Case Study in a Residential Home for people with Learning Disabilities
Using the thinking behind positive psychology, music therapists Alistair and Meta have tried out a unique approach “What Good Looks Like” to improving residential care and so reduce the likelihood of abuse and safeguarding interventions.
This case study is of a residential care home in Surrey. At the time of this intervention the home was under some stress due to being in the process of being sold. This created an atmosphere of uncertainty for staff and residents. The music therapy service delivered a project called ‘What Good Looks Like’ at the home. The aim of this is to enable management and staff to identify and build on their strengths. To support this process the have received 24 sessions of Community Group music therapy with the aims of staff development and improving service user quality of life. The sessions lasted 45 minutes and were facilitated by Music Therapists Alistair Clarkson and Meta Killick. The sessions took place in the communal lounge area on the ground floor of the home.
What Good Looks Like
'What Good Looks Like' is a strengths analysis tool listing indicators of good practice. It is a development of work commissioned by the University of Hull which identified risk factors of vulnerable adults in residential settings.
The home managers at the home were invited, in co-operation with their staff team, to identify examples of good practice. The home manager chose to do this by making a draft of his ideas, putting this to one side and then devoting a staff meeting discussing the indicators with the team. He was supported in getting authentic feedback from his staff on the quality of management and leadership by the home’s owner who facilitated this part of the discussion. The document was then shared with the music therapists and signed off as a record of the homes self assessment of their strengths at that time. The therapists then went on to facilitate community group music therapy for staff and residents at the home.
Community Group Music Therapy
The group was open for any resident or member of staff at the home to attend. The aims of the group were to promote staff confidence and creativity, increase the quality of relating and communicating between all who live or work at the home and to reduce social isolation and promote a sense of community within the home.
Group Music Therapy is a process in which emotional themes and relationships can be explored. By using a person-centred approach, people’s abilities and strengths are involved and engaged in therapeutic change. The therapists worked to gain an individual's consent to music therapy at each session. In so doing the therapists are respecting and valuing people’s right to choose and promote the freedom to direct their own therapy. This is the model that was offered purposefully for staff to engage with.
Following thought and discussion by the managers and staff at the home they felt that they were an above average home with their greatest strengths as follows:
Staff talk to service users positively and authentically and express a generally non-judgemental attitude
All service users are confident and at ease with staff and their environment
External agencies and professionals are welcomed and individuals are encouraged to have contact with them. Example: Positive quality assurance questionnaires
Managers and staff seek, record and act on feedback from practitioners and families who have contact with the service
The service is realistic and open about challenges, reports incidents promptly and informs external agencies and families where appropriate
Staff and managers are open and honest when asked about the service by other professionals, welcoming discussion and support
It is clear for everyone what the nature and purpose of the service is. Example: Mission statement, philosophy-social model
There are accessible activities and social opportunities for the service users. Example: ‘My week’ Time Table
Service users have financial security and the money to which they are entitled Example: (Negative) SU exception. Monies hard to access
The manager is visible and available, responding promptly to enquiries and requests
The quality of the engagement with the tool was factual. Not all the strengths are evidenced. The examples are document based - questionnaire, statement, time table. Also, evident from the high scores the home was not aware of their potential for change and growth in some areas.
Self-reported strengths over time
These strengths are the areas of most improvement reported after 14 sessions. For this the manager again reviewed the indicators of good practise and spoke with her staff individually about their views. She offered an additional list of staff evidence to compliment the examples given.
The areas of most improvement are as follows:
Staff have good information, skills and knowledge to support service users. Examples: “Having spent time in the sessions staff can see better how people express themselves and how therapists allow people to take the lead.”
All service users are thriving, any medical needs are promptly met and staff are offering good care and attention to them. Example: “Observing SUs over the 14 weeks staff were able to show distinct changes in individuals”
All service users are confident and at ease with staff and their environment. Example: "Even more at ease now"
Service users behaviour is consistent over time within what is expected of the individual. Example: “Staff commented that SU coped well with loud music over a period of time.”
External agencies and professionals are welcomed and individuals are encouraged to have contact with them. Example: “Staff are not intimidated by professionals so are confident and trusting.”
The layout of the building allows service users to move freely and to socialise or be with other people. Example: “Potential for change when new owners takeover”
Equipment is used appropriately and is well maintained. The environment is clean and there is good hygiene. Example: “Improved moral and happiness has improved people’s approach to these tasks”
Managers are aware of and manage to the strengths of their service and are honest and open about any difficulties. Example: “Manager allows staff time and space to the lead and trusts them to do things.”
The manager is visible and available responding promptly to enquires and requests. Example: “Been even more visible every Monday and leads from the front.”
The areas all have examples as evidence showing increased engagement and investment in the process. Moreover, the evidence is broadly congruent with the music therapy feedback and the observations of the therapists. Significantly the examples are about the lived experiences of the staff and service users. This is well evidenced in the examples for 21&22 and the example for 27. This contrasts with the style used at the start of the intervention.
Engaging in the process of in identifying and building on the strengths and abilities has motivated the manager to work more confidently and assertively with problem areas for the home. This is evident in the improvement to the layout of the building. Due to the improved morale and imaginative thinking a realistic plan is now in place to change the layout of the building for the benefit of the service users.
The process of valuing and building on abilities and strengths has improved the manager and staff’s confidence. This, linked to the therapists’ observations and staff’s individual feedback, has given good evidence for the potential for sustained improvements in the quality of life of service users at this home.
Outcomes for What Good Looks Like
Staff have grown in confidence and the moral of the home has improved. This is pleasing in the context of the uncertainty of the home being sold. Staff are willing to take on the qualities of emotionally intelligent communication modelled by the therapists. In addition there is good evidence that this confidence has generalised into other areas outside the music therapy group.
Physically the home is reported to be cleaner and better maintained and there is a concrete plan in place to change and add to the ground floor foot print.
Service users are spending more quality time with staff and are more motivated to infer a communicative purpose to their initiations and so interact with them more consistently. Staff are initiating more creatively with service users which is evoking a broader range of communicatively directed responses from them. Service user’s health needs are more acutely observed.
Community Group Music Therapy analysis
The community group music therapy was evaluated through the use of questionnaires for staff and observational monitoring for service users including analysis of session recordings. The feedback from the 5 service users was as follows:
Resident’s observational monitoring results
Did the group promote the individuals abilities to communicate?
4 of the service users actively demonstrated improved abilities to communicate within the sessions. 1 did not consistently actively engage.
Did the group promote relating?
4 members of the group actively engaged in relating within the sessions shown in their body movements, vocal responses, smiles and eye contact. The other service user did not consistently show awareness of relating within the group.
Did the group support a sense of community for the individual?
For the majority of the service users it was unclear how much peer relating and community building had occurred. However, there was evidence that for 2 service users the sessions supported a sense of community.
Has the individual benefited from this episode of music therapy?
4 out of 5 service users achieved an improvement in their quality of life from the music therapy group. 1 did not consistently actively engage consequently there was no sustained evidence of benefit.
(This data was compiled by the therapists and therefore is subject to bias; however in the context of clinical effectiveness monitoring the data was independently reviewed by each music therapist.)
Summary for Service Users
Most service users have benefited from attending the music therapy groups. There is clear evidence, from the positive responses that the groups have enabled service user’s relating. However, it is unclear whether the sessions have supported their sense of community.
A total of 8 individual support staff consented to and attended therapy and all 8 filled in the feedback forms. In the feedback form staff were asked if the music therapy group had met its aim of bringing staff and residents together. In addition staff were asked to rate the effectiveness of the sessions from their point of view and also to rate how motivating they found the experience of being in the group. Finally staff were asked to give their opinions.
8 out of 8 staff responding thought that the community group music therapy had achieved its aims
The staff rated the experience as 83% effective
The staff rated the experience as 90% motivational
The feedback form also encouraged staff to give their personal opinions.
These were implicit from the sessions but also explicit on the feedback form. From the feedback form, staff understood the purpose of the sessions well and appeared to find them helpful in improving the quality of their interactions both with the residents and each other:
‘Participating with both service users and staff, seeing how they interact with each other.’
‘Being together. To socialise.’
Attendance was voluntary for all group members. This was explicit and pro-actively enabled by the therapists.
Staff have, however, been consistently present for all the sessions. This has enabled the therapists to develop a working relationship with them and to witness their positive participation and growing confidence in the sessions. Their confidence is evident in the feedback:
‘Music is a great way to communicate and we will try and use this in our working environment.’
‘To help and support staff to feel confident with supporting the service users to express themselves through use of music.’
‘We can have sessions in the house applying the same techniques.’
This is evidence of staff’s development in confidence in relating and creative communication from attending the sessions.
Summary for staff
It is clear that all staff feel very positive and are engaging with the service users with increasing flexibility and creativity. This is evident both during the sessions and from the feedback received.
Outcomes from the Community Group Music Therapy
Supporting staff and transferring of skills
Through the achievement of the first aim for service users 'Promoting individuals’ abilities to communicate' staff have been supported in gaining transferable skills including increased confidence in using musically attuned communication. The music therapy setting has increased staff’s confidence and trust in their own abilities to communicate spontaneously and creatively. Staff have modelled on the therapists shown in their increasing awareness of their own and others’ responses within the group. This is evidenced through the quality of the staff’s participation in the sessions and from their feedback.
Improving the Music Therapy Service Provision
The assessing and monitoring of the aims of the project has lead to improvements in the quality of the music therapy service provision. Reviewing the music therapy input in co-operation with the home manager has provided feedback on additional strengths and needs of the music therapy service. Staff feedback has also supported this process.
Developing individual residents’ motivation to interact
The aim "To promote relating including peer interaction" has now been achieved for most residents. This is evidence that the music therapy setting has motivated residents to increase their interaction with staff.
The staff at the home now have a deeper understanding of the music therapy process and some ownership of their skills as interactive music makers. Consequently, the service users’ purposeful participation in meaningful relating and communicating has been facilitated. This has effectively paralleled and supported the process of staff and management development which has led to important improvements in the quality of life of service users at the home shown in the self assessment ratings of the What Good Looks Like tool. Inviting the home to identify their strengths and practically working through music therapy with their strengths and abilities has led to positive changes.