Scottish Borders
Learning Disability Service
ASSERTIVE OUTREACH TEAM
Operational Policy
(November 2006)
Assertive Outreach Team
West Grove Annexe
Waverly Road
Melrose
TD6 9SJ
Tel: 01896 824583
E-mail: [email protected]
Content
1
Overview
page 2
Mission
page 2
Values
page 3
Aims & Scope
page 4
How Will We Work?
page 5
Evaluation of AOT
page 5
Training Others
page 5
How Do You Ask For Our Support?
page 6
What Do We Expect of Other Stakeholders?
Page 6
Concerns
page 7
AOT Organisation
page 7
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Overview
The Assertive Outreach Team (AOT) is a team of experienced and skilled nurses able to
offer support and advice to people with learning disabilities whose behaviour or needs
challenge those around them. The AOT offers a service to people over 18 years of age,
with a learning disability living within the Scottish Borders. We work with people &
services in their own setting, whether that be home, day services or any other community
setting. The co-operation and support of family carers and service providers is key to
successful working.
The service provides practical advice, support and guidance over the management and
amelioration of challenging behaviour. An intrinsic aim of the service is to help to reduce
the need for the individual to show challenging behaviour by overall improvements in the
individual's quality of life through developing competencies of the carers or support
workers and the client.
We work with individuals in their own environment, helping those people the individual
interacts with on a daily basis. We aim to provide skills, support & mentoring to the
people currently supporting the individual, directly enabling them to implement and
maintain change.
Mission
The AOT will endeavour to ameliorate the effects of challenging behaviour through
understanding the reasons why people & services do the things they do, and through
constructive educational and therapeutic interventions. We use the framework of Positive
Behavioural Support (PBS) to work with individuals and services, providing assessments,
interventions, training, mentoring and facilitation.
Values
We are committed to improving the quality of life for people with learning disabilities
through a person-centred approach. Our service philosophy is drawn from ‘ordinary life’
principles, social inclusion, equality and fairness. (Same as You, Scottish Executive,
2000). Our methods of working are grounded in Positive Behavioural Support (PBS)
which combines Applied Behaviour Analysis with the values inherent in Person Centred
Planning.
PBS is an approach that blends values about the rights of people with disabilities with a
practical science about how learning and behaviour change occur. The overriding goal of
PBS is to enhance quality of life for individuals and their support providers.
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PBS is a way of working & supporting individuals whose behaviour challenges others or
limits their own opportunities. PBS involves a proactive, assessment-based approach that is consistent with the
science of behaviour & person-centred action
 examines not only the person but their life contexts
 encourages collaboration among families and professionals from a variety of
disciplines through group action planning
 is dynamic & responsive
 is effective in promoting positive durable lifestyle changes for people with
significant behavioural challenges and sustainable service designs for
organisations
 is about skill & capacity building for everyone involved.
PBS may be seen as a process for functional behavioural assessment, goal setting,
implementation, and evaluation. This process is most effective when bolstered by
effective system-wide policies and procedures and which is actively implemented by
those supporting the individual directly.
PBST work is based on these values:
 people are individuals with gifts and hopes
 people are members of families, peer groups, and society
 people influence their circumstances in personally meaningful ways
 people have the right to be treated with dignity and understanding
 relationships and contexts impact on the quality of a person's life
We recognise the need for a robust risk management approach that balances individual
choice with responsibilities and consequences. We are therefore committed to the
principles elaborated in The Adults With Incapacity (Scotland) Act 2000 and The Mental
Health (Care and Treatment) (Scotland) Act 2003.
Aims & Scope
The AOT is based in Melrose and covers the Scottish Borders. The service has been set
up as part of a formal redesign process following the closure of the in-patient assessment /
treatment service, with the aim of providing intensive support in the management and
amelioration of severe challenging behaviour in community settings. It should be
emphasised that the AOT does not replace the need for some people with complex mental
health needs and severe challenging behaviour to require a planned proactive admission
to hospital for assessment and treatment.
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Similarly the AOT will not be held responsible for placement breakdown due to
challenging behaviour in circumstances where the care package for that individual is
assessed as inadequate.
An intrinsic aim of the service is to help to reduce the need to show challenging
behaviour by overall improvements in the individual's quality of life & skills.
Additionally, we aim to enable
 The client to remain in community settings
 The client to achieve a reduction in challenging behaviour
 The carers to acquire the necessary skills and competence to effectively manage the
challenging behaviour
The people we work with will most likely be individuals who have moderate to severe
learning disabilities who would benefit from the PBS approach in understanding
behaviours others find challenging. It is most likely to be individuals who receive
support, possibly from a range of carers.
Challenging behaviour is defined as culturally abnormal behaviour(s) of such intensity,
frequency or duration, that the physical safety of the person or others is likely to be placed
in serious jeopardy or behaviour which is likely to seriously limit use of, or result in the
person being denied access to, ordinary community facilities (Emerson, 2001).
The AOT can provide a range of services, including
 Functional Assessment & Analysis of Behaviour
 Development of Positive Behavioural Support Programmes
 Mentoring and Supervision
 Training
 Consultation & Advice
How Will We Work?
The team is intended to complement but not replace existing services. We expect to be
working in the settings used by the individual, alongside the carers and others who have
significant links with the person.
In exceptional circumstances we will provide intensive support to the client and carers for
time limited periods in other community settings e.g. emergency short break facilities.
We shall respond rapidly to requests for support and will carry out an initial assessment in
order to decide whether or not our full involvement will be appropriate. If it is not, we
shall explain why at the time. If it is, we shall then agree with the carers the timing,
duration, goals and type of involvement, as well as expectations on both sides.
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We will offer and actively work toward close links with other agencies and team
members. The AOT consider their first priority to be the individual person.
We will work collaboratively with the Community Learning Disability Team with
designated sessions (when resources allow) from Psychiatry, Clinical Psychology and
Allied Health Professionals.
Evaluation of AOT
Evaluation of the service will be an integral part of the service. Additionally, satisfaction
questionnaires will be provided to users of the AOT service. People coming in contact
with the AOT are invited to comment on their experiences. Constructive comments are
fed back into service design and practice.
Training Others
The team will provide hands-on training and support to implement the agreed
interventions. Generally we expect the services we work with to have at least a basic
understanding of challenging behaviour and learning disability. Specifically we also
anticipate supporting provider agencies with particular expertise in severe challenging
behaviour.
How Do You Ask for Our Support?
Referrals must come via a member of the Scottish Borders Learning Disability Service.
Following receipt of a referral a brief initial assessment will be completed. The Team
will then consider this information at a weekly meeting and will accept or decline the
request. Such decisions are evidence based. Our aim is to have an initial assessment
carried out in most circumstances within 1 week of accepting a request for assistance.
Once the initial assessment has been completed and it has been agreed further work may
be beneficial for the individual and will be supported by the service, generalised and
maintained work can continue along at least three lines
 functional assessment
 functional analysis
 positive behaviour support programme developed
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What Are Our Expectations of Other Stakeholders?
We expect others to be committed to, and actively involved in, implementing the
principles & practice of PBS, for example
 the planning of assessment
 keeping clear records
 agreement of work to be undertaken by all stakeholders
 applying person centred values
 best practice
 the implementation and evaluation of interventions
Concerns
The AOT welcome any comments, suggestions or concerns about the service. We view
this positively. Concerns should be addressed in the first instance to
Assertive Outreach Team
West Grove Annexe
Waverly Road
Melrose
TD6 2AT
AOT Organisation
We meet our aims through
 Individual Clinical Work including functional assessment, functional analysis,
positive behavioural support, consultations and networking.
 Service Intervention which involves organisational consultation work to improve
quality and delivery of support within services.
 Training, Mentoring & Supervision which includes supervising staff & managers,
providing or receiving training, and mentoring key staff.

Other Activities such as team’s own supervision, involvement in special interest groups, research
projects or service development.
References
Emerson, E. (2001). Challenging Behaviour: analysis and intervention in people with severe intellectual
disabilities. Cambridge, Cambridge University Press
Scottish Executive (2000). Same as You: A review of services for people with learning disabilities. The
Stationary Office, Edinburgh.
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