Transcript - Studio 3

Leadership & Reducing
Restrictive Practice
Roy Deveau, Honorary Research
Associate - Tizard centre, University of
Kent and Research Associate, Studio3
The programme
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Morning:
Introductions
Examine staff practice and leadership
Afternoon:
Examine frontline practice leadership and
apply to our contexts to reduce RP
• Make plans for some sort of action/change
• Why leadership?
• See references: Allen and Colton
IASSIDD 2014 Vienna
Reducing the use of restraint and
restrictive approaches to support
ordinary community living
Roy Deveau, Tizard centre, University
of Kent and Studio3, UK.
This presentation discusses
• implementation of Government policy at the
frontline.
• Recent reverses to the policy of limiting the use
of hospital settings for people with ID and
challenging behaviour.
• Implementation of policy and its relationship to
frontline staff practice.
• what determines frontline staff practice, drawing
on the distinction between management and
leadership.
Deinstitutionalisation
• UK Government policy to enable people with
intellectual disabilities and especially those
who exhibit challenging behaviour to live in
smaller ordinary community houses rather
than large scale, isolated, long stay, NHS
hospitals has been largely achieved.
• Scandals in the media helped drive this policy.
One county learning disability hospital
closed in 1990s
Re-institutionalisation
• Another hospital scandal drew attention to
increasing use of hospitals again. Government
policy commitments followed the BBC TV
Panorama investigative documentary into
Winterbourne View Hospital (May, 2011).
Re-institutionalisation
• A recent letter to the Prime Minister, Cameron
from two major charities representing families
and people with LD highlighted the failure to
meet policy deadlines for moving people out
of A&T hospitals and into local community
places by 1 June 2014 (e.g.3,250 people in
hospitals, 2014). MORE people are being
admitted than being discharged (over 6
months, 544 admitted & 339 discharged).
Winterbourne View, a modern hospital
• Apart from being illegal, this clip illustrates
something that hospitals, are and always have
been, designed to achieve. The exercise of
CONTROL over unsafe behaviour through the use
of restrictive environments and staff practices
e.g. seclusion rooms and the most restrictive
restraints - Floor restraints, requiring 3/4 staff.
• These practices and environments require staff
that are trained and reinforced to exercise control
AND are counter productive to achieving
community living.
Policy into practice
• Many examples (I am sure the UK is not
unique) of Government policy not achieving
what was intended. Poor policy, unintended
consequences, poor implementation may be
factors.
• I am interested in staff attitudes, cultures and
practices at the frontline that can support or
deny people the opportunity to live in
ordinary small scale local communities.
Policy examples, Health & Social Care Act 2008 CQC Regulations 2010
7H People who use services benefit from practice where the use of restraint and
management of behaviour that presents a risk is:
●● Always risk assessed to ensure the appropriate techniques are used.
●● Practised in a way that protects the dignity and respect of people who use
services and protects their human rights.
●● Discussed, agreed and documented in advance, wherever possible, with the
person who uses services as part of the processes for planning care.
●● Identified and documented in a plan that sets out preferred measures to prevent
and minimise the use of restraint, which is reviewed as the person’s needs change.
●● Used as a last resort and is the minimum response necessary for the shortest
possible time, to make them and others as safe as possible.
●● Recorded.
●● Where applicable, used in line with the restraint guidelines in the Mental Capacity
Act 2005 Code of Practice and the Mental Health Act 1983 Code of Practice and
including a best interest assessment.
Reducing RP - emerging legal issues
• An increasing trend for using a human rights
approach to support e.g. Council of Europe
declaration (2004) Persons with mental
disorder should have the right to be cared for
in the least restrictive environment available
and with the least restrictive treatment
available ---.
• Mental Capacity Act 2005 (DOLS)
(Social Care Institute of Excellence,
2011)
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•
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•
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Restrictions can include:
Close supervision in the home
Use of some medication e.g. to calm a person
Requiring a person to supervised when out
Physically stopping someone from harming
themselves.
WE HAVE PLENTY OF POLICY; WHAT ABOUT
ACTION. What determines good staff practice –
what does good & restrictive practice ‘look like’
• Have a quick look at your organisation brochures and
discuss in small groups what they say about how your
organisation is going to determine staff practice is ‘good’
and how this should be experienced, what about
restrictions?
• And let’s discuss restrictive practice (RP) The Slippery Slope
(McDonnell et al., 2014) suggested that small RPs are
common and can lead to major RP and abuse, if allowed to.
In your groups, each discuss an example of a small RP that
either became major or you felt strongly about but couldn’t
get agreement it was a problem or do anything about.
Two views of an organisation
• Neat organisational tree
As a chaotic system
• Analysing organisations as complex adaptive
systems “-- neural-like networks of interacting,
interdependent agents” (Uhl-Bien & Marion,
2009 p.631)
Rome IASSIDD conference 2010. Are the variables
that determine of staff practice: simple,
complicated or complex (Bigby et al., 2010)
Management versus Leadership
Leadership is a dynamic human process, in
essence the use of social influence to develop
and achieve organisational goals, focus on
organisational values and culture.
Management is the scheduling and
monitoring of staff to ensure routine policies
and procedures are carried out
A framework for thinking about frontline management
/leadership in ID (Deveau & McGill, in submission)
Management
Formal Administrative
system
-planning
-setting goals
-monitoring
-controlling
-improving
-doing things
right
-efficiency
-budgeting
Combined in
-coaching
-developing
others
-networking
-acting as a
role model
-creating a
climate
Performance of
designated routines &
tasks. Paperwork,
housework, safety,
personal care. Linear
relationships expected.
Written evidence
required.
Formal organisational
culture
Leadership
-visioning
-strategic thinking
-aligning
-inspiring
-doing the right things
-effectiveness
-opening doors
-building alliances
-removing blocks
Informal interaction
system
Emerging activities and
relationships are
unpredictable.
Internalised rules,
values and culture
reinforce actions. Non
linear relationships
expected. Observation
& testing required
Informal organisational
culture
What determines good frontline/practice
leadership – what does good leadership
‘look like’
• Do your brochures say anything about
leadership?
A confession - general answers to these questions are not
available. Because these questions and answers are specific
to particular contexts – the people – the environment etc.
Example from an NHS provided service tendered out to a
charitable organisation
Leadership in three major public
services
• NHS Leadership Academy .Towards a New Model of
Leadership for the NHS (June 2013). Motivated by failures in
health care and media scandals e.g. Staffordshire hospitals.
Excellent review of the leadership literature.
• National College for School Leadership. 10 strong claims
about successful school leadership (2010). Excellent
summary of school leadership based upon many years of
the College’s research since 2000.
• National Skills Academy for Social Care. Leadership starts
with me (2013). In part a response to winterbourne view
scandal. Not based upon research but a focus group
exercise involving many parties, providers, purchasers
service users, discussing what they want from leaders. Only
recently started discussing leadership in social care.
NHS leadership Academy ( a decade of leadership development)
Towards a New Model of Leadership for the NHS, snippets: “the overall goal –
offer a view of what good leadership in healthcare ‘looks like”. Research
review organised into 3 elements which “contain sets of leadership
behaviours”
1. provide a clear sense of purpose: an ‘explicit focus of the needs of service
users’
reinforce an inspiring vision of the mission
2. motivation of teams & individuals to work effectively: a positive emotional
climate
3. improve system performance: “construct compelling case for change – find
ways to intervene informally – modelling learning new behaviours –
analyse self and unit – reveal some self doubt & mistakes”
National College of School Leadership providing
research and development since 2000
10 strong claims, snippets:
Head teachers (HT) are main source of leadership in schools
HT defined success in terms of social and personal outcomes not just exam results
HT personal values are key to their success “ who they are”
No single model of leadership for achieving success but some basic practices (behaviours i.e. NHS)
Difference in context affect nature and pace of successful leadership actions
Act incrementally layering strategies and actions depending upon context
Successful HT distribute leadership progressively based upon developing trust (NHS document criticised
distributed leadership) Measuring outcomes informally and formally is crucial to developing trust
HT use 8 key dimensions: define values and vision to raise expectation – set direction & build trust – enrich
curriculum – enhance teacher quality – build collaboration internally and externally – reshape conditions
for teaching and restructure organisation and leadership roles/ responsibilities.
Some examples of successful HT behaviours:
They HTs are all over the place you don’t know where she will turn up – support trials and experiments – have
a go mentality - open door access – still undertake some real work – ‘it ain’t what you do it’s the way that
you do it’ (different emphasis to the NHS) - encourage use of data and research.
Social Care (national skills academy)
Leadership starts with me, snippets:
WHAT: values: integrity- dignity – compassion –promote equalitypraise effort
Practice principles: social purpose – co-production- innovation – risk
responsibility
Qualities: self wariness – managing self – continuous personal
development
Based upon these, leadership in practice ‘looks like’ - quality of
personalised support – understand risk & safety - find shared
purpose - any worker can exercise leadership - relationship between
practitioner and service user is key - leaders need to be developed
and emerge.
HOW TO IMPROVE LEADERSHIP: follow programmes and activities –
‘produce a statement of social care leadership intent’
Map assets - stick to budgets
Leadership in ID the forgotten factor n
outcomes WHY?
• Some work on organisational culture (Hastings et al., 1995; Noone
et al ., 2003; Hatton et al., 1999)
• Some on frontline/practice leadership (Deveau & McGill, 2014;
Clement & Bigby, 2010; Lowe et al., 2010)
• Yet when I ask experts what makes the difference between poor
and good staff practice – usual answer the on-site manager.
We have experts in ID: speech, occupational, behavioural - so
why do we need leadership?
Low political priority
Clarity of gaols, what is social care supposed to produce, what
do/should leaders aim for as a vision?
The rational and irrational in leadership
(FT management blog, August 2014)
• Most chief executives think of themselves as rational. Certainly, in
the world of closely scrutinised listed companies, it would be
unwise for corporate leaders to project any other image.
• But, as Manfred Kets de Vries of Insead business school puts it in a
new working paper … “our everyday lives consist of webs of
constantly shifting and irrational forces that underlie seemingly
‘rational’ behaviours and choices – and life in organisations is no
exception”. To lead successfully, he suggests, requires a
“psychodynamic approach” that seeks to understand the hidden
factors motivating teams. . Organisations have to try to unearth
these “messy complexities”…. using coaching, 360-degree
feedback, group exercises, and leadership questionnaires... After all,
a little self-knowledge can go a long way
Good afternoon
• We start by looking a some of the relevant
research in ID and challenging behaviour.
• We then think about our own work and devise
RP reduction plans/ideas suitable to our work
contexts.
What makes great leaders?
Followers
Leadership research in ID
•
Practice leadership (PL) introduced in ID (Mansell et al., 1993) “Perhaps the most
difficult part of the interventions was redefining the role of house managers and
patch managers as primarily concerned with “practice leadership” rather than
administration” .
•
PL defined in context of implementing Active Support is ‘the development and
maintenance of good staff support for service user through managers: spending
time observing staff work, providing feedback and modelling good practice,
providing staff with regular one-to-one supervision and facilitating team meetings
focused upon improving service user engagement (Beadle-Brown et al., 2009) and
developed a PL questionnaire.
•
Using the PL questionnaire not much PL is being experienced by staff (BeadleBrown et al., 2009) also when using interviews/observations and survey (Bigby et
al., 2014). However, staff of a self selected group of Registered Managers
experience greater PL ( Deveau & McGill, 2014).
Higher PL is associated with better staff experiences of working with CB and
implementation of Active Support.
•
Driving up Quality Code.
One organisation self audit staff survey results: Leadership &
management
• PL measure (16 items) how often staff experience:
individual supervision, team meetings and being
watched whilst working and receiving feedback. What
subjects are discussed and are the main focus with
managers i.e. supporting service users to participate in
activities or form filling.
• The organisation’s staff (53% response rate n=57)
average PL score was high 76%. This compares with
41% for large sample from a national charity and 68%
from 21 services (Deveau & McGill 2014).
• On the PL (and other) measures a good result.
One organisation’s staff audit results:
Leadership & management
• High PL results show staff feel well supported during supervision
and team meetings, that are meaningful and useful and discussion
is focussed upon how to engage service users in activities.
• However, results were less positive for staff’s experience of being
observed and provided with feedback by managers on their work
(similar to Deveau & McGill, 2014).
• For example, “When they (managers) watch you work do they show
you how to work well with the service user you support?” 44%
responded always but 19% responded, rarely or never . And 46% of
staff agreed or strongly agreed with the statement. “My manager
only gives me feedback when I have done something wrong”
• There are no widely recognised and implemented standards for
managers observing and giving feedback on staff practice.
Leadership & Management, overall
organisational focus & mission
Jim Mansell and many others have pointed to the vital role of
organisation’s most senior managers/leaders providing the
overall focus/direction/ vision in their organisations.
But as with being observed and provided feedback on practice
by frontline managers this aspect of the organisation was less
positive:
• For example, 81% of staff agreed or strongly agreed with
the statement “Managers don’t get involved much in how
we support service users”
• And 75% of staff agreed or strongly agreed with the item
“Management is more interested in smooth running than in
helping service user engage in meaningful activity”
Qualitative interviews conducted with 19 managers
(Deveau & McGill, in submission)
settings
• Large house in ordinary
residential area was the
usual setting
• 123 service users in total
Mean per service 6.5
people
• Max 11 in one house
• Min 3 in two houses
Intellectual disability
• MMID 67 people
• SID 46 people
• PMID 10 people
A variety of challenging
behaviours described
76 people (61%) had Autism
8 services had all people with
Autism
Method, Interpretive
Phenomenological Analysis (IPA)
(Smith et al. 1999)
 Semi- structured interviews, were aimed at gaining an
understanding of the daily lived experiences of managers
as they interact with staff and their wider environment to
support people with challenging behaviours .
 Some very specific topics:
 How do you develop behaviour support plans?
 Some less specific topics:
 What made you the sort of manager you are now?
Final thematic structure
• 16 themes organised into five groups .
Manager’s
knowing
what’s
going on/
monitoring
Developing
new ways of
working with
service users
Manager’s
developing
and shaping
staff
performance
Influence of
employing and
external
organisations
Manager’s
personal
feelings
and values
Group 1.
Group 2.
Group 3.
Group 4.
Group 5.
Managers knowing
what’s going on/
monitoring
Developing new practice
and ways of working with
service users
Manager’s approach to
developing and shaping
staff performance
Influence of employing
and external organisations
Manager’s personal feelings
and values
The importance of
personal observation and
knowledge for managers
Degree of staff inclusion/
involvement in developing
new practice
The importance of personal
observation and contact to
inform shaping performance
Positive/negative influences
of external organisations on
managers
Managers promoting their value
base within the team
Covert/informal versus
formal/structured
approaches to
monitoring
Recognising and using
individual staff abilities &
observations
Long-term, patient
development of staff, but
happy to ‘let them go’ if
performance will not improve
Positive/negative influences
of employing organisations
on managers
Managers working within the
constraints and strengths of their
own personalities and
experiences
Keeping on top of staff
performance which can
go ‘downhill’ very
quickly
Using in-house and external
professionals
Using positive/negative
feedback
Implementation of new
practice requires more formal
management processes
Use of modelling & role play
The prime importance of
development of self, staff and
service users
Group 1-Manager’s knowing what’s
going on/ monitoring
Keeping on top of staff performance which can
go ‘downhill very quickly.
Theme - Covert/informal v formal structured
monitoring
Some managers felt they would get a more
realistic idea of how staff were behaving:
“Staff behave differently when the managers
around.. All that means is they know how to
behave.. I keep it informal, sit around and then
you get to see how staff actually behave
towards the residents”
Theme - Covert/informal v formal structured
monitoring
 Some managers placed importance upon hearing
rather than seeing:
“They (staff) really don’t realise how much I can hear
through the floor here… so I know how they’re talking
to clients, I know what the resident is doing at the
time”
 and having a central, accessible, office:
“I’ve been told by my line manager that sometimes I just
need to shut that office door and say “no I’m busy, I
struggle with that I really do”
Do trainers emphasise formal approaches & why?
Group 1 Keeping on top of staff performance which
can go ‘downhill’ very quickly
 Only 2 managers discussed the speed with which staff
practice can deteriorate without their intervention:
“It snowballs doesn’t it, and then the whole team starts failing.
You get one person that’s not doing it, especially if you’re in
such a small knit team such as we’ve got here. It really does
snowball if you don’t nip it in the bud and keep things under
control” (9, 43).
‘The Slippery Slope’ article emphasised gradual RP leading to abuse?
Group 2- Developing new ways of working with
service users
Staff involvement in developing new practice
Recognising and using individual staff abilities &
observations – emerging behaviours
Good or bad
Theme - Staff involvement in developing new
practice
Most managers described extensive staff involvement, leading
to various benefits, including:
 Better implementation:
“I’m not the one… trying to get that person doing that new thing
every-time... If you want staff to be successful then the best
way … is for staff to feel that they have involvement”
 Better plans:
“ the staff, they work with them day in day out, they’re faced
with the problems ….Yes, we can sit in the office and come up
with ideas, but they (the staff) will help finalise the idea, how
they think it will be better. Because they’re always in the
environment and they’re the ones dealing with the
challenging behaviour, a little bit more than people up here
making decisions” (9,14).
Theme - Recognising and using individual staff abilities
& observations – emerging behaviours
• “Something you maybe took for granted, you actually think…..well it is only
that person who does that, you know or it’s only that person who tends to
have that rapport with that service user…..if something’s working well for
one service user with one staff member, we’ll try and incorporate that into
the support plan so all staff have the opportunity to work at that level with
that service user” (5, 5).
• “…..recently, we’ve got L. (a service user who needed a physical
intervention (PI) to get him out of the car). M (the behaviour specialist)
and I did a lot of work with the staff team. However,…..because we got
them involved (two staff who worked a lot with L) they literally changed
the whole guidelines from what M. and I thought, into how they felt and
basically they ended up leading the sessions with the staff team and they
were sort of doing their little role play and showing the staff as well, whilst
M and I are sitting there observing them doing it…..we haven’t used a PI
for months” (3, 4).
• How do structured training approaches combine with the certainty of and
potential benefits from emerging practices?
Managers being themselves
‘leadership starts with me’
 Managers described developing a ‘team’ based upon
getting people with the same values. The managers
own experience of ‘life’ and work mentors/role models
both good and bad shaped their actions and values:
 “I think my own life experiences, my upbringing
was…..if you’re not going to do it, don’t expect
everyone else to” (5, 20).
 “I think I had a really good mentor when I came into
the profession… I started off as a support worker. And I
think I’ve always been quite fortunate that I’ve always
had good mentors.. I think that’s had quite an impact”
Managers being themselves
‘leadership starts with me’
And poor role models had an effect on how
managers express their values:
“I always thought that when I get my first
managers role, it’s something that stuck in my
mind.. Not to be like that.. So I will always
listen to people’s ideas. I suppose that’s part of
why I am what I am”
Managers being themselves
‘leadership starts with me’
• The managers expressed their experiences in ways which
showed how committed and personally they were involved.
These were not technocratic, transactional leaders.
• Some showed courage:
• “Now, we have individuals here who staff wouldn’t dream
of taking out on their own arguing that in the past it’s
always taken two or three staff. I have taken four of the
client group on my own to the cinema, with everybody
going, you’re mad, it’s dangerous, (I explained my risk
assessment and how I would deal with any problems). It is
hopefully demystifying and de-demonising” (17, 12).
Managers being themselves
‘leadership starts with me’
• Challenging potential restrictive practice.
“ I’ve had a man start this week and it’s his tone of voice and his body
language, that it just appears quite aggressive and he’s already been
involved in a couple of incidents…..”
Researcher: “how are you going to go about changing this staff?”
Manager: “In all truthfulness, with this one and this isn’t going to look very
good on me, but I’m not convinced that I’m going to…..(my deputy) and I
are going to have a chat with him about how he needs to sit and read the
support plans thoroughly, because they talk about body language and tone
of voice…..I think we can only support him, keep telling him and give him
supervision, but…..with this one it’ll be either he leaves or there will be an
incident where by he has to leave…..he’s come in as an experienced man
and who are we to jump on this…..He said to me, don’t you think you’re
over the top what you do with C…..(Regarding the staff member changing
his work) he will have to, he will absolutely have to and we’ve got to give
him the benefit of the doubt…..but if at the end of the day that is still not
happening then he won’t be able to work here” ( 6,8-9-15-13).
Managers being themselves
‘leadership starts with me
• Challenging potential RP
The manager of service 7 described her response to the staff member who
had attempted to stop the service user making herself a sandwich, then
the manager of service 17 explains how he got his staff team to accept the
kitchen door being unlocked:
“She (staff) felt she’d supported the client and now I’ve actually said (to the
client) you can absolutely go, it’s your kitchen, so she (staff) felt, I think,
undermined. What was important to me was not that she felt undermined
but that she understood why we couldn’t make that decision.” (7, 9).
“When I came I basically indicated the kitchen would be opened, I met an
awful lot of resistance from staff, I then offered a compromise that we
would lock the kitchen as long as the lounge was also locked and that
personally I would rather be hit by an empty kettle than a television.
Needless to say I won the argument.” (17, 6).
Reducing RP: quick guide
• All people in supported living should have at least one
active goal and support plan that reduces RP
• If a restriction is felt to be necessary then one should be
reduced – The one in - one out principle.
• All restrictive practice should be reviewed and advocates,
staff team and managers, commissioners involved.
Although I am amazed at how much groups will accept.
• At 2007 BILD conference it was suggested that any service
that has a BSP that includes RPI should also include a BSP
to reduce the restrictiveness or frequency with which this is
used (Deveau & McGill, 2007)
So lets try to sum up some triggers for
you in your work
•
•
•
•
•
•
•
Leaders are no good without followers – make sure somebody trying to achieve
change doesn’t think they can do it alone. What about trainers not being engaged
over the long term?
Do trainers help to build support from all staff for registered managers to achieve
change.
Frontline/practice leaders need a supportive context – what does the CEO expect,
how much paperwork is there to do, what expectation are placed upon frontline/
practice managers - how is their work measured – incident reports – budgets adult protections or RP reduction and service user progress.
How do frontline managers include staff in practice developments, do they
observe staff working, informally, formally, do they give feedback, structured or
informal.
Can managers be tough enough to set a direction, can you see that evidenced. Not
accepting pressure from staff for small RP.
Do trainers/practitioners attempt to intervene in the wider context or just pile
more pressure upon the frontline practice leader.
Lets discuss some more
What are you going to do to reduce RP
• In pairs make some plans and more important
decide some actions.
• Remember: “Those who fail to plan, plan to
fail” (David Allen, 2011) However, “Plans are
only good intentions unless they immediately
deteriorate into hard work” (Peter Drucker,
cited in Deveau, 2012).
• Thank you for listening and being such a
rewarding audience.
• If you would like to chat about the ideas we
discussed or can’t get hold of any of the
references please feel free to contact me
[email protected].
Useful references
• Towards a new model of leadership for the NHS (June 2013) available form
www.leadershipacademy.nhs.org
• 10 strong claims about successful school leadership (2010) available from
www.ncsl.org.uk/publications
• Leadership starts with me (2013) available from www.nsasocialcare.co.uk
• Colton, D. (2004). Checklist for assessing your organization’s readiness for
reducing seclusion and
restraint. http://www.ccca.dmhmrsas.virginia.gov/content/SR%20Checklis
t.pdf
• Colton, D. (2007). Leadership’s and Program’s Role in Organizational and
Cultural Change to Reduce Seclusions and Restraints. Nunno, M., Bullard,
L., and Day, D., (Eds.). For Our Own Safety: Examining the Safety of HighRisk Interventions for Children and Young People. Washington, DC. Child
Welfare League of America. 143- 166.
• McDonnell et al., (2014) How nurses and carers can avoid the slippery
slope to abuse. Learning Disability Practice, 17, (5) 36-39.
Useful references
•
•
•
•
•
•
•
Deveau, R. & McDonnell, A. (2009) As the last resort: reducing the use of restrictive physical
interventions using organisational approaches. British Journal of Learning Disabilities, 37, pp
172-177.
Deveau & McGill (2013) Leadership at the front line: Impact of practice leadership
management style on staff experience in services for people with intellectual disability and
challenging behaviour. Journal of Intellectual and Developmental Disability,
http://dx.doi.org/10.3109/13668250.2013.865718
Deveau & McGill (in submission) Practice leadership at the frontline in supporting people
with intellectual disabilities and challenging behaviour : A qualitative study of Registered
Managers of community based, staffed group homes.
David Allen (2011) Reducing the use of restrictive practices with people who have intellectual
disabilities: A practical approach. BILD Publications.
Noone et al., (2003) Experimental Effects of Manipulating Attributional Information about
Challenging Behaviour. Journal of Applied Research in Intellectual Disabilities,16, 295-301.
Hastings, R.P. (1995) Understanding factors that influence staff responses to challenging
behaviours: An exploratory interview study. Mental Handicap Research, 8, pp 296-320.
Driving Up Quality Code: Self Assessment Guide. Available at (www.drivingupquality.org.uk)