programme Analysis of Service Systems (PASS) social integration ratings, and (b) the average frequency of social and community activities per resident per month


from an average of 3 - 20 per person per month with a mean of 8. Clearly, some residents have very restricted social lives. Those in Houses 1, 3, 7, 8, 9 and 12 have about one social engagement per week. Residents in only four houses had 12 or more social contacts per month (Houses 6, 10, 13 and 14). Residents in House 14 had 20 social contacts per month, two every three days on average. With House 4 excluded, the combined frequencies of community and social activities were significantly related to resident ability (Spearman rank correlation coefficient = 0.79,p<0.01).

Social interaction

On average, each resident received contact from staff for 14% of time (range, 2% - 31 To) (Figure 3). The variability in staff contact was not greatly related to resident ability, although average levels in Houses 1 - 7 were 55% higher (at 17%) than in Houses 8 - 14 (1 1 To). Such increased rates of contact were the result of considerably higher staffing levels. Average staff/resident ratios were twice as high in the lower numbered seven houses than the higher. Receipt of contact from other residents was, on the whole, less frequent (mean, 2.5%; range, 0% - 15%) and related to resident ability (Spearman rank correlation coefficient = 0.73, p<O.Ol). It was not observed to any appreciable extent in Houses 1 - 6. However, even some of the relatively able residents, such as those in Houses 13 and 14, spent relatively little time in direct contact with each other: about one minute per hour. Residents in House 12 were the most sociable, each being contacted by another for about nine minutes in every hour.

Resident engagement in two-way interaction was extremely variable. I t averaged 7% of time, or four minutes per hour, but the range went from 1% -26%. Residents in House 1-6 mainly interacted with staff and time spent engaged (mean, 4% or two minutes per hour) broadly reflected levels of staff contact although the rank-order association was not significant (Spearman rank correlation coefficient = 0.75, p 0 . 0 5 ) . For these residents, two-way interaction occurred, on average, for about a fifth of the time contact was received. Residents in Houses 7 - 11 and House 13 were engaged in social interaction for about 8% of time or for five minutes in every hour. Residents in House 12 were the most sociable, spending an average of 26% of time or about sixteen minutes per hour engaging in social interaction. Residents in House 14 spent less time engaged in social interaction than others in the higher numbered houses. Two-way interaction was significantly related across these houses to total contact received (Spearman rank correlation coefficient = 0.86, p<O.Ol). Moreover, these more able residents


Figure 3 Social interaction: (a) the percentage times spent receiving contact from staff or other residents and engaged in two-way interaction per resident, and (b) scores on the Group Home Management Scale (OHMS) social distance domain (using an inverse axis).


were three times more socially responsive than their counterparts in House 1 - 6. Two-way interaction occurred, on average, for about three-fifths of the time contact was received.

Figure 3 also shows the social distance scores of the GHMS. High scores indicate greater social distance between staff and residents and, thus, the mean of 30% (range, 1 1'70 - 57%) and the fact that the majority of houses ( 1 1 of the 14) scored less than 40% suggests that social distance was generally low. Social distance was significantly inversely related to the extent of contact residents received from staff (Spearman rank correlation coefficient = - 0.79, p<O.Ol), providing supporting validation for the overall picture of social interaction presented.

Activity

Houses scored an average of 38% of the total possible on the age and culture appropriate activities, routines and rhythms ratings from PASS 3 (range, 0% - 80%). Scores were generally related to resident ability with each of Houses 7 - 14 other,than 1 1 scoring between 50% and 80%. Scores for the first six houses were low, three scored zero, one 7 . 5 % and two 16% of the total possible. Such scores reflect low levels of activity, an undue reliance on simple, repetitive or passive leisure activities for occupation and the pursuit of activities evocative of those done normally by children.

Observed engagement in activity was consistent with the PASS scores (Figure 4). Total time spent engaged averaged 54% (range, 16% - 89%) and was significantly related to resident ability (Spearman rank correlation coefficient = 0.90, p<O.Ol). Residents in Houses 1 - 6 were engaged for an average of 33% of the time, or for twenty minutes in every hour. Those in Houses 7 - 14 were engaged for more than twice that: for 70% of time, on average, or for about forty-two minutes per hour. Engagement in personal activity (mainly eating and drinking) was relatively constant across houses. Participation in running their own households as evidenced by engagement in domestic activity was virtually non-existent for residents in Houses 1 - 4 and rose to levels around 25% of the time for residents in Houses 12 - 14. Overall, engagement in domestic activity averaged 12% of time and was significantly related to resident ability. Engagement in leisure activity also tended to rise with ability; it was the largest component of activity in the majority of Houses 7 - 14. Much comprised fairly passive activity such as watching television.


CJ Leisure activity Personal activity Domestic activity

- - - - Total engagement in activity (combining non-social activity and two-way interaction)

Figure 4 (leisure, personal and domestic)

Percentage times spent engaged in total and in non-social activities

Development

Figure 5 shows the PASS developmental growth orientation subscore and the average annual change in the ABS for each setting. PASS scores were consistently low (mean, 18%; range, 0% - 34%) and unrelated to ability. Apart from House 4, which was one of two which scored 34%, the assessment of the emphasis given to developmental growth in the lower numbered houses was particularly low. However, in contrast, the ABS


Figure5 Percentage of the total possible scores on the Programme Analysis of Service Systems (PASS) developmental growth orientation ratings and average annual change in total Adaptive Behaviour Scale (ABS) scores.

results show that developmental growth was greatest among residents who were the least able. The most able residents (Houses 11 - 14) changed very little over the two years, while those in Houses 9 and 10 noticeably regressed.

Autonomy/choice

The majority of the houses scored in the upper quartile of the CMS (Figure 6), all except House 1 (53%) and House 3 (55%). The GHMS data concerned with block treatment, rigidity of routine and depersonalisation, which was also collected but is not displayed in Figure 6, showed a similar general picture, bearing in mind the inverse scoring system. The majority of houses had scores in the lowest quartile, that is, they were relatively free of the three


Figure 6 Percentage of the total possible scores on the Choice Making Scale (CMS) and the Programme Analysis of Service Systems (PASS) autonomy and individualisation ratings.

negative characteristics assessed. Only House 1 (42%), House 3 (33070), House 6 (39%) and House 8 (29%) had scores outside this range. However, the PASS ratings concerned with autonomy and individualisation showed a contrasting picture. The majority of scores (10 of the 14) were in the lowest quartile of the possible range and only two were greater than 50%: House 4 at 89% and House 7 at 73%. In none of the three measures were scores significantly related to resident ability.

Discussion

The data surnmarised above provide a description of the level of quality achieved and maintained on a broad range of indicators within a number of typical, recently provided, supported housing schemes in Wales for people


with learning disabilities of differing levels of severity. In assessing the significance of such achievement, we will first look to compare the average attainment across the disability spectrum served against findings from other research. A number of scales used in this research were employed, either in the same or modified form, by Raynes et al. (1992) in their study of 150 facilities, which also served people with a range of disabilities. Using an abbreviated form of the ABS, a third of residents were assessed as having abilities in the lower half of the scale, a third in the third quartile and a third in the upper quartile. Facilities ranged in size from 2 - 31 places, but only a third used ordinary housing stock. Data on the ‘Physical Quality Index’ (a brief version of the Scale) were gained for 115 settings and an overall mean of about 67% of total score was obtained. Homeliness of rooms also averaged about two-thirds of possible score. Average PQS and CPE scores in this study, the latter including an assessment of the homeliness of rooms, were both of a similar order (about 63% of the possible totals). With some caution due to the differences in the precise detail of the measures used, therefore, it is possible to conclude that the houses in this study were comparable in environmental quality to the settings studied in England by Raynes and her colleagues. However, houses in the original American study by Rotegard et a/. (1983) scored an average of 83% of total score. By this comparison setting quality was not so high if equivalent subjective judgements were made in completing the measure.

Comparison to the findings of Raynes et al. (1992) can also be made in relation to the GHMS, CMS and ICI. They used an adapted form of the GHMS whereby high scores represented individually-oriented care. Settings in their study averaged 57% of total score. The houses in this research were found to be considerably more individually oriented. Used in its original form in which individual orientation is denoted by low scores, the Welsh houses averaged 24% on the GHMS, or 76% inverted for comparison purposes. This difference may reflect the higher average size of the Raynes e ta / . facility sample. Higher scores were also found for the Welsh houses on the CMS. They averaged 85% of the possible 72 point score range (from 24 - 96) whereas the Raynes et al. sample had a mean score of 70, that is, an addition of 46 over the minimum score of 24, or 64% of the possible score range. Similarly, the Welsh houses showed evidence of greater integration as reflected in the ICI, the Raynes et a/., sample averaging 44% of possible score whereas 55% was found for the houses studied here. Across the indicators compared, therefore, the Welsh houses appear to offer generally superior quality. This may be viewed by many as consistent with their smaller scale and more typical housing design.

Social and community integration were also reflected here by data on the

3 04 MENTAL HANDICAP RESEARCH

frequency of social contacts and community activities. A weighted average of 16 community-based events occurred per person per month which converts to a frequency of 96 over six months. This was less than the 115 found by de Kock et al. (1988) for two houses in Andover over a similar period and the 144 per person per six months found in the NIMROD research (Lowe & de Paiva, 1991). The average number of social contacts per month was 7.5, giving a six-monthly rate of 45 per person. This was greater than the 37 found in Andover by de Kock et al. (1988) over a six-month period. It is also greater than the average of 5 per month found across the Care in the Community pilot projects for people with learning disabilities studied by Knapp et al. (1992). Taking the data on the ICI and the frequency of social and community events together, the integration achieved by the Welsh houses would seem to be on a general level with other community housing services.

The direct observational data on staff and resident activity can also be compared to the findings of other studies. Staff interaction received per resident in the Welsh houses averaged 14% of time, a level lower than found in some other studies: 20% and 27% (Felce el al., 1986a), 23% (Felce et al., 1991), 21% (Hewson, 1991). However, the average proportions of time residents spent engaged in activity both in total (54%) and in some form of non-social activity (49%) are comparable to the weighted engagement average calculated across British studies by Emerson & Hatton (in press) (48%). The single studies referred to above also found engagement levels of a roughly similar nature. Felce et al. (1986a) found an average level of engagement in non-social activities across two houses of 53% and Felce el al. (1991) found a corresponding level across a wider sample of houses of 41%. Hewson (1991) reported a mean engagement level across ten houses of 50%.

The results on the change in ABS scores in the Welsh houses over time showed a pattern contrary to the majority of other indicators. Better outcome was associated with higher ability on most measures where a relationship between outcome and resident ability was evident. However, in the case of the ABS, progress was found only in those settings serving people with greater disabilities. Other research has found similar findings. For example, Hemming el al. (1981) reported that it was the most able adults who benefited least from transfer from institutional to smaller scale settings in terms of changes in ABS. Smith et al. (1980), using a different developmental measure, also found evidence of greater progress among children and adults rated as non-ambulant or severely behaviour disordered compared to those rated as continent, ambulant and without severe behaviour disorder when deinstitutionalised groups were compared to control subjects remaining in hospital. Further analysis of the ABS results is being pursued to investigate


whether such results stem from the characteristics of the measure interacting with resident characteristics or the nature of service settings (Perry & Felce, in preparation). However, not all studies have reported results consistent with this picture. For example, Conroy et al. (1982), using an abbreviated form of the ABS, found that gains among people transferred to community settings with mild or moderate learning disabilities were similar to those for people with severe or profound disabilities.

The inability to explain the ABS data satisfactorily added to the level of unreliability in staff reporting of resident abilities found in this and other studies means that the levels of change reported in different research exercises should only be compared with caution. An average annual increase in ABS score across all residents of 5.6 points was found here. This appears broadly consistent with the 3.6 point per person per year improvement on the ABS within the NIMROD service (Lowe et al., 1993) and the 24 point change over three years, or 8 point increase per year, found among those experiencing small home residence in the Andover research (Felce el al., 1986b). Caution would suggest that it would be unwise to make too much of the scale of difference found between the services evaluated.

Overall, therefore, the level of outcome found in the Welsh houses fits within the general run of findings for housing services within the British deinstitutionalisation literature. There are grounds for a degree of satisfaction in relation to the question raised by Bratt & Johnston (1988) about the quality of second versus first generation housing alternatives to institutional care. A widespread ability to provide a reasonable standard of housing seems to have emerged. Such houses seem to provide a context for integration as good as earlier model services as reflected in the ICI and the frequency of social and community contacts and events. Moreover, developmental progress is reported for residents with the most limited skills. Services are individually-oriented according to the GHMS and supportive of choice as measured by the CMS. Levels of observed activity, although leaving considerable room for improvement, were typical of those reported more widely. It is, therefore, possible to extrapolate with some confidence that the settings researched here offer better quality on average than more traditional larger community units or hospital services.

However, there are also grounds for continuing to take note of the cautionary analysis offered by Bratt & Johnston. For example, even where relatively high levels of social and community activities have been achieved, residents may still have very limited social networks and engage in few activities which bring them into close relationship with other citizens - they may remain on the fringes of society (Firth & Short, 1987; de Kock et af., 1988; Donegan & Potts, 1988; Fleming & Stenfert Kroese, 1990). Eleven of


the 14 houses in this study scored below 50% on the PASS social integration rating cluster, which in PASS terms is the minimally acceptable level, suggesting that most houses could make better use of local integrated amenities and that the images of houses and residents could be enhanced to facilitate social integration. Moreover, although research may be accumulating a fairly consistent picture derived from the comparison of average outcomes, it is also demonstrating the wide range in outcome found between different services of similar design. This range is reflected in Emerson’s & Hatton’s recent review and also in the four-, five-, and six-fold differences on different indicators found between the lowest and highest scoring settings among the houses studied here.

Variation in outcome bore a relationship to resident ability on a number of dimensions. Resident ability showed a gradual transition across the 14 houses from a relatively low to high level. The greatest single step was between Houses 6 and 7 and this point may be viewed as a discontinuity in an otherwise continuous variable. The data on many of the outcome measures for Houses 1 - 6 demonstrate that achieving high quality outcomes for people with the most severe and profound learning disabilities is a challenge requiring further developmental effort. All bar House 5 had scores on the CPE, reflecting homeliness, below the mean. Houses 1 - 3 and 6 had the four lowest ICI scores. Staff contact per resident was compounded by differing staff input, which itself was related to resident ability (see Felce & Perry, in press b). Five of the seven lowest rates of stafflresident interaction taking account of staffing level are found among Houses 1 - 6 (Felce & Perry, in press b). Moreover, the data presented here show that these houses are characterised by an almost complete absence of resident/resident interaction, which reflect the very limited language abilities and the common occurrence of social impairments among residents. The differences between Houses 1 - 6 and 7 - 14 are also illustrated in the extent of resident engagement in social activity in response to social contact from others. Residents in Houses 1 - 6 were three times less socially responsive, on average, than those in the other houses. Engagement levels were lower in Houses 1 - 6 than in any of the higher numbered houses and engagement in household or domestic activity was especially low in Houses 1-4. Such findings were also mirrored in the PASS assessments of age and culture appropriate activity, routines and rhythms. Scores for all six houses were below 20% of the possible score (three scored 0%) whereas scores for all bar one of Houses 7 - 14 were 50% or above. In summary, with the exception of the ABS data discussed above where positive progress was found only among residents with greater disabilities, such relationships as existed between outcome and resident ability illustrate the difficulty in providing services


capable of achieving high quality outcomes for people with more substantial disabilities. In addition, such a conclusion suggests that any comparison of quality between services must take some account of the ability level of the people served.

The research by Felce et al. of houses in Andover was in fact limited to residents of a similar range of ability levels as those in the lower numbered houses studied here (an ABS score range of 54 - 168 across individuals with a mean of 1 1 1 compared to ABS averages of 60 - 179 across Houses 1 - 8 with an overall mean of 11 I) . There was a slightly lower frequency of social and community activities found in the Welsh houses (34 social events and 94 community activities per person per six months in Houses 1 - 8 compared to 37 and 115 in a similar period found by de Kock et al. 1988). Differences are also evident in the pattern of staff and resident activity within the houses. The first two Andover houses (Felce et al., 1986a) produced higher levels of staff contact per resident (mean 24% compared to the 16% average across the first eight Welsh houses) despite lower staff/resident ratios (1 :2.3 compared to 1 : 1.5) (see Felce & Perry, in press b). The second study (Felce et al., 1991), including observations from the NIMROD service, again showed higher staff contact per resident (23%). In both studies, the proportion of staff cdntact in the form of assistance to people to engage in activity was considerably higher (75% and 41% respectively) than that in the first eight houses studied here (19%). Resident engagement in non-social activity was higher (means, 53% and 41 Vo for the two studies) compared to the 36% found in Houses 1-8. Participation in household activities was greater than in any of the houses studied here, and four times the average level in Houses 1 - 8, occupying about 30% of each resident’s time on average or about three-fifths to three-quarters of the total.

The extent of assistance received is probably the key to participation in activity for people who lack independent abilities. This has been shown in a detailed analysis of the data from the Andover research (Felce et al., 1986a; Felce, in press) and by Emerson in relation to residential services provided for multiply disabled people by SENSE-Midlands (Emerson et al., 1993 reported in Emerson & Hatton, in press). Thus, the relationship between outcome and the nature of the service, as represented by the size of setting, building design, location, staffing and other features which define the permanent or semi-permanient environmental context, is mediated by internal organisation, working methods and the procedures which shape what staff do. As a consequence, Felce (1988, 1989, 1991, in press), Mansell et al. (1987; 1993), McGill & Toogood (1993) have argued that the implementation of an ‘active support’ model through clearly defined structures for planning staff and resident activity and for the delivery of


practical help to residents to meet the behavioural demands of commonplace situations is an essential component of high quality provision for those with more substantial disabilities. The fact that a considerable number of people in this study were not engaged in anything constructive for more time than they were and that it was only in House 14 that the level of engagement (85%) approached what would be normal in the general population underlines the importance of continuing to address the role of staff in enabling residents with learning disabilities to participate in the conduct of their own lives.

Correspondence

Research in Learning Disabilities, 55 Park Place, Cardiff, CF1 3AT. All correspondence should be directed to Dr. David Felce, Professor of

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