ListenThere is quite a lively global conversation going on about quality standards in the context of residential care. Conferences are being convened to discuss such standards, new research and/or editorials in the literature on this topic abound, and policymakers across many jurisdictions are busy trying to articulate such standards. One specific challenge is how one might measure performance against those standards, which is further complicated by the prevailing view that residential care ought to be steeped in relational practices, and these have always been difficult to concretely define and meaningfully measure. One emerging outcome at least in some jurisdictions is a hard turn to the past. By this, I mean a return to hard categories of pathological assessment and labeling, such that the breadth and depth of clinical interventions become the flag bearer for quality in residential care. People are talking about categorizing young people according to their diagnoses, their assessed functional capacities, and their deficits. In fact, entire systems are being built to match services to such clinical profiles, where quality care is equated with the way the complexity of a young person’s psychological circumstance corresponds to the availability of high-end clinical resources, such as psychiatry, psychology, a battery of assessments and fidelity to evidence-based practices.
This might be a good time to remind ourselves that child and youth care practice, and by extension relational practices as a theoretical foundation for child and youth care practice, emerged specifically in resistance to this medical model of treatment. In North America, the treatment movement, driven by medical systems and ideologies that defined any behaviours of young people that were challenging to the norms of society as disease and illness to be cured, was very good at ‘hospitalizing’ children and youth, separated from their families and communities, and accultured into institutional ways of being. They were not so good at care. In fact, treatment involved little more than coercive interventions that imposed medications, control, surveillance, and conformity for as long as children and youth were within the system and then allowed for complete abandonment once they were discharged. Several generations of survivors from this cruel approach are still working through their trauma, and many are failing at that as evidenced by the relatively high rates of homelessness, addictions, and suicide amongst system survivors.
The current movement toward defining quality standards in residential care is probably not stoppable, and at any rate, it may not be a bad thing to focus on quality standards in relation to care. The question is where to start and what to focus on, and here I want to (once again) weigh in with my suggestions. I will do these over the course of my next three contributions to CYC-Online, this being the first one. Each month, I will speak to two standards from the six quality standards as described in the title of this essay: Sleep, Eat, Play, Learn, Be You, and Community. In my view, if one could raise the quality of these across all residential services, we would have a transformational impact on how such services are experienced by children, youth, their families and their communities. This month, I will describe the first two of these standards: Sleep and Eat.
Sleep
Sleep constitutes not only the physiological base for health, but it also represents one third of every person’s life. Therefore, focusing on sleep and ensuring that the benefits of sleep are maximized is a critically important measure of quality of care. To this end, the following standard is measured routinely.
Quality Standard
Every young person in residential care must have a bedroom (shared or single, depending on preference and availability) that features a quality bed with a high quality mattrass and pillow, and bedding that is chosen by the young person and reflects the young person’s needs and preferences in terms of weight of the bedding (eg: weighted blankets) and the aesthetics of the bedding (eg: something important to the young person). Furthermore, the lighting of the bedroom reflects the young person’s needs from a trauma and desire perspective and is adjustable based on mood and the current moment. All bedrooms (or sleeping spaces if shared) are personalized to reflect things that are important to the young person (family pictures, transitional objects, etc.). White noise is available to young people who want that. The bedroom is the young person’s private space, of the highest aesthetic quality available, and a sanctuary from the burdens of the day past and the day coming. Beyond the bedroom walls, the residence pays attention to the sensory factors that impact on sleep, including noise, smells, and temperature and humidity regulation.
Service providers must track the quality of sleep experienced by young people in three different ways. First, all young people are invited to rate the quality of their sleep each morning. Second, all overnight staff maintain a separate tracking of each child or young person’s sleep from their perspective, noting sleep interruptions and the causes for these wherever possible. And third, all periodic reviews of a young person’s experience in the residential setting (eg: Plan of Care meetings) include a discussion of sleep, including dreams, and such discussions are documented.
All Plans of care must include a section that speaks to current and ongoing work to improve the sleep experience of every young person in the home.
Eat
Food and Nutrition are known and evidence-based factors in health, learning, behaviour, cultural connections, identity, and the development of personal autonomy through expressions of ideological preference (eg: veganism). What we eat and how food is handled in a residence reflects multiple dimensions of the care environment. To this end, the following standard is measured routinely.
Quality Standard
Food is always available to all children and young people in the home. Food is not locked up and children and young people must be able to access food without having to ask for it from staff. The types of food available in abundance must reflect the cultural and identity factors of the current group of young people living in the residence. Children and youth have leadership roles in determining the methods of procuring food, the menu planning process, the preparation of food for meals and snacks, and the allocation of resources pursuant to food in relation to the allocation of resources pertaining to other items in the home. While staff maintain teaching and guidance roles in discussing health-related matters pertaining to food (eg: limits on junk food; menus correspond to national food guides), all food-related matters in the home are subject to collaboration between young people and staff and neither group can veto the desires or preferences of the other.
All individual children and youth have food and nutrition plans documented in their case files. Such plans must take account of nutrition-based substitutes or enrichments for pharmacological interventions. Such plans must also take account of the connection of food to identity formation, cultural and religious needs and preferences, and the development of personal autonomy on the part of individual children and youth with respect to ideological preferences (meat-less diets, organic foods, halal or kosher foods, etc.).
Food regimes in homes must be reflective of building a sense of belonging and care, and therefore food (withholding of food or offering reduced quantities or quality of food) can never be used as a punishment or a behaviour management measure. Furthermore, the food in the home is the only food for all people in the home at any given time. Staff cannot bring their own food (except for medical reasons) to the home, order food for themselves, or eat separately from the group. All food-related activity is activity reflecting the whole home environment, not the environment for children and youth separate from the environment for staff or other adults.
All residential care providers must have a dietician on staff or procure consulting services through a registered dietician, who reviews individual food plans for each child or youth as well as the overall food system in the home and makes recommendations to optimize the impact of food in the home. Documentation must be in place of all such recommendations and the home’s response to these. Furthermore, all residential care providers must have a defined articulation of the food system in the home and its interfaces with child health, learning, and cultural and identity promotion. Finally, all residential care providers must provide an annual report on their expenses on food, and all such expense reports must demonstrate at minimum year over year increases in line with inflation.
Next month, I will describe the next two quality standards: Play and Learn. These are more complex than Sleep and Eat but equally important and certainly interface with Sleep and Eat as well. Once again, while these quality standards may appear as simplistic, once I have described them all, I will synthesize how these standards give rise to a relational care environment that is sustainable and can be measured.
