The determinants of staff and resident activity in residential services for people with severe intellectual disability: Moving beyond size, building design, location and number of staff

Abstract

The replacement of institutional residential services for people with severe intellectual disability with community-based alternatives has progressed similarly in many of the countries of the developed world. In the first wave of reform, the idea of reversing institutional conditions provided a design brief for the alternative services which emphasised various structural characteristics of the settings: smallness of scale, typical housing design, homelike equipment, furnishings and decor, community location in typical residential areas, autonomy over household management and increased staff support. As the poor quality of existing services was widely seen as due to “institutionalisation”, there was an equally wide-spread belief that such reforms would lead automatically to high quality outcome. However, expectations for improved quality from the initial reforms, while partially met, were far from fully confirmed by research evidence. A decent, homelike, well located, reasonably staffed environment may be a necessary condition for good outcome, but these factors are not sufficient to guarantee it. The existing metaphor of institutionalisation needs further elaboration if it is to be useful, and the design brief for the alternative service requires expansion to include factors such as the orientation of staff and their working methods and training, which are shown by the research literature on the micro-organisation of settings to make a difference. Based on a review of the literature which inevitably but not exclusively favours British research on community alternatives to institutional care, the paper shows how the quality of staff and resident activity is dependent on an interaction between the structure, orientation and procedures followed within the setting.