SH

IP

WORKING

IN

Joint Health Education Review into

The Delivery of Postural Management Programmes In Special Schools

To maximise access to education, children need to be comfortable

This document contains background information about the project, a summary of findings and a selfevaluation tool for education and health staff September 2003- September 2004
Helen Dabbs Physiotherapist and Clinical Lead for Childrens Therapy - Mansfield and Ashfield District PCT Mark Richardson Deputy Head Teacher, Ash Lea School Chris Harrison Access and Inclusion Officer Nottinghamshire LEA

SC

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PA R T N E

NHS

About The Project

This document is the result of a joint health and education review that has been undertaken between September 03 and September 04

What did the review consider?

The review considered:
Current practice in Nottinghamshire special schools Current practice in special schools in other authorities The availability and use of specialist equipment Staffing levels Roles and responsibilities Aspects of practice which can be seen to be effective The impact of facilities and the physical environment on the delivery of services Identification of effective partnership How school ethos impacts on delivery of postural management programme

What is the aim of the review?

The aim of the review is to produce a model of best practice for health and education staff who are working together to meet the needs of pupils who require postural management programmes. The review is based on the assumption that postural management and regular changes of position is of benefit to and therefore essential for a child with disabilities. The review examined practice in a number of schools in an attempt to identify key aspects of school organisation which enable children to change position on a regular basis, to ensure the optimum use of the school environment. Effective postural management is ongoing throughout the childs day and night. It is essential that the child or young person, their parents/carers are actively involved at all stages . This review focuses on the management of the childs posture throughout the school day.

How was the review conducted?

The project team visited 8 special schools and conducted interviews with Head Teachers, Teachers, Support Staff, Physiotherapists and Occupational Therapists. Details of the schools visited and staffing and pupil information gathered is contained within Appendix 2. The names of the schools who took part in the project are contained within the acknowledgment (page 17). The questions used in the interviews are contained as Appendix 3.

What is the intended outcome?

The review has sought to produce a set of recommendations. These recommendations will set out examples of good practice in implementing postural management programmes in special schools. The recommendations will seek to enhance partnership working between health and education staff, parents and pupils. It will clarify roles and responsibilities of all partners and encourage joint responsibility for the integrated implementation of programmes.

Project Timescale
Discussion with the head teachers, senior therapists and team leaders (January to May 2004) Discussion with sample of students Consulting prior to publishing (September 2004) Production of summary document (October 2004) Dissemination of findings (Nov 2004)

What is Postural Management?

Postural management is a programme of activity and controlled posture which manages a childs posture. It enables a child to be comfortable in a sitting, lying, standing or moving position. Children that are comfortable are more able to learn. One of the aims of a postural management programme is to enhance a childs learning experience. Maximum benefit is gained when this aim is shared by health and education. Postural management is a central part of a childs daily life at home at school and elsewhere. There are many activities which contribute to maintaining good posture and some of these are described on the following chart.

The Projects Findings

The research aspect of the project aimed to identify successful delivery of postural management programmes for pupils in school. The project members have analysed the interview findings and summarised this under the following twelve headings. The headings represent reoccurring themes which together inter-relate to provide a structure for effective practice 1. taking Account of Pupil Views Pupils were asked a range of questions on their views regarding their personal postural management programme. Their views can be summarised by the following statements.
If I dont move it is uncomfortable and it can take ages before I am comfortable again I need to be moved to prevent pressure sores developing I feel uncomfortable for the rest of the day if I am not moved Sometimes when you are in pain and you need to be moved into a different position some people think it is an excuse to leave class

Experiences and activities which contribute to a postural management programme

Physical Activities

PE, games and exercise programmes Rebound Therapy Hydrotherapy

Individual treatment Allocation of specialist equipment and advice on how to use

Individual Programmes Standing equipment Walking equipment Specialist seating Floor equipment, e.g. Wedges, side lyers Moving equipment such as walking frames and wheelchairs 24 hour postural management programme including night time sleeping positions Alternative seating Programmes of activity Working Together Group and other uses of special facilities.

Pupils views highlighted the necessity to take account of dignity, comfort, safety, sufficiency of time and good communication whilst recognising the desirability of being moved on a regular basis throughout the day. If possible pupils views should be sought and their opinions valued.

Home programmes

2.Good Communication Schools with effective practice had both formal and informal channels of communication around postural management. This included:
Constant dialogue between health, education staff,pupils and the home environment Defined times to meet and discuss Shared written records which combined manual handling, postural management and personal care needs. Good communication between the identified members of staff with responsibility for the planning of the delivery of postural management programmes

Other programmes

When all the above was in place an atmosphere of trust and respect was nurtured

3. Good understanding of the purpose of Postural management Where staff were able to demonstrate an understanding of the purpose and value of postural management they were able to implement the programme with enthusiasm. Effective practice in schools demonstrated:
a shared belief in the importance of postural management that all staff had a hands on approach that staff had a shared belief that in order to maximise educational opportunity children must be comfortable.

6. Responsibility for Postural management Programmes In schools demonstrating good practice there was a clear understanding of roles and responsibilities.
There was an identified member of the school team who had responsibility for the organisation of the postural management programme. The Physiotherapist was always responsible for writing and reviewing postural management programmes. Often the person responsible for coordinating manual handling in the school was also the same person with responsibility for postural management.This person was seen as the key link person between health and education staff The physiotherapist always contributed to the manual handling programme

A childs posture should be a consideration in all activities in the day and is therefore everyones responsibility.

4. Good Professional relationships We observed good professional relationships in a number of schools. Good relationships resulted in effective practice where all concerned were working together appreciating and respecting each others roles. This meant
Teachers, TAs,PCAs, Health Staff had a clear understanding of each others roles and responsibilities which enabled a generic team approach All planning was child centred Staff had shared plans Staff had open channels of communication

When it worked well all concerned knew what they were doing, why they were doing it, and who they were doing it with!

7. Integrating Postural Management into the School Day There was evidence that good practice was demonstrated when students had a timetabled daily routine. For example
Students arrive at school in their wheelchairs, and following floor or exercise programmes, they would transfer into a standing frame in time for their first lesson They would use a class chair for lunch They would have floor time, rebound sessions, PE, hydrotherapy, soft play and back into their wheelchair in time for home. All staff worked together to achieve this daily routine, with minimal demarcation

A team approach resulted in a child centred holistic approach which reduces potential conflict. Professionals trusted each other.

5. Shared responsibility Schools that embraced a philosophy of shared responsibility for postural management ensured a child centred approach. This meant sharing responsibility across
all agencies and home all grades of education and health staff

Shared responsibility leads to a decrease in physical stress and strain on individual members of staff. It also leads to child centred holistic approach as the childs needs can be met immediately and flexibly without the needs to wait for specialty designated staff. This allows for a small team to be based around a child, and that familiar team can provide for a range of pupil needs. Although responsibility for delivery is shared it is essential to have an individual to act as a link person.

Postural management was seen as an integral part of the day rather than a specific exclusive programme. Postural management was integrated into the childs daily routine. In schools with effective practice there was a shared understanding of the educational benefits of comfort and integrated approaches to learning and movement.

8. Good Planning The team saw evidence of shared planning leading to shared responsibilities. Planning was most effective where there was:
Cross agency planning Careful timetabling with key people involved Integration of health and educational objectives Accessible, readable plans Production of concise information covering a range of requirements including Postural Management Programmes, Care Plans, Safe Handling Plans, Medical Health Care Plans

11. Effective Organisational Structure Where there was evidence of effective practice there was evidence of an effective structure and relationship between health and education staff. The illustration below demonstrates a common effective structure and set of relationships.

Physiotherapy Occupational Therapy and Support Staff Advisory Write programmes Assessments and reviews Provide training 1-1 therapy session class and group based work

Classroom based staff Overall classroom responsibility Delivery of postural management programmes planning curriculum and joint planning postural management programmes

To ensure this integrated planning there needs to be the time and opportunity for joint planning. It is possible to consolidate a number of plans.

9. Adequate facilities There had been an expectation that specialist facilities were essential to delivering good programmes of care. In fact, whilst space was important there was no apparent correlation between facilities and good practice. There were a number of observations about facilities worth noting. These are,
Space for standing frames and other equipment in classrooms or nearby is essential Accessible equipment stores should be available Schools had made very effective use of space designated for activities such as trampoline, soft play, sensory room, hall space, pools and outside play areas. These areas should be timetabled to allow optimum usage and varied physical programmes for pupils. Hydrotherapy was seen as an important part of curriculum and most schools had provision for this The use of dedicated space for Rebound Therapy and Trampoline work was effective in providing alternative PE and therapy provision.
Education Lead Person on Postural management Named person for school Some management responsibility for PCA team Safe Handling Coordinator

12 Visions Schools shared their visions and aspirations for future development. Key themes are;
an increased need for better storage, better facilities and more space to develop the concept of a one stop shop for pupils including easier access to a variety of health and education professionals for better liaison with home and more flexible working across home and school

Schools that made best use of available spaces provided a varied and interesting physical programme for children. 10. Training In schools where training was evident the need for postural management programmes was better understood. The training provided was varied but contained key features. Training
is delivered at key transitional stages is often child centred and involves specific requirements for individual pupils covers specific areas such as Rebound Therapy and Safe Handling

to improve joint planning

There is a need for ongoing training in a variety of formats.

Next Steps For Education and Health Service Staff

The project team suggests that education and health service staff jointly consider the aspects of good practice identified by the project, in relation to current practice in their schools and services. The team suggests that schools coordinate a meeting of all staff concerned to jointly carry out a self audit (See attached Appendix 1). This is in order to;
identify areas for improvement open up a discussion between key members of staff consider ways of improving delivery of postural management in their school develop a whole school ,multi agency approach to postural management 3. Staff in school have clearly identified roles and areas of responsibility. 4. There are positive working relationships between all staff involved in postural management programmes 5. There are good channels of communication. 6. All staff have a good understanding of the purpose of and physical and educational benefits of postural management. 7. Planning and implementing a postural management programme is child centred

Staff should
consider the key indicators make a judgment about the practice in their schools identify areas for improvement produce an action plan

The Project has identified 7 key indicators which represent good practice in schools. The 7 key indicators have been compiled in the form of a self audit tool contained as Appendix 1. These key indicators are:
1. Effective postural management programmes achieve regular quality changes of position. 2. Postural management programmes should be an integral part of the school day

This review has highlighted the need for further work in the following areas.
The delivery of postural management programmes in mainstream schools Involving pupils and parents in the delivery of 24 hour postural management programmes

Acknowledgments
The Project Team
The project team consisted of
Helen Dabbs - Physiotherapist and Clinical Lead for Childrens Therapy - Mansfield and Ashfield District PCT Mark Richardson - Deputy Head Teacher, Ash Lea School Chris Harrison Access and Inclusion Officer Nottinghamshire LEA

Schools Involved
The project team visited five special schools in Nottinghamshire and three special schools in other authorities These were:
Ash Lea School, Cotgrave Aspley Wood School, Nottingham City LEA Fountaindale School, Mansfield Priory Woods School, Middlesborough Orchard School, Newark St Giles School, Retford Yeoman Park School, Mansfield Glyne Gap School, East Sussex.

The project team would like to thank all those who contributed during the visits and discussions. The project also employed the services of Trudi Clark of the Physical Disability Support Service, who interviewed a number of pupils on our behalf.

Appendix 1
Self Evaluation Tool
How to use this self evaluation tool
The project team suggests that education and health service staff jointly consider the aspects of good practice identified by the project, in relation to current practice in their schools and services. The team suggests that schools coordinate a meeting of all staff concerned to jointly carry out a self evaluation. This is in order to;
identify areas for improvement open up a discussion between key members of staff consider ways of improving delivery of postural management in their school develop a whole school, multi agency approach to postural management 1. Effective postural management programmes achieve regular quality changes of position. 2. Postural management programmes should be an integral part of the school day 3. Staff in school have clearly identified roles and areas of responsibility. 4. There are positive working relationships between all staff involved in postural management programmes 5. There are good channels of communication. 6. All staff have a good understanding of the purpose and benefits of postural management. 7. Planning and implementing a postural management programme is child centred

Staff should
consider the key indicators make a judgment about the practice in their schools and indicate on the spectrum line where current practice can be represented identify areas for improvement produce an action plan

The Project has identified 7 key indicators which represent good practice in schools. The 7 key indicators have been compiled in the form of a self evaluation tool contained as follows These key indicators are:

Indicator 1
Effective postural management programmes achieve regular quality changes of position. This means that;
children are repositioned or moved at least 3 times a day

always achieved

sometimes achieved

never achieved

Action Required

Indicator 2
Postural management programmes should be an integral part of the school day. This means that;
careful consideration is given to timetabling and curriculum organisation in order to maximize the opportunities to change pupils positions effective use is made of specialist facilities postural management is seen as an integral part of the school day rather than an exclusive programme

always achieved

sometimes achieved

never achieved

Action Required

Indicator 3
Staff in school have clearly identified roles and areas of responsibility. This means that
school has identified a key person/persons to lead on postural management and safe handling all staff understand their roles and responsibilities and the roles and responsibilities of others Physiotherapists and Occupational Therapists write postural management programmes in consultation with school staff, pupil and their families as appropriate

always achieved

sometimes achieved

never achieved

Action Required

10

Indicator 4
There are positive working relationships between all staff involved in postural management programmes This means that;
the school ethos supports the principle of multi agency working. schools and health staff trust, value and respect each others roles.

always achieved

sometimes achieved

never achieved

Action Required

11

Indicator 5
There are good channels of communication. This means that;
there is evidence of cross agency planning integrating health and education objectives there is constant dialogue between health and education staff there are defined times to meet and discuss there are shared records

always achieved

sometimes achieved

never achieved

Action Required

12

Indicator 6
All staff have a good understanding of the purpose and benefits of postural management. This means that;
school has a training programme in place, which informs staff of the benefits of postural management programmes there are informal opportunities for staff development staff can demonstrate they understand why they are implementing a postural management programme

always achieved

sometimes achieved

never achieved

Action Required

13

Indicator 7
Planning and implementing a postural management programme is child centred. This means that;
there is a clear and shared understanding of an individuals needs facilitated by close liaison with home where appropriate a pupils views are sought and considered there is an effective review process in place where feasible, plans such as manual handling, postural management and care plans are combined

always achieved

sometimes achieved

never achieved

Action Required

14

Appendix 2
Chart to Show Pupil and Staffing Numbers (taken from information gathered at the time of school visits)
School No. of Pupils Pupil requiring post mgt Teachers TAs PCAs Physio Physio Asst/ T.I. OT OT asst/ T.I. Generic Health Care Ass 3.0 Post Mgt Team

St Giles

104

38

21

35 TAs and PCAs 18 18

0.3

0.8

Monthly

F/dale

71

65

11.1

1.6

4.2

1.0

0.6

Orchard

86

26

14

28

10

0.4

0.3

0.2

0.1

Yeoman Park Aspley Wood Ash Lea

90

33

15

32

1.0

1.2

0.6

0.4

39

39

8 +3p/t

2.0

2.0

0.5

82

29

11.8

16

1.0

0.9

0.2

0.1

Priory Woods Glyne Gap

143

56

15 +6p/t

27+6p/t

2 + 4p/t

0.4

2.0

0.2

98

30

12

30 + 0.5 fitness coach

0.8

0.1

0.1

15

Appendix 3
Questionnaire for visit to school
School:

Interviewers:

Interviewees:

Date:

Theme Context

Discussion areas How many pupils Age range How many education staff Pupil to staff ratio PT/OT input Are these staff timetabled to be in school How is this organised Skill mix Facilities What equipment do you have and who takes responsibility for it

Notes

Roles and responsibilities

Understanding of your role and of other key people in school Do staff have key roles and responsibilities

Working practice

Therapy activities in school Who decides on the childs therapy and postural care programme For those children with programmes, how often is it implemented and how often do they change position Who implements these programmes - what is the PT/OT/Education role in postural care Joint planning sessions Joint working Shared documentation Do health staff provide teaching around delegated tasks Differing levels of input depending on age of child Complaints Differences in different schools where staff work Working relationships

Overview

Aspects of practice which are effective What are the key obstacles What would you change What is your vision

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