This month’s blog is a reflection on work commissioned by Pathways Associates CIC who requested training for Experts by Experience and Clinical Advisors involved in Care and Treatment Reviews. Care Treatment Reviews (CTR’s) have been introduced following the introduction of the Government’s Transforming Care policy. In the North West, Pathways Associates CIC have led the organisation of these reviews and have created teams of Experts by Experience and Clinical Advisors. Part of the review includes looking at the quality of care and this involves a check of appropriate communication strategies. To our knowledge there is no detailed guidance on the communication approaches to review in the process. The Royal College of Speech and Language Therapists 5 good communication standards is a useful benchmark.
The Five Good Communication Standards
1. There is a detailed description of how best to communicate with individuals.
2. Services demonstrate how they support individuals with communication needs to be involved in their care and their services.
3. Staff value and use competently the best approaches to communication with each individual.
4. Services create opportunities, relationships and environments that make individuals want to communicate.
5. Individuals are supported to understand and express their needs in relation to their health and wellbeing.
The Royal College of Speech and Language Therapists (RCSLT) 2013
For further information please visit: www.rcslt.org
Observation in the review process seemed to indicate a particular focus on communication passports. NHS England Care and Treatment Review: Policy and Guidance (2015) makes the following reference;
‘Records will be reviewed (including care plans, person centred plans, positive behaviour support plans, medication cards, communication passports, care programme approach review notes, health action plan, Mental Health Tribunal reports). The service provider must ensure that all relevant information is provided at the beginning of the day and where possible in a format that is clear to all the team.’
Communication needs are therefore mainly addressed by asking about a communication passport, rather than referring a Speech and Language Therapy report which would be more likely to provide detailed recommendations and to highlight needs. Communication passports are without doubt a valuable tool. The usual style of communication passports see http://www.callscotland.org.uk/blog/personal-communication-passports/) is something which is owned by the person with learning disabilities and communication needs and which is developed in conjunction with them. It’s our experience that the communication passport in the context of a CTR is often more in the form of a profile completed by staff and stored on file. This is far- removed from the original concept, which was one issue we wanted to make people aware of. The main purpose of our training was to raise awareness of the range other possible approaches to supporting and developing communication and to increase the expectations of providers in providing a wide range of communication tools and techniques. The approaches we covered included:
Objects of reference
Communication Passports and profiles
Using photographs, line drawings and symbols
PECS, Social stories, comic strip conversations
Accessible information and adapting meetings
We also looked briefly at the development of communication and understanding of spoken language.
This whistle stop tour of the communication approaches listed above, gave participants a brief overview of each approach and provided a taster designed to raise awareness of the possible range of therapeutic strategies and the role of the Speech and Language Therapist (S<) in implementing them.The list is not exhaustive and guidance from the S< should be a priority.
Blog authors, Alison and Steph have experience of CTR’s from the perspective of the provider and in Alison’s case, also as the Clinical Advisor.
Oi Mei Wrightson from Pathways Associates commissioned Total Communication Services CIC to provide training on inclusive communication for clinical advisors and experts by experience. The course briefly covered the majority of approaches which might be used to support and develop communication, including supporting understanding and was delivered by Alison, Speech & Language Therapist and volunteer Communication Advocate, Steven.
By happy co-incidence Steph is an undergraduate S< student and Transitions Worker with a lead role for implementation of communication approaches in a NW provider service. She is based on a ward for people with mental health issues and autism. Being based on the ward means Steph can keep a close eye on the use of communication strategies used by individuals and their support staff.
Course attendees were asked to rate their knowledge of the different tools and techniques before and after the course, the graph below illustrates their views on their knowledge levels.
People on the course were asked if the training would make any difference to their practice.
The responses were that it would:
Increase in ability to make choices about important aspects of life, express emotions and feeling
Help staff understand individuals better
Reduce challenging behaviour
Make recommendations for communication
Make experiences more positive
Provide more opportunity for the individual to contribute to CTR
Mean less frustration, as people were being listened to
Increase in preference and choices
The difference it would make to the CTR process included:
Changes to the pre meeting sheet
Pass on knowledge to team
Change in approach to CTRS - communication emphasised
Asking what approaches are being used
Will use talking mats to support CTR process
Will ask communication specific questions
Improve contributions to CTRS
Make more of symbols
Assist in collaboration to prepare for meetings
Possibly assist in collaboratively establishing capacity regarding specific decsions
As a result of the training Steph felt more aware that not all communication strategies which are used with people on the ward are widely recognised. She also felt the approaches were not used often enough to encourage individuals to be able to communicate thoughts, feelings and choices; especially in important meetings that discuss their care and treatment. However there was some recognition of the level of skill required to work well with individuals. Steph adds
‘An interesting part of the workshop was having the opportunity to use objects of reference to communicate. It gave me the opportunity to be put into the shoes of a person with communication difficulties. It has made me think a lot about how objects used to aid communication need to be person centred, andnot what I would assume somebody would understand. For example, a cup might mean ‘do you want a drink?’ to me, but to someone with a communication difficulty, it might hold another meaning entirely. It’s working out what objects mean to the individual that is important. ‘Resources createdSome of the time in the sessions was dedicated to creating a checklist for experts by experience and clinical advisors. The checklist will provide prompts towards important topics of conversation that might otherwise be missed, ensuring that the individual’s communication needs are being looked at to see if they are currently being met. Having this checklist will hopefully ensure that more areas of communication are reviewed. Looking at how systems and aids are used by staff and the individual is imperative, as just having the aids physically present is not enough.
A short training session on talking mats proved a useful addition and some time was spent creating a picture based vocabulary pack using Boardmaker symbols, based on the suggestions on the Experts by Experience and Clinical Advisors.
This pack can be used with a Talking Mat approach but it is not exclusively designed to be used in this way. The aim of the pack is to provide a flexible resource which can be used in a number of ways to support understanding and expression in conversation about care and treatment. The pictures provided will not meet the needs of every discussion in a CTR, it is intended as a starting point and as an example to spark other ideas and approaches. It has helped CTR panel members to have an insight into an additional tool that can be used to find out how an individual is feeling about their care and where they are currently residing.
Communication Check List for CTR's
Images to support a discussion
about care and treatment
Outcomes from the course in the provider service
Steph and Alison introduced symbol keyring’s that ar used to help patients make choices about activities, and to help them express how they are feeling.
The emotions symbols are used widely across the ward with most of the patients. It has given them the opportunity to explore their emotions, and to start to express more clearly to staff about how they are feeling. These resources are available as a download from our online shop for just £1.00 https://www.totalcommunication.org/online-store
During the training, the group discussed how skilled staff adapt their communication styles almost subconsciously and at a fast rate depending on the needs of the individual they are communicating with. Back on the ward, inspired by this discussion, Steph created a wall display that entitled ‘we are skilled communicators’. It has acted as a reminder to staff that they have many of the skills needed to communicate well with people, and has boosted confidence in this area. It has also acted as a prompt to staff to remember that sometimes communication difficulties can be a barrier, and that they should use their skills effectively to enhance patient care. Alison, Steph and the team on the ward have also started to put together a communication dictionary for one person that is already providing food for thought. Feedback from the team is that is has been helpful and has started to make staff think more about what is going on for this young man, and how they can help to improve his care and quality of life.
Some key learning for us has been partnership working, the unique experience of working with Experts by Experience, Clinical Advisors a representative from a provider service and NW Pathways Associates has meant that all views were heard and ideas and solutions created together; being inclusive is a key to improving communication.
Director and Speech & Language Therapist
Student Speech and Language Therapist and Transitions Worker