“I can see what you can’t see” – How Warwickshire County Council involves people with learning disabilities as peer reviewers

People with learning disabilities know things about the services they receive that inspectors do not or cannot know. This is why the Customer Engagement Team of Warwickshire County Council (WCC) established a group of 23 trained Peer Reviewers in 2011 to co-assess the quality of commissioned services. Five of these Reviewers have learning disabilities and focuss specifically on services used by people with learning disabilities.    

Read this case study to learn how Warwickshire County Council uses the skills and knowledge of people with learning disabilities to improve service quality.

This project was part of a pilot peer review programme which involved customers and carers in reviews of services in adult social care. These reviews complement mandatory service reviews.  The Contract Monitoring Team at Warwickshire County Council carry out both proactive and risk focused quality assurance monitoring visits to providers of adult social care, to ensure they are meeting their contractual requirements and that customers are receiving a high quality service. The visits carried out by the Peer Reviewers have complemented and supported these reviews ensuring that standards are continuously improving.

The objectives of the Peer Reviews are:

• Capture previously unrecorded information about the customer’s experiences of quality in Providers services.
• Support customers and carers to utilise their lived experiences of receiving services (experts by experience) to input into quality monitoring processes and service provision/development.
• Provides an extra dimension to the reviewing process that ensures the customer voice is heard and recognised.
• Recognises the value of people who have/are using services as ‘experts’.

Review Preparation

The project was managed throughout by 2 Customer Engagement Officers from the WCC Customer Engagement Team. In preparation for the pilot, potential Peer Reviewers were sourced in discussion with a variety of relevant stakeholders, via:

• Representatives at Learning Disability Partnership Board meetings.
• Individuals suggested by the Advocacy Service.
• People with learning disabilities who expressed an interest in participating, after being involved in a review of Learning Disability Day Services.

After communicating the project to stakeholders, a selection process began to choose Reviewers from those that had expressed an interest.  In total six people with learning disabilities applied.  Reviewers were selected following an informal meeting or phone conversation, with a Customer Engagement Officer who talked the individual through the responsibilities of this role. All six Reviewers undertook the training, with one Reviewer deciding not to continue after this, leaving a core group of five Reviewers.

WCC commissioned the local non-profit organisation Changing Our Lives that have a well-established Peer Review programme, to provide a one day training programme for the Reviewers and support them during the review.

The training day concentrated on ensuring that Reviewers understood:

• The role and responsibilities of a reviewer, and what constitutes a good and bad reviewer;
• Safeguarding – recognising different types of abuse, duty to report;
• What constitutes quality and how to measure it – using locally defined quality of life standards;
• Confidentiality – understanding the meaning of confidentiality & the need to share information when appropriate;
• Self-advocacy – understanding individuals’ choices and rights.

Due to the vulnerable nature of the client groups that would be visited, CRB checks were performed with all Reviewers. To reinforce the credibility of the role, each Reviewer was provided with ID badges, and folders with the following documentation:

• Quality of Life Standards to use as a framework to measure what people with disabilities should expect from a service and their customer rights;
• Safeguarding advice material;
• Contact sheets.

It was decided that in liaison with Contract Monitoring Officers, six service providers would be chosen from over 100 local Providers to be reviewed. These six providers were then contacted about the Peer Reviews, given information on the process and objectives and asked if they were willing to take part. As only WCC funded or referred Customers were to be involved in the project it was essential to identify Customers accessing those particular providers and seek their agreement to participate.  As this was a pilot project, WCC was keen to ensure Reviewers were not asked to visit services that were subject to on-going Contract Monitoring Team investigations or visits.  The Contract Monitoring Lead Officer for Learning Disability Providers identified the 6 service areas for the pilot as Providers who would be supportive of the pilot and likely to use the feedback generated.

The six Providers Services included Day Opportunities and Supported Living.

Review Process

When the project was ‘live’ two reviews ran concurrently at different providers. Reviews were conducted over a period of three days.  Reviewers were seeking to assess if services meet the needs of individuals and the outcomes established in the Quality of Life Standards.  The Quality of Life Standards were developed using the seven key themes of Warwickshire’s joint commissioning strategy for adults with a learning disability for 2011-2014.  They cover the whole of a person’s life and have seven key objectives:

• Keeping Safe – People want to feel safe.
• A Place to Live – People want a safe and secure place to live.
• A Fulfilled Life - People want to have a more fulfilled life.
• Good Health – People want to be healthy and well.
• More Choice and Control – People want more choice and control.
• Seldom Heard Groups - People and Carers want to be more involved in the development of services and support.
• Supports for Family Carers – Carers want a fulfilled life of their own.

Reviewers spoke to Customers, their family and friends and looked at photographs, DVDs and support plans with the permission of the person concerned, if this was the Customers’ preferred communication method.  They also watched and listened to see how staff supported Customers. Each Reviewer was supported by a Customer Engagement Officer and a Changing our Lives member of staff.  During the process, these support staff gave prompts if Reviewers got stuck, but ensured that the Peer Reviewers led the reviews.  Either the Customer Engagement Officer or Changing our Lives staff member would take notes to capture the information gathered.  Lunch breaks provided Reviewers with the opportunity to reflect or speak more informally with other Customers.

Reporting post review

After the review visits, Customer Engagement Officers and Reviewers went through the notes that had been written up during the three days and ensured the reviews accurately captured what was discussed. When writing their reports, a template was used that followed the seven Quality of Life Standards, with a ‘sound bite’ box at the bottom of each standard section for statements to be entered.

After the reports had been compiled, each Reviewer went through these reports, with a Customer Engagement Officer, to ensure that their observations were captured completely.  Once the reports had been agreed by the Reviewers a copy was sent to the manager of the Provider and the Contract Monitoring Team. During the process of finalising the reports with the Reviewers, there was a high degree of negotiation around language used. Some Reviewers felt the terminology had too much complex jargon - so this was changed. The Reviewers were able to ensure that they had supporting information for statements made so reports were balanced and not overly subjective, whilst still being firmly rooted in their experiences and knowledge as experts

Report Findings

None of the reviews highlighted safeguarding or serious concerns but did highlight various areas across services that could be improved and equally some areas to be celebrated as good practice.

One Reviewer noted that a lady he spoke to asked for some support to get a drink on several occasions whilst he was in her flat, but staff did not acknowledge this.  He was very clear that this was not good support, as she should be able to have support in her own home when she asked for it from staff.

Another Reviewer noted that one lady was given children’s toys to hold in her hands as she liked the tactile sensation of carrying things.  He suggested that as an adult, she was supported to have and carry adult appropriate items and not be seen as a “child”.

An area of good practice highlighted by a Reviewer was where a Provider ensured that people with high support needs were supported to do hobbies and things they enjoyed at any time and weren’t restricted by staff shift times.  So some people they supported were DJ’ing, going to pubs and nightclubs and coming back when they wanted, not because of staff shift times ending.

This project has built a strong case for WCC to continue to develop the programme further. Indeed the Customer Engagement Team are exploring the possibility of broadening the scope of the programme to include domiciliary care health services and acute care in hospitals in the future.

Once the Reviews were completed and reports finalised, a Reviewer de-brief meeting was held to allow for the sharing of experiences and make recommendations.  The Reviewers were unanimous in expressing that they had enjoyed the process and talking to people to find out how they were supported.  The Reviewers had expressed that they had found it a steep learning curve taking in the whole environment surrounding services, but that their confidence had increased throughout the process.  The Reviewers were clear that it had been a worthwhile experience and that they were committed to undertaking future visits. 

Immediately after the reviews a short questionnaire was sent to all six Providers who took part in the pilots. They were asked to comment on pre-review preparation, what went well and not so well on the review day and finally make suggestions for any changes to help in the programme development. The responses were positive about the pre-review preparation, although it was suggested that supplementary information about the process would have also been helpful. Looking at how the Peer Review programme can be developed it was suggested by a Provider that a printed leaflet, in easy-read format would allow staff to talk to people they support about the process and how to become Peer Reviewers themselves, which WCC has now produced.

One of the Reviewers received a letter from the Provider they visited, outlining the changes they had made to their service following the Reviewers Report – this included:

• Making sure that Customers were supported and encouraged to make and prepare their own drinks, rather than this being led by staff, to help improve skills and confidence.
• Ensuring that key Day Programme areas are covered with experienced staff when regular staff are away/on holiday.

There are now regular requests for Peer Reviewers to review service provision in a variety of areas and the performance and impact of the programme as it is further rolled out will be evaluated and assessed.

Several issues arose during the project. They included:

Confidentiality – because local networks within learning disability services are limited, Reviewers may potentially know other Customers and staff at review sites.  This did cause some anxiety to Reviewers, so any potential conflicts of interest will be mitigated in future visits by asking all Reviewers to sign and agree confidentiality agreements and via the training to ensure Reviewers can identify and recognise situations where it would be inappropriate to continue with the visits.

Skills Gaps – Some Reviewers who visited Customers with high support needs found it difficult to elicit information from people who did not communicate verbally.  This is being addressed via specialist input and training for Reviewers to increase skills and confidence in future reviews.

The reviews carried out by the Peer Reviewers provided additional information to the qualitative data collected by the Contract Monitoring Team and give a unique insight from the Customers and Carers’ perspective.  This information gathered from the Reviewers, along with other sources assists the CMO to prioritise and risk assess visits to providers, potentially enabling issues or concerns to be addressed before they escalate. In addition it can also highlight examples of good quality care that can be shared.

For further information please visit: www.warwickshire.gov.uk