Work package 3: qualitative investigation of staff and service user experiences of supported accommodation

The aim of WP3 was to complement the quantitative findings of WP2i by exploring staff and service user experiences of supported accommodation to understand in greater depth the support provided in the three types of supported accommodation services across England and the aspects of care considered most helpful and unhelpful.

Methods

A purposive sample of 30 staff and 30 service users was recruited from the three types of supported accommodation recruited from across England in WP2 (i.e. residential care, supported housing and floating outreach), taking account of gender, age, length of stay (service users) and seniority and experience (staff). The researchers approached potential participants after completing data collection for WP2 and invited them to take part in an interview about their experiences of living or working in supported accommodation services. They were given an information sheet about the study and the researcher explained its purpose and answered any questions. Written informed consent was gained before the interview. Separate topic guides for the staff and service user interviews were developed by the PMG with the researchers, and reviewed and amended after discussion with the Service User Reference Group and North London SURF (see study website for copies of the topic guides: www.ucl.ac.uk/quest). Both had a similar structure and addressed four main areas:

• Staff –
  • Views on the goals and purpose of supported accommodation.
  • Views on the most effective aspects of the support/care provided in the service.
  • Areas where they experience challenges to providing effective support/care.
  • How the service promotes independence/move-on?
• Service users –
  • Purpose of being in supported accommodation.
  • Experiences and aspects of the support or service they find helpful.
  • Experiences and aspects of the support or service they find unhelpful.
  • Barriers to gaining more independence and move-on.

Prompts were used to elicit specific examples from participants’ own experience, when possible, to illustrate issues that could have a bearing on the success or breakdown of a placement. In preparation for WP4, participants’ views about comparing the effectiveness of two models of supported accommodation (supported housing and floating outreach) through a randomised controlled trial (RCT) were explored and they were asked to suggest appropriate outcomes for such a study.

Data analysis

Interviews were recorded digitally, transcribed and anonymised before being entered into NVivo 10 (QSR International, Warrington, UK) software for coding. Transcripts were subjected to inductive semantic thematic analysis41 with the main research questions forming the basis for the initial coding frame. Further analysis sought to identify differences in the experiences of staff and users of different service types and the aspects of care considered particularly helpful/unhelpful. Coding was based on the search for patterns in terms of things occurring in a similar way, things occurring in different ways, if things occur in a sequential way, frequency of occurrence and any ascribed causation. A second coder checked for consistency and validity of interpretations in a randomly selected 20% of the coded interviews. Once this verification procedure was complete, the categorisation and theme generation process commenced. Conceptually similar codes were grouped to form subthemes, which were then grouped to form larger, candidate main themes. The thematic structure was agreed through discussion between the researcher (Sima Sandhu) and the leads for WP3 (SP and GL). Further details of the approach to data analysis are available in Sandhu et al.25

Results

Participants

The length of time that service user participants had lived in the current supported accommodation service ranged from 3 months to > 11 years, with a mean of 3.3 years. Staff had worked in the current service for between 3 months and 20 years, with a mean of 6.5 years, and they had worked in mental health services from 1 to 31 years, with a mean of 12.75 years. Participants’ demographic characteristics are shown in Table 3.

Main themes

Purpose/goals of the service

There was consensus between service users and staff about the main purpose of supported accommodation, which was most frequently cited as being to provide support for users to attain and sustain greater independence. Four related subthemes emerged: supporting people with their mental health; providing safety and stability; building confidence; and building independence:

I think the purpose is to support people that um, generally obviously have a mental health problem, support them from being at crisis stage, back into independence, and to um, bring about positive outcomes, so that they can become independent.

To achieve this, services needed to provide practical support for users to gain confidence in managing activities of daily living, encouraging them to build on their existing capabilities, and to provide living environments that were safe, secure and stable:

And most of the people that come here have struggled to live independently on their own without any ongoing support. So um, so they’ve found it a lot safer and a lot securer.

Staff, in particular, emphasised their role in supporting service users with their financial affairs (budgeting, paying bills, accessing appropriate benefits and managing debt) and in advocating for service users:

We would look at income and expenditure – particularly if they were worried about money, or found themselves in debt. If they found themselves in debt I would, and I have done, encouraged them to make the call to the debtor and explain their circumstances, and maybe a little bit of their own personal background, so that there’s an element of understanding, and try if necessary to come to an arrangement whereby, you know they are making repayments on a lower, at a lower rate.

Service users reported that staff gave them the encouragement and help they needed to achieve the things that they wanted to do. Across service types, this included gaining independence with activities of daily living, and in floating outreach services, users valued being supported to work towards employment:

Well it’s confidence-building, helping you to deal with things that you need to know about, like it’s how to pay rent and your bills and how to keep yourself clean and . . . and where you should go.

I wish to one day you know become like that so I could live independently; I’d really love that – you know?

Effective/helpful aspects of the service

Six interrelated themes reflected staff views about how to work effectively towards the goals: incremental steps to progress; knowing the individual well; the support of other service users; working together to avoid de-skilling and dependency; tailoring support for social and community engagement; and good liaison with other services.

Services that supported their users to gain skills incrementally were regarded as effective and helpful by staff and users alike. These services tended to ‘support with’ rather than ‘do for’ people:

. . . and that progress report is looking at what they achieved last month and what new things have been introduced this month. So the idea is to keep introducing new things, and to step away from the things they no longer need support with. So, you know, we have service users where we would be going to the cinema with them two or three times a week, who now go to the cinema by themselves. So what we would then do is introduce an activity that maybe they will need support with – and then they go and do that by themselves, and that’s the progress.

Services were more likely to be considered effective when staff understood their clients well and formed trusting relationships:

Well . . . they’re there to support you, they’re there to support you and um, you can trust them. I mean they’re sincere, genuine, um, they have a proper attitude.

Staff noted that service users also appeared to benefit from feeling supported by other clients living in the accommodation:

I think you can see them support . . . like especially [Name] and [Name]. They’re particularly supportive of each other, so . . . I feel with a lot of them they do come together and they will support each other. They’ll always ask the other one ‘oh are you OK’ and ‘how are you doing?’, and you know it’s nice.

There was an awareness from both staff and service users that individuals needed to be encouraged and supported to do things to encourage them to gain/regain skills:

I got a little bit of support with it yeah. Kind of . . . you know, a bit from me and a bit from the staff really . . . They’re . . . it’s not like they force you to do things but you’ve got to put, you know, you’ve got to input yourselves . . . because it does take, primarily it does take yourselves to do it, yeah.

Staff were mindful that social and community-based activities needed to be tailored to the individual to maximise their appeal, with the aim of creating wider social networks as part of the person’s rehabilitation:

Well I think what we’ve done initially is we’ve actually took the time to sit down with people and actually talk to ‘em about what their interests are; so what they actually would like to do. Like we found out that one of the residents apparently was a keen cook, many years ago, so we got him engaged with a local mental health charity who do cooking lessons and bakery lessons, so he goes every week . . . he’s absolutely delighted with that.

Um, we do . . . we run activities here, we do the gardening clubs, walking clubs to get people socialising sort of with other customers in the area and to get people active as well. Um, we’ll organise things; we organise trips for them to go out from here as well so that they, you know they’re not socially isolated.

Staff also noted the importance of appropriate training, regular supervision and being flexible in their approach. Joint working with community mental health services and other agencies was seen as crucial for an effective service, as was awareness of when involvement from other services was needed:

Yes, because if something’s not working, then at least it’s more than one head thinking right well, what else can we try, where else can we go with this?

Service users noted that the practical and emotional support given when attending appointments with external agencies was particularly helpful:

So . . . I, I went for um, a scan . . . and ECG [electrocardiogram], and [Name] came with me to see the consultant for the results. And I’m so glad she did . . . So you see I have got very little faith in the medical profession. Um, and as I say, [Name] supported me through that . . . she helped me through it.

Challenges/unhelpful aspects of the service

Poor communication with other agencies was seen as a particular challenge by staff, as well as a lack of suitable training and supervision. In addition, staff and service users felt that staff were pressured and did not always have adequate time available to support service users with their activities (inside the accommodation and in the community), which limited their progress:

Well just . . . or . . . just mainly that it’s getting tied, where there’s only one staff and you can’t leave the building – for me that’s the . . . the major stumbling block.

And I asked to go to Asda [www.asda.com] in the day, with [Name], because we were getting . . . I wanted a few things from there. He said, ‘oh, no you can’t go . . .’. Then I ended up not going . . . we, we ended up not going – couldn’t go . . . because it, because there wasn’t other people going . . . There’s not always enough staff on here to go out.

Both staff and service users also reported that conflicts between service users were particularly unhelpful and stressful:

But then you’ll get somebody say like [Name] who will come into the room and just start like throwing things, um, and then obviously tensions mount or you’ve got two people that wanna get in the lift at the same time together and neither of them will back down so they’ll just try and get in there together and then have a fight.

Sometimes I think . . . the only sort of criticism if you wanna call it that, is that sometimes, you know another resident might be annoying you or there’s something going on . . . You know I’m not talking massive things, I’m just like, you know um . . . I dunno, say upstairs messing our kitchen up or something say. Just, you know nothing . . . um, or someone’s behaviour . . . you know . . . that you know is outside of the rules if you like.

Service users reported that a lack of choice and involvement in decisions about things that concerned them was unhelpful. Related to this, some staff also expressed a particular concern about creating dependency among service users:

I think that um, still . . . the relationship I think is very much a dependency relationship from the resident’s point of view; I think that the residents um, still look to the staff as . . . or do look to the staff as kind of their nursemaids and their housemaids and their [in-breath] um, you know everything to do with that really.

Others noted the particular difficulties that arose when users did not engage with services:

The only thing that gets in the way is the client engagement side of things. I would say we . . . we can offer across . . . we can either offer the support or signpost to the support that that service user needs . . . The support services are there, the support that we can provide are there, the only barriers sometimes to clients being successful is their engagement.

Facilitators of and barriers to moving on to greater independence

As noted earlier, staff felt that preparing for greater independence could be achieved by working incrementally on specific skills to help service users gain confidence. Staff emphasised the importance of planning for move-on a long time ahead. This included ensuring that there was good communication and close working with staff from the relevant community mental health team throughout the process to ensure that adequate support would be provided after the move. Staff also highlighted the need to have open conversations with service users throughout their time with the service about move-on, but without forcing the issue with them:

So it’s discussed at every support plan meeting – they happen monthly, 2-monthly, 3-monthly, depending on what the client’s needs are, um, so we just, we discuss about moving on, if it’s moving on from accommodation based, or whether it’s to another accommodation setting that they require, [in-breath] but was also discuss about the steps towards independent living and what services, or support needs to take place to achieve that.

Aside from a lack of suitable accommodation to move on to, staff reported that the biggest barrier to service users’ progress was anxiety about move-on (both the process and the likelihood of success), which could manifest in resistance from service users and staff. Service users expressed appropriate concerns about the location of any future home, if they would have enough support and if they would feel lonely if they moved to more independent accommodation:

Yeah I do yeah, because um, what’s in the back of my mind is that, you know, what I’ve been through, I don’t want to, I don’t want a repeat of that again. So, you know, if you take that support away – you know moving on from here to another place – you know, in the back of my mind, I don’t wanna, I don’t wanna go through again what I’ve been through ‘cos I don’t think I could come back from another one.

Views on comparing the effectiveness of two models of supported accommodation through a randomised controlled trial

The majority of staff and service users felt that a study to compare the two models of supported accommodation would be useful and should go ahead but there was concern about the use of random allocation in such a study:

I can understand that it would be useful. The . . . the problem I’ve got really is that if I’m quite sure that if I was to go er, back to head office and say well we’ve got . . . we’re discharging someone, we’re just gonna flip a coin and say well you’re going here and you’re . . . that they would say well, it’s not person-centred and you’re not, you’re not addressing the needs of the individual.

No I think they should really leave it down to the person, individual to say, d’you know what, I’ll give that a go or I’ll give that a go. And then they can . . . then they decide which they think is gonna be better for them – you know – and how they coped in both those situations.

However, many participants stated that as long as service users’ needs and preferences, and the views of the referring clinicians, were taken into account, randomisation could be possible in some cases. Participants suggested the following outcomes for assessment in the trial: mental health (including hospitalisations); physical health; quality of life; social inclusion; managing the tenancy; level of independence; substance misuse; incidents of risk; medication adherence; ability to manage activities of daily living/social functioning; and engagement and satisfaction with services.

Links to other work packages

Although some concerns were raised regarding randomisation, service user and staff participants were supportive of the planned feasibility trial (WP4).

Limitations

A number of limitations are acknowledged. Although we attempted to maximise the generalisability of our findings through purposive sampling, we cannot be certain that the views and experiences reported here fully capture, or reflect, those of all staff and service users in these settings. It is possible that participants were unwilling to report particular events or behaviours, such as poor working practices, in case they would be perceived in a negative way. In addition, the inclusion of diverse models of supported accommodation may have led to overly inclusive conclusions, but the high levels of thematic convergence suggest that this was not a significant issue.

Key findings

• Staff and service users, across all supported accommodation types, shared an understanding of the purposes of these services to build skills and confidence for more independent living.
• Staff described how they worked with service users to achieve this in an incremental, tailored way that built on their strengths and interests and incorporated a rehabilitative and recovery-orientated approach.
• Conflicts between service users were noted by staff and service users as unhelpful. Both staff and service users expressed anxieties about managing with less support after move-on.