Care homes for people with behaviours of concern

When people have complex health conditions, they can show aggressive or verbally abusive behaviour, which can make safely caring for them a challenge.

While many people with behaviours of concern, also known as challenging behaviour, are able to live in mainstream residential homes or supported living, others thrive in care homes that specialise in care for people with these behaviours.

One company that offers specialist care is Exemplar Health Care, a leading provider of specialist nursing care for adults living with a range of complex and high acuity needs.

Julie Booth, head of quality at Exemplar Health Care, reveals how these care homes operate and how they support residents with behaviours of concern to feel safe, cared for and understood.

What are behaviours of concern?

The term ‘behaviours of concern’ refers to behaviours that can cause harm or distress to the person doing them and/or other people around them or associated with them.

Behaviours of concern can include:

• Physical violence towards others or to themselves
• Verbal abuse
• Damage to property and possessions
• Sexually inappropriate behaviour, such as touching, language or taking their clothes off in communal areas thus impacting on their dignity
• Refusing to eat, drink or wash

Ms Booth says: “The people we support usually display behaviours which have made it difficult for them to interact with others safely or effectively, such as physical or verbal aggression or offensive language. Many of them have been deemed to have behaviours that are considered ‘too complex’ for mainstream nursing and care services.”

How long a person lives with behaviours of concern depends on the cause and the individual. Many people with a brain injury can make a full or near-full recovery, while for people with dementia or other degenerative disorders, the damage to their brain gets progressively worse over time. Care for behaviours of concern supports each person and the challenges they face on an individual basis.

Ms Booth explains: “Our community-based homes and OneCare services provide person-centred care and rehabilitation that focuses on maximising independence, building everyday living skills and empowering people to live as fulfilled lives as possible.”

Why do people have challenging behaviour?

Behaviours of concern can have a range of causes, often involving damage to the brain or a mental health condition. 

People can experience behaviours of concern due to:

• Dementia
• A mental health condition, such as depression, bipolar disorder, schizophrenia or personality disorders
• A brain injury, such as from trauma to or medical insult to the brain such as a tumour, haemorrhage or infection
• A disability the person was born with, such as autism, or genetic conditions
• Stroke

These can affect a person’s ability to regulate their behaviour and emotions as well as others. They may lose their inhibitions, their reasoning and analytic skills or experience very strong emotions due to the chemical imbalances in the brain.

People may exhibit these behaviours in response to something they are feeling but they are unable to understand why they feel that way or to express themselves or communicate effectively. They may show the behaviour because:

• They feel ill, in pain, hot, cold or uncomfortable
• They are confused or disorientated
• They are feeling a negative emotion, such as loneliness, sadness, anger or helplessness
• They feel overwhelmed by a strong urge or unpleasant thought
• They feel suffocated by their surroundings, such as in a loud or busy place

Learning skills to manage and reduce behaviours of concern

Through professional care, many people find new coping strategies and learn skills to manage their feelings.

Ms Booth explains: “Our trained teams work with individuals to understand the reasons for their behaviour, learn the skills to manage their own behaviour, to identify, remove and reduce any trigger factors and implement strategies to reduce the frequency, duration and impact of incidents of behaviours of concern. 

“We look at psychological methods of distraction and diversion before other methods are considered.

“Our approach to behaviour support focuses on how we can prevent the need for restrictive practices and reduce the frequency and intensity of behaviours of concern, so that people can live a fulfilling life and integrate with society without their behaviour restricting what they can do.

Care homes that care for people with challenging behaviour will have high staffing levels, often one member of staff to one resident, or two members of staff to one resident. They will also have in-house activities and life skills teams that enable people to take part in everyday activities that are meaningful to them. “This helps to reduce feelings of frustration for people who display behaviours of concern,” adds Ms Booth.

Creating care plans

Every person who receives professional care has a care plan which takes into account the person’s medical needs and care and support needs, plus their hobbies, interests and how they want to live a fulfilling life.

Ms Booth states: “When a referral is made to one of our specialist care homes, one of our Clinical Assessors will visit them (and their families and professionals, where possible), to do a full assessment of their holistic needs.

“Our assessment is broken down into over 15 domains of care that are based on decision support tools used by local authorities and CCGs.

“We work with the individual, their family and their care team to identify what their care needs and goals are, and what this care will look like and how it’ll be provided.”

Need for medication 

Using medication to minimise behaviours of concern should be a last resort.

At Exemplar Health Care, “if people do use medication, we regularly review its efficacy and necessity,” says Julie Booth.

Activities and social opportunities

Activities are an important part of any care home, and in a care home that specialises in behaviours of concern, having meaningful activities for the residents to take part in is an important part of supporting them to manage their behaviours of concern.

Ms Booth says: “‘Meaningful activities’ will depend on what’s meaningful to that person, based on their interests, history, experiences and hobbies. 

“This may include everyday activities that promote a sense of worth or purpose, including choosing out clothes for the day or making a cup of tea, as well as social activities based on their interests and hobbies. As part of some people’s rehabilitation, we’ll work with them to develop everyday skills such as managing money or taking a bus journey.

“The people who live in our homes regularly go out shopping, to the cinema and for walks in the local area, as well as attend local events such as concerts and gigs, and more recently, local Christmas light displays!

“We will always take a positive and proactive approach to this. If there are any risks associated with people going out of the home, we assess these and ensure that we have strategies in place, in advance, on how they’ll be managed.”

Keeping residents safe

A concern for people looking for care for a loved one with behaviours of concern can be how the care home ensures residents are kept safe, both from themselves and from other residents, particularly if they have aggressive behaviours.

Ms Booth says: “As part of the assessment process, we do a ‘community fit’ assessment which looks at whether our home is the right ‘fit’ for the individual, and if they’d be a good ‘fit’ for the home and the people who already live there.

“We carefully plan our care and support to minimise risk to everyone, and have stringent safeguarding procedures in place. 

“Alongside many of our care homes we have OneCare services. These services are flats or houses that offer specialist nursing care in a single or dual occupancy domestic living environment, that’s separate to the main care home. 

“They’re ideal for adults who have complex needs that cannot be met in a group setting. This may include those whose behaviours require that they live alone, or those who have difficultly tolerating living with others in a way that increases risk.”

Supporting staff safety and wellbeing

Care work can be an extremely rewarding job, but it is not always easy. Supporting staff wellbeing in care homes for people with behaviours has to be a high priority.

Ms Booth explains how they ensure the support and wellbeing of their team members at Exemplar Health Care: “All of our care and nursing colleagues complete our Exemplar Positive Behaviour Support (EPBS) training that’s been certificated by the British Institute for Learning Disabilities Association of Certified Trainers (Bild ACT). 

“This confirms that the learning meets the Restraint Reduction Network (RRN) Training Standards 2019. 

“The certificated EPBS training includes up to five days of learning – two of which cover PBS theory, psychological support, self-protection skills and break away techniques, and up to three days of level two training which covers restrictive practices. 

“The training provides colleagues with the skills and knowledge to protect people’s fundamental human rights and promote person-centred, best interest and therapeutic approaches to supporting people when they’re distressed. 

“We also have a central team of Mental Health and Behaviour Support Specialists who support our colleagues and service users who display behaviours of concern, including crisis or rapid intervention when a person’s behaviour is escalating.

“The team is made up of Behaviour Support Specialists who take the time to observe the individual, understand the reasons for their behaviour and suggest strategies to reduce distress or discomfort which might be causing the behaviour.