Full text of DOI:10.1046/j.1468-3148.2003.00146.x

Journal of Applied Research in Intellectual Disabilities 2003, 16, 63–74
Resident Involvement in Activity in Small
Community Homes for People with
Learning Disabilities
Jim Mansell, Julie Beadle-Brown, Susan Macdonald and Bev Ashman
Tizard Centre, University of Kent at Canterbury, Beverley Farm, Canterbury, Kent CT2 7LZ, UK
Accepted for publication 29 October 2002
Background Determining the relative importance of vari-
ables including client characteristics, setting features, staff-
ing and care practices on the lives of people with learning
disabilities in residential care continues to be a relevant
topic for research.
Results Only adaptive behaviour and care practices
predicted resident engagement in meaningful activity;
only age and adaptive behaviour predicted care prac-
tices.
Conclusions Given the limited scope for changing resident
adaptive behaviour, attention should be given to improve
active support in residential homes in order to promote
greater engagement in meaningful activity by people with
learning disabilities.
Methods Measurements were made of the adaptive and
problem behaviour of 343 adults with intellectual disabil-
ities living in 76 residential homes and of various aspects of
staffing, care practices (extent of active support) and resi-
dent engagement in meaningful activity. Ordinal and
logistic regression was used to identify variables best
predicting engagement and care practices.
Keywords: active support, engagement in meaningful acti-
vity, quality of care, residential care
overall size, cost, staff ratio or level of disability of the
residents (King et al. 1971; McCormick et al. 1975). Orienta-
tion and autonomy were associated with care practices
aligned more with the needs of service users. Emerging
evidence of generally superior outcomes in community-
based services (Tizard 1964; Kushlick 1980; Haney 1988)
supported policy decisions in favour of deinstitutionaliza-
tion and community living, and in recent years there has
been a substantial shift in favour of residential accommo-
dation in the community (Ericsson & Mansell 1996).
In general, community-based services have been shown
to provide much richer physical environments (Pratt et al.
1980; Felce et al. 1985), higher levels of staffing (Lakin et al.
1988), more user-focused care practices (Felce et al. 1980;
Landesman 1987; Mansell 1995) and better outcomes for
users in terms of adaptive behaviour (Larson & Lakin 1989;
Emerson & Hatton 1996; Young et al. 1998; Kim et al. 2001),
involvement in household activity (Emerson & Hatton
1996; O’Neill et al. 1981) and participation in community
life (Raynes et al. 1994; Conroy 1996; Emerson & Hatton
1996; Young et al. 1998). However, although the worst
features of physical deprivation and poor staffing levels
Introduction
The quality of residential care for people with learning
disabilities has been a major focus of policy and research
attention for nearly 40 years. At the beginning of this
period, the dominant form of provision was the large
institution (Ericsson & Mansell 1996). During the 1960s
and 1970s, increasing concern was expressed about the
quality of care provided by these institutions in terms of
gross physical deprivation (overcrowding, poor food,
clothing and environment), abuse (ill-treatment, theft of
possessions and over-use of medication and restraint) and
neglect and inactivity (lack of care, lack of contact and
stimulation and extensive periods of disengagement and
isolation) (Morris 1969; Martin 1984; Willer & Intagliata
1
984).
Early research on determinants of the quality of care
identified the orientation and autonomy of people mana-
ging the living unit (that senior staff should have a child
care rather than nursing training, and should have effec-
tive control over many aspects of the day-to-day running
of the setting) as more important than factors such as
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found in institutions have been remedied by the move to
community services, there has been increasing concern at
the wide variation in the quality of care offered and the
results achieved for service users within these services
Recent multivariate studies (by Felce et al. 2000b focused
on people with challenging behaviour and by Hatton et al.
1996 focused on people with sensory impairments) again
found that client ability and staff/client interaction were
the most important determinants of resident engagement
in meaningful activity. However, these were relatively
small-scale studies (34 and 40 participants, respectively).
This study provided the opportunity to consider the effect
of many variables in a larger sample of community group
homes than has been previously studied. The aim of the
study was to identify which variables predicted resident
engagement in meaningful activity.
(
Emerson & Hatton 1996; Landesman 1988).
A central concern of commentators is the extensive
inactivity and isolation still seen in community services.
Participation in meaningful activity is important (i) as a
primary outcome in its own right (Mansell et al. 1987;
Bellamy et al. 1990; Saunders & Spradlin 1991; Risley
1996), (ii) because of the negative impact of inactivity on
various important aspects of health (Robertson et al. 2000)
and (iii) because of the possible connection between parti-
cipation in meaningful activity and other important out-
comes like relationships (Mansell et al. 1987) and skill
development (Mansell et al. 2001, 2002b).
Method
Participants and settings
Among the most important determinants of levels of
meaningful activity by people living in community resi-
dential services is adaptive behaviour (Felce & Perry 1995;
Thompson et al. 1996), so that the more disabled the
residents, the lower their activity level. For these residents
in particular, staff occupy a central role in mediating access
to opportunities, and facilitating and reinforcing resident
engagement in activities (Mansell et al. 2002b). Although
community services have more staff than the institutions
they replaced, staff : client ratio is not closely associated
with better client outcomes including higher levels of
participation in meaningful activity (Mansell et al. 1982;
Felce et al. 1991, 2000b). Instead, there is evidence that it is
staff care practices which are important determinants of
resident activity, both from comparative studies (Mansell
et al. 1984; Felce et al. 1986; Mansell 1994) and, more
recently, from experimental demonstrations ( Jones et al.
Participants were 343 adults with intellectual disabilities
living in 76 residential homes in England. The homes were
part of a larger study covering 95% of the residential
services for people with intellectual disabilities provided
by a national charity (Mansell et al. 2002a). Participants
were included in this study if assessments had been made
of their participation in meaningful activity and of staff
care practices (described below).
Measurement
Information was collected on the adaptive and problem
behaviour of participants, the cost and aspects of the
staffing of each home, the care practices of staff and on
the extent to which participants were observed engaging in
meaningful activity.
1
999; Felce et al. 2000a).
Three instruments were used to measure the adaptive
and problem behaviour of participants: the Adaptive
Behaviour Scale (ABS) (part 1) (Nihira et al. 1993), Beha-
viour Problems Inventory (BPI) (Rojahn 1994) and a Social
Impairment Scale (SIS) made up of selected items from the
Handicaps, Behaviour and Skills (HBS) scale (Wing &
Gould 1978), chosen to measure the degree of social
impairment of each person.
Despite the consistent thread of research evidence from
King, Raynes and Tizard to the present day that staff care
practices are important determinants of participation in
meaningful activity, policy debates continue to be domi-
nated by discussion about the gross characteristics of
services – whether better results are achieved, for example,
by village communities, supported living or group homes
(
Kinsella 1993; Cox & Pearson 1995; Allard 1996; Emerson
et al. 2000) and by quality assurance processes such as
accreditation (Accreditation Council on Services for People
with Development Disabilities 1990) or the British Care
Standards Act (Great Britain 2000), which often focus
predominantly on setting variables such as size, staffing,
building design and location. Determining the relative
importance of variables including client characteristics,
setting features, staffing and care practices continues
therefore to be a relevant topic for research.
Adaptive and problem behaviour
The ABS, BPI and the SIS were sent by post to the manager
of every service who was asked to ensure that each ques-
tionnaire was completed by the member of staff who knew
the individual resident best. Questions and clarification
about the information required were dealt with by the
fourth author, who also followed up data collection to
obtain the fullest information possible, and dealt with
queries arising during data processing.
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Journal of Applied Research in Intellectual Disabilities 65
The ABS measures independence and adaptive beha-
viour, and has a possible maximum total score of 322. It is
divided into 10 behaviour domains: physical develop-
ment, language development, domestic activity, numbers
and time, economic activity, independent functioning,
vocational activity, self-direction, responsibility and socia-
lization. Normative data are provided to calculate percen-
tile ranks from raw scores.
measured in the study of which this was part by asking the
same member of staff to repeat the rating a few weeks
after initial data collection (i.e. the measure was of pretest/
post-test reliability). Pairs of ratings were made for 4% of
the population studied (19 residents for the ABS and 21 for
the BPI and the SIS). Pearson product–moment correlation
coefficients were calculated for pairs of total scores on each
measure. Table 1 shows the level of reliability achieved.
The BPI rates 29 specified problem behaviours in groups
relating to self-injurious behaviour, aggression and stereo-
typed behaviour, with the opportunity to specify addi-
tional problems. Problems were rated for frequency (never
occurred, less than monthly, monthly, weekly, daily,
hourly or more than hourly). Following McGill et al.
Cost and staffing
Information was abstracted from the computerized
records of the charity on the annual cost per place, various
aspects of staffing and staff training of each home.
The total staff in post was calculated as the number of
whole-time equivalent staff actually employed by the
charity to support the residents in each home at the point
of data collection, including, where appropriate, a share of
a first-line manager post. The staff ratio was calculated as
the number of residents per whole-time equivalent staff in
post. The seniority of the staff team was calculated as the
percentage of whole-time equivalent staff in post graded
as Manager, Deputy Manager or Senior Team Member.
The average length of service of all staff in each home in
months was recorded. Staff turnover was calculated as the
number of staff leaving the service in the previous year
divided by the mean number of staff in post, expressed as a
percentage. Whether senior staff had attended training
provided by the charity was also recorded.
(
2001), frequency of problem behaviours was summed
to give a total score (maximum 222) indicating the overall
burden represented by each person’s challenging beha-
viour. Each behaviour was also rated for whether it pre-
sented a behaviour management problem for staff,
distinguishing between those causing severe management
problems (staff had to intervene, upset other residents,
marked effect on social atmosphere or unacceptable in
public), lesser problems, those not causing a problem and
potential problems (where the problem was controlled in
the present environment but was likely to reoccur as a
severe problem if the environment changed).
The SIS comprised seven items relating specifically to
social impairment from the Abnormal Behaviour section of
the Handicaps, Behaviour and Skills Schedule (Wing &
Gould 1978). These items related to whether the person
made and used eye contact with other people, spontaneous
showing of affection, their response to age peers, social
play, willingness to join in leisure activities and overall
quality of social interaction. These items were summed to
give a total score, expressed as a percentage. The degree of
social impairment was then classified as profound, severe,
moderate or mild.
Active support
Each home was visited in order to observe the way staff
provided support to residents. Observations were made
over a 3–4-h period around a meal time, because this
seemed likely to provide many opportunities to see staff
providing support. For each resident, the nature and
quality of staff support was rated for the whole session
using a 15-item rating scale, the Active Support Measure
(ASM) (Mansell & Elliott 1996). Each item was scored on a
scale of 0 (very poor performance, e.g. because no activities
provided), 1 (weak, inconsistent performance), 2 (mixed
performance), 3 (good, consistent performance), yielding a
range of total scores from 0 to 45. The items were:
The reliability and validity of the ABS, BPI and the HBS
(
from which the SIS was drawn) have been studied and
reported as acceptable by their authors. Reliability was
Table 1 Reliability
ꢀ
ꢀ
ꢀ
ꢀ
ꢀ
Age appropriateness of activities and materials.
‘Real’ rather than pretend or very simple activities.
Choice of activities.
ꢁ
Pearson’s r
n
Demands presented carefully.
ABS
0.955
0.745
0.786
0.848
19
21
21
21
Tasks appropriately analysed to facilitate client involve-
ment.
BPI Frequency
BPI Severity
SIS
ꢀ
ꢀ
Sufficient staff contact for clients.
Graded assistance to ensure client success.
ꢁ
All values significant at P < 0.0001.
ꢀ Speech matches developmental level of client.
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ꢀ
ꢀ
ꢀ
ꢀ
ꢀ
ꢀ
ꢀ
Interpersonal warmth.
Differential reinforcement of adaptive behaviour.
Staff notice and respond to client communication.
Staff manage serious challenging behaviour well.
Staff work as a co-ordinated team to support clients.
Teaching embedded in everyday activities.
Specific, written individual programmes in routine use.
Inter-rater reliability was assessed by having a second
rater make independent assessments for 38 residents.
Individual item scores made by each observer were highly
correlated (rho ranges from 0.688–0.996) as were total ASM
scores (rho ¼ 0.98; P < 0.001). Internal consistency in the
main study for all residents with a rating (n ¼ 409) was
high (Cronbach’s a ¼ 0.92).
Engagement in meaningful activity
At the same time that ratings of active support were made,
researchers rated the engagement in meaningful activity of
residents in each home using a similar 4-point scale
(
0 ¼ largely disengaged, 1 ¼ engaged less than 50% time,
2
¼ engaged between 50 and 75% time and 3 ¼ engaged
more than 75% time). Inter-rater reliability was assessed
using Cohen’s kappa (Cohen 1960) for 38 residents. Kappa
was 0.953 (P < 0.001).
Design and analysis
The design was a multivariate analysis, using ordinal and
binary logistic regression. The data were analysed using
MINITAB (MINITAB Ltd. 1998) and SPSS (SPSS Inc. 1998).
The first dependent variable studied was engagement in
meaningful activity by participants. The independent vari-
ables were client characteristics (age, ABS, BPI frequency
score, whether the person had any severe or potentially
severe behaviour problem, social impairment); cost and
staffing (cost per place, total staff in post, staff : client ratio,
seniority of staff group, management development, active
support training, length of service, staff turnover) and care
practices (active support score).
The variables identified were checked for intercorrela-
tions (Table 2). Social impairment, cost and staff : client
ratio were all highly correlated with ABS (rho > 0.5); staff : -
client ratio and cost were also highly correlated. ABS was
therefore selected for inclusion, since social impairment is
one aspect of adaptive behaviour and staff : client ratio and
costs are probably largely dependent on adaptive beha-
viour. The remaining variables (age, ABS score, BPI fre-
quency score, whether the person had any severe or
potentially severe behaviour problem, total staff in post,
seniority of staff group, management development, active
support training, length of service, staff turnover and
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Journal of Applied Research in Intellectual Disabilities 67
active support score) were then entered in an ordinal regre-
ssion. In order to emulate a backward stepwise regression
procedure, the variable with the least significant coefficient
was then removed and the regression rerun. This procedure
was repeated until only significant coefficients remained.
A second analysis was run for the dependent variable
active support categorized into quartiles. The independent
variables (age, ABS score, BPI frequency score, whether the
person had any severe or potentially severe behaviour
problem, total staff in post, seniority of staff group, man-
agement development, active support training, length of
service and staff turnover) were entered in an ordinal
regression in the manner already described.
Table 4 Severity of problem behaviour (n ¼ 343)
People (%)
Behaviour problem
Lesser
Potential
Severe
Total
Self-injury
Aggression
Stereotypy
Other
25
20
31
5
8
8
20
24
5
53
53
41
17
78
5
2
10
39
Any of above
25
13
Table 5 Degree of social impairment (n ¼ 343)
Degree of social impairment
Results
Profound Severe
Moderate
Mild
(75–100%) Total
Participant characteristics
(0–24%) (25–49%) (50–74%)
The mean age of participants was 40 years (range 16–89).
Sixty per cent of participants were men and 97% were
White British.
%
21.3
28.6
26.5
23.6
100.0
The total ABS score of participants in this study aver-
aged 135 (range 11–298). Table 3 presents the average
percentile rank for participants for each of the 10 domains
of the ABS, compared with the normative data presented
by Nihira et al. (1993) drawn from a representative sample
of 4103 people with intellectual disabilities in USA. This
shows that participants in this study have a very wide
range of ability, but on average, they were in the most
disabled half of all people with intellectual disabilities.
Rating of any problem behaviours shown by the parti-
cipant were made using the BPI. On average, participants
had a total frequency score of 13 (range 0–96). Table 4
presents the number of participants rated as having pro-
blem behaviour of different levels of severity. This shows
that 78% of individuals had some problem behaviour;
almost all homes included at least one person with such
problems.
The degree of social impairment, based on the total
percentage score on relevant items of the HBS scale (Wing
& Gould 1978) was classified as profound, severe, mod-
erate or mild (Table 5).
Setting characteristics
Participants lived in homes averaging 6.4 residents (range
2–14), with 72% of residents living in homes of less than
eight places. The total number of staff in post in each home
Table 3 Mean percentile rank for each ABS domain (n ¼ 343)
ABS (part 1 domains)
Minimum
Maximum
Mean
SD
Independent functioning
Physical development
Economic activity
1
1
9
1
9
5
1
1
2
1
100
98
98
99
98
100
91
99
95
99
35.69
57.31
28.13
30.51
30.63
50.76
31.83
36.86
34.35
41.86
29.72
29.12
23.28
31.68
27.69
34.67
23.85
32.26
31.02
29.37
Language development
Numbers and time
Domestic activity
Prevocational/vocational activity
Self-direction
Responsibility
Socialization
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Table 6 Provision of active support by staff (n ¼ 343)
Table 7 Engagement in meaningful activity (n ¼ 343)
Active support
Engagement in meaningful activity
Weak (0–15) Mixed (16–30)
24.2 51.3
Good (31–45)
Total
Engaged
<50%
time
Engaged
50–75%
time
Engaged
>75%
time
Largely
%
24.5
100.0
disengaged
Total
%
38.8
48.1
9.6
3.5
100.0
averaged 11 (range 1–25). The average staff : client ratio
was 1 : 0.67, ranging from 1 : 0.29 to 1 : 3.13. The length
of service of all staff in each home averaged 45 months
Resident engagement in meaningful activity
(
(
range 5–116 months). Average staff turnover was 45%
range 0–227%). The revenue cost per place per year
Table 7 shows the distribution of engagement levels
among participants. Thirty-nine per cent of residents were
observed to be largely disengaged during the 4-h observa-
tion period, with another 48% engaged for less than half
the time.
averaged £43 179 at June 2000 prices (range from £10 635
to £67 416).
Staff teams had widely varying compositions and train-
ing: the percentage of senior staff (Manager, Deputy Man-
ager or Senior Team Member) ranged from 27 to 100% with
an average of 63%. The percentage of the charity’s own
management development programme completed by each
Service Manager averaged 68% (range 0–100%). The per-
centage of the Manager and Deputy Managers in each
service who had attended ‘active support’ training (con-
cerned with care practices designed to promote and facil-
itate resident engagement in meaningful activity)
averaged 70% (range 0–100%).
Determinants of resident engagement in
meaningful activity
Table 8 presents the results of the first regression, includ-
ing all the independent variables. Following the sequential
removal of variables where the coefficient failed to reach
significance, only two variables remained: ABS and active
support score (Table 9). In each case, the coefficients had
a negative sign and the Odds ratios were less than 1,
indicating that an increase in the independent variable
was associated with an increase in engagement in mean-
ingful activity. The regression model correctly identified
92% of cases and the G statistic was highly significant
(G ¼ 342.007; d.f. ¼ 2; P < 0.0001).
Care practices were assessed using the ASM (Mansell &
Elliott 1996). Only about a quarter of participants were
rated as receiving good, consistent performance from staff
on this measure (Table 6), another half were rated as
receiving mixed, inconsistent performance and the
remaining quarter as receiving poor or no support.
Table 8 Results of initial regression on engagement in meaningful activity
9
5% Confidence interval
Predictor
Coefficient
Z
P
Odds ratio
Lower
Upper
Age
0.0129
ꢂ0.0106
0.0142
1.15
0.249
0.000
0.205
0.119
0.152
0.226
0.683
0.863
0.223
0.561
0.000
1.01
0.99
1.01
0.63
1.04
2.31
1.00
1.00
0.99
1.00
0.74
0.99
0.98
0.99
0.35
0.99
0.60
0.99
0.99
0.98
0.99
0.71
1.04
0.99
1.04
1.13
1.09
8.91
1.01
1.01
1.00
1.01
0.78
ABS
ꢂ4.45
1.27
BPI
Sev/Pot
ꢂ0.4642
0.0362
ꢂ1.56
1.43
Staff
Senior
0.8354
1.21
Management development
Active support training
Length
0.0021
0.41
0.0008
0.17
ꢂ0.0078
ꢂ0.0022
ꢂ0.2959
ꢂ1.22
ꢂ0.58
ꢂ10.82
Turnover
AS Score
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Journal of Applied Research in Intellectual Disabilities 69
Table 9 Final regression on engagement in meaningful activity
5% Confidence
A binary logistic regression using a dichotomous coding
of engagement (0 ¼ largely disengaged, 1 ¼ any engage-
ment) and the same variables as entered in the initial
ordinal regression described above but using the categor-
ized ASM and ABS variables had a model significance of
9
interval
Odds
ratio
Predictor Coefficient
Z
P
Lower Upper
2
w ¼ 256.517 (d.f. ¼ 20; P < 0.001). This model correctly pre-
dicted 88.6% of the observed values and revealed that ASM
predicted engagement, in particular, low ASM scores
predicted low engagement levels (ASM in 1st quartile:
Wald, 53.370; P < 0.001; coefficient, 6.828; ASM in 2nd
quartile: Wald, 17.447; P < 0.001; coefficient, 3.319). In this
initial analysis ABS was not significantly predictive but the
presence of a severe or potentially severe challenging
behaviour was predictive of low engagement (Wald,
4.697; P < 0.05; coefficient, 0.947). Stepwise elimination of
the smallest non-significant coefficient at each step
resulted in only two variables left in the model – ASM
and ABS (see Table 10 for variables in the equation output).
The overall model coefficient was highly significant
ABS
ꢂ0.0117
ꢂ5.68 0.000 0.99
ꢂ11.47 0.000 0.74
0.98
0.70
0.99
0.78
AS score ꢂ0.3019
The coefficient in the regression equation indicates the
change in logit of an increase in one unit of the indepen-
dent variable. The observed range of active support scores
was 40 and of ABS scores was 287. Multiplying these
values by the coefficients to determine the relative effect
of these two independent variables shows that active
support was about 3.6 times more powerful than adaptive
behaviour in predicting engagement in meaningful activ-
ity.
2
(w ¼ 259.204; d.f. ¼ 6; P < 0.001), and this reduced model
However, although the model appeared highly predic-
tive of engagement, the goodness of fit tests indicated that
the model did not fit the data very well (Pearson
still correctly predicted 87% of observed values. As can be
seen from Table 10, all levels of ASM are significant pre-
dictors of engagement, although lower scores are most
predictive of low engagement. For ABS, however, only a
score in the first quartile was significantly predictive of
lower engagement scores.
2
w ¼ 10902.775; d.f. ¼ 1075; P < 0.0001). After further inves-
tigation using categorized variables of active support and
ABS (scores were divided into four ranked categories by
quartile scores), it was apparent that the model was
explaining only some of the engagement values well, for
example, when people were coded as being largely dis-
engaged, both ASM and ABS scores were low, and when
people were scored as being engaged more than 50% of the
time, both ABS and ASM scores were higher (above the
Finally, the binary logistic regression was run exactly as
before, but for engagement categorized into 0 ¼ engaged
less than 50% of the time and 1 ¼ engaged 50% or more of
2
the time. For this analysis the final model (w ¼ 105.889;
d.f. ¼ 6; P < 0.001) predicted 90% of the observed values
and again included just ASM and ABS. In this model, ABS
was predictive at more than the lowest level but ASM still
produced higher coefficients (See Table 11).
5
0th percentile). However, for those who were engaged at
least part of the time but not more than 50% of the time,
there was no obvious pattern, with scores on both ABS and
ASM reasonably well spread across all categories.
A further analysis was undertaken in which categorized
ASM was the dependent variable. Table 12 presents the
Table 10 Results of final binary logistic regression on engagement (where 0 ¼ largely disengaged and 1 ¼ engaged)
Variables in the equation
B
Wald
d.f.
Significance
Estimated Odds ratio
ASM2
–
83.264
57.127
15.646
3.906
3
1
1
1
3
1
1
1
0.000
0.000
0.000
0.048
0.006
0.002
0.120
0.548
–
ASM2(1)
ASM2(2)
ASM2(3)
ABS2
ꢂ6.679
ꢂ2.976
ꢂ2.976
–
0.001
0.051
0.204
–
12.623
9.561
ABS2(1)
ABS2(2)
ABS2(3)
ꢂ1.626
ꢂ0.831
ꢂ0.338
0.197
0.436
0.713
2.422
0.361
ASM2 is the total ASM score divided into quartiles where ASM2(1) ¼ total ASM score in the first quartile of the distribution. ABS2 is
categorized in the same way.
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Table 11 Results of final binary logistic regression on engagement (where 0 ¼ engaged less than 50% of the time and 1 ¼ engaged 50%
or more of the time)
Variables in the equation
B
Wald
d.f.
Significance
Estimated Odds ratio
ASM2
–
43.404
13.539
18.781
23.137
23.678
8.754
3
1
1
1
3
1
1
1
0.000
0.000
0.000
0.000
0.000
0.003
0.000
0.002
–
ASM2(1)
ASM2(2)
ASM2(3)
ABS2
ꢂ3.851
ꢂ2.518
ꢂ2.605
–
0.021
0.081
0.074
–
ABS2(1)
ABS2(2)
ABS2(3)
ꢂ2.372
ꢂ2.429
ꢂ1.364
0.093
0.088
0.256
15.874
9.231
Table 12 Results of initial regression on active support
9
5% Confidence interval
Predictor
Coefficient
Z
P
Odds ratio
Lower
Upper
Age
0.0209
ꢂ0.0352
0.2450
2.55
0.011
0.065
0.626
0.128
0.107
0.969
0.345
0.572
0
1.02
0.97
1.28
1.01
0.99
1.00
1.00
1.00
0.99
0.76
1.00
0.93
0.48
1.00
0.99
0.99
0.99
0.98
0.99
0.49
1.04
1.00
3.42
1.01
1.00
1.01
1.00
1.01
0.99
1.19
Staff
ꢂ1.85
0.49
Senior
Management development
0.0057
1.52
Active support training
ꢂ0.0060
ꢂ0.0002
ꢂ0.0026
ꢂ0.0047
ꢂ0.0117
ꢂ0.2715
ꢂ1.61
ꢂ0.04
ꢂ0.94
ꢂ0.57
ꢂ6.85
ꢂ1.2
Length
Turnover
BPI
ABS
Sev/pot
0.228
results of the initial regression, including all the indepen-
dent variables. Following the sequential removal of vari-
ables where the coefficient failed to reach significance, only
two variables remained: ABS and age (Table 13). For ABS,
the coefficient was negative and the Odds ratio was less
than 1, indicating that an increase in ABS was associated
with an increase in active support. Younger age was
associated with an increase in active support. The regres-
sion model correctly identified 67% of cases and the G
statistic was highly significant (G ¼ 53.264; d.f. ¼ 2; P <
0.0001). Goodness of fit tests indicated that the model fitted
2
the data well (Pearson w ¼ 1127.209; d.f. ¼ 1102; P ¼ 0.292).
Discussion
Adequacy of the data
Where data were abstracted from records no reliability
information is available, but since staffing and finance
records are critical to the operation of the charity, they
are likely to be more accurate than ratings by staff or
observers. Behavioural characteristics in this study were
assessed by staff: pretest/post-test reliability showed
acceptable levels of agreement. Care practices and resident
engagement were rated by observers: interrater reliability
showed acceptable levels of agreement.
Table 13 Results of final regression on active support
9
5% Confidence
interval
Odds
ratio
Predictor Coefficient
Z
P
Lower Upper
Age
ABS
0.0206
2.89 0.004 1.02
ꢂ6.95 0.99
1.01
0.99
1.04
0.99
There are three important possible limitations of these
data. Since the data depend on ratings by independent
ꢂ0.0101
0
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Journal of Applied Research in Intellectual Disabilities 71
observers of staff support and care to residents, there is the
possibility of reactivity. The likely direction of any reaction
would be to improve the quality of support and care
offered by staff, and this possibility cannot be excluded.
Although inter-rater reliability was good, some caution
should be exercised over the validity of the observational
data because they were not collected independently. There
is therefore the possibility that observers rated engage-
ment as occurring more extensively when they rated more
active support. In the absence of independent data (e.g.
contemporaneous time sample observation collected by
others) it is not possible to rule this out.
stable over many years in community services (Cambridge
et al. 1996; Cambridge et al. 2001). In terms of improving
resident engagement in meaningful activity, expecting
increases in adaptive behaviour to feed through into
increased activity therefore, seems likely to be a relatively
weak strategy. It would also have the disadvantage of
denying access to many important activities at home
and in the community to people who did not yet have
the adaptive behaviour to undertake them relatively inde-
pendently (Saunders & Spradlin 1991). In contrast there is
good evidence that when care practices are changed the
engagement of people in meaningful activity increases
(Jones et al. 1999; Mansell et al. 2002b). This also has the
advantage that its benefits are experienced by the most
disabled individuals (Felce et al. 2000a).
The third possible limitation is that the data were all
obtained from services provided by the same agency and
therefore they may not be representative of all community-
based residential services for people with intellectual dis-
abilities. In the absence of comparable data from a national
sample, this possibility cannot be excluded and caution
should be used in generalizing from these findings to other
services. However, some comparative data is available.
The homes in this study were on average slightly larger
than those studied by Emerson et al. (2000) and Felce et al.
Although care practices can be changed readily in
demonstration projects, there is mixed evidence about
the ease with which change can be implemented more
widely, and the extent to which staff will maintain the
changes needed to sustain greater engagement in mean-
ingful activity by the people they serve. Jones et al. (1999)
reported maintenance over 8–12 months in three of five
houses, whereas others (Mansell et al. 1994; McGill &
Mansell 1995) give examples of mixed results in maintain-
ing trained changes. Jones et al. (2001) have reported failure
of trained managers to train staff in the practical work
required, with consequent failure to change care practices.
Factors implicated in the difficulty of introducing and
sustaining changes in care practices include conflict
between staff values and the working methods required
(McGill & Mansell 1995), the difficulty of working inten-
sively with residents, the belief that other work is more
valued (Mansell & Elliott 2001) and beliefs that senior
managers and commissioners of services only pay lip
service to the goal of improving resident quality of life
(
2000b). The average costs were similar to those in homes
of 4–6 places in the study of Emerson et al. (2000) (the basis
for cost calculation in the Felce et al. (2000b) study does not
permit direct comparison). Staff : client ratios were on
average approximately half those found by Felce et al.
(
2000b) and were comparable to those found by Emerson
et al. (2000). They were almost double those reported in a
988 study of 143 homes by Raynes et al. (1994), reflecting
1
the shift to small-scale settings and the increasing needs of
people with learning disabilities in residential care (Man-
sell et al. 2002a). Thus these data are broadly comparable,
in some respects at least, with some other major studies of
community-based residential homes.
(
Mansell 1996).
In this study the only variables predictive of the imple-
Conclusions
mentation of ‘active support’ care practices were resident
age and adaptive behaviour; implementation was more
likely for younger, more able residents. None of the staff-
ing, staff characteristics or training variables predicted
implementation.
The regression of independent variables on engagement in
meaningful activity by residents shows that only two
variables appear to be important predictors: the overall
level of adaptive behaviour of the resident and the care
practices of the staff. This is consistent with earlier studies
(
Mansell et al. 1984; Felce et al. 1986; Mansell 1994; Felce &
Implications and further research
Perry 1995; Thompson et al. 1996; Jones et al. 1999; Felce
et al. 2000a). Despite extensive literature demonstrating the
efficacy of behavioural intervention to increase personal
skills (Berkson & Landesman-Dwyer 1977; Reid et al. 1991),
there is evidence from studies of deinstitutionalization
that, after an initial increase on transfer to community-
based services, adaptive behaviour remains relatively
This study provides further evidence that the inputs pro-
vided in residential services – seniority, length of service,
turnover, training– are not in themselves important deter-
minants of the level of engagement in meaningful activity
of people with learning disabilities. The most important
factor is the adoption by staff of care practices which
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2003 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 16, 63–74

72
Journal of Applied Research in Intellectual Disabilities
directly facilitate engagement, particularly for people with
the most severe disabilities. For policy makers, this study
should caution against expecting improvements in
engagement in meaningful activity when resources alone
are changed; attention needs to be given to care practices
and decision makers should remain sceptical of service
proposals for people with severe and profound intellectual
disabilities, unless they attend to this issue.
Cambridge P., Carpenter J., Beecham J., Hallam A., Knapp M.,
Forrester-Jones R. & Tate A. (2001) Twelve Years On: the Outcomes
and Costs of Community Care for People with Learning Disabilities
and Mental Health Problems. Tizard Centre, University of Kent at
Canterbury, Canterbury.
Cambridge P., Hayes L. & Knapp M. (1996) ‘Care in the commu-
nity’ 5 years on. Tizard Learning Disability Review 1 (3), 44–46.
Cohen J. A. (1960) A coefficient of agreement for nominal scales.
Educational and Psychological Measurement 20, 37–46.
Further research is needed to identify the factors asso-
ciated with the adoption and maintenance of ‘active sup-
port’ care practices. In particular, since the resource inputs
in this study were not important, attention needs to be
focused on the values, skills and motivation of first-line
managers and the extent to which they provide ‘practice
leadership’ through direct teaching and coaching of their
staff (Mansell 1996; Jones et al. 2001).
Conroy J. (1996) Results of deinstitutionalization in Connecticut.
In: Deinstitutionalization and Community Living: Intellectual Dis-
ability Services in Britain, Scandinavia and the USA (eds J. Mansell
& K. Ericsson), pp. 149–168. Chapman & Hall, London.
Cox C. & Pearson M. (1995) Made to care: the case for residential and
village communities for people with a mental handicap. Rannoch
Trust, London.
Emerson E. & Hatton C. (1996) Impact of deinstitutionalization on
service users in Britain. In: Deinstitutionalization and Community
Living: Intellectual Disability Services in Britain, Scandinavia and the
USA (eds J. Mansell & K. Ericsson), pp. 169–184. Chapman &
Hall, London.
Acknowledgements
The authors wish to thank the people with intellectual
disabilities and their staff who provided the information
used in this study, and the charity which provided access
to its services and funded part of the study. This study was
also partly funded by the National Health Service Execu-
tive. Thanks are also due to Eryl Bassett for statistical
advice and assistance.
Ericsson K. & Mansell J. (1996) Introduction: towards deinstitutio-
nalization. In: Deinstitutionalizationand CommunityLiving:Intellec-
tual Disability Services in Britain, Scandinavia and the USA (eds J.
Mansell & K. Ericsson), pp. 1–16. Chapman & Hall, London.
Emerson E., Robertson J., Gregory N., Hatton C., Kessissoglou S.,
Hallam A., Knapp M., Jarbrink K., Walsh P. N. & Netten A.
(2000) Quality and costs of community-based residential sup-
ports, village communities, and residential campuses in the UK.
American Journal on Mental Retardation 105 (2), 81–102.
Felce D., Bowley C., Baxter H., Jones E., Lowe K. & Emerson E.
Correspondence
Any correspondence should be directed to Prof. Jim
Mansell, Tizard Centre, University of Kent at Canterbury,
Beverley Farm, Canterbury, Kent CT2 7LZ, UK (e-mail:
j.mansell@ukc.ac.uk).
(
2000a) The effectiveness of staff support: evaluating active
support training using a conditional probability approach.
Research in Developmental Disabilities 21, 243–255.
Felce D., de Kock U. & Repp A. C. (1986) An eco-behavioural
comparison of small community-based houses and traditional
large hospitals for severely and profoundly mentally handi-
capped adults. Applied Research in Mental Retardation 7, 393–408.
Felce D., Lowe K., Beecham J. & Hallam A. (2000b) Exploring the
relationships between costs and quality of services for adults
with severe intellectual disabilities and the most severe challen-
ging behaviours in Wales: a multivariate regression analysis.
Journal of Intellectual and Developmental Disability 25 (4), 307.
Felce D., Mansell J. & Kushlick A. (1980) Evaluation of alternative
residential facilities for the severely mentally handicapped in
Wessex: staff performance. Advances in Behaviour Research and
Therapy 3, 25–30.
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