Intimate care for disabled pupils

Background
The movement towards inclusion and integration, supported by legislation which upholds the rights of disabled people against discriminatory practices, is leading to increasing numbers of pupils with severe and complex needs being enrolled in mainstream schools.

Many of these pupils have a high degree of dependency on the adults around them. At the same time, mental and/or communication difficulties may render them less able to register and convey a problem if things start to go wrong. How, for example, can a child who is operating at the level of a two-year-old describe what is causing their unhappiness when a support or care assistant is sarcastic or simply cold towards them? They can feel the effect, though the cause may be too subtle for them to identify.

Such children are particularly vulnerable to abuse of every kind and bring working practices into sharper focus. The case study below exemplifies some of the practical problems which have to be solved and the lessons learned in the course of addressing them.

Case study: a boy who needed intimate care
A boy with complex medical and developmental problems transferred from a specialist setting to a mainstream school, according to parental wishes. The child had suffered brain damage, amongst other problems, and was double incontinent, requiring frequent nappy changes. The mainstream school, unlike the special school, did not have a hygiene room and raised worries about how it could safeguard the child’s dignity under these circumstances. The LEA support service dealing with children with physical difficulties visited on several occasions but no dedicated private space could be identified. Ultimately the school was instructed to use a cloakroom floor as a changing area, and purchased a mat and movable screens.

All agreed that this was less than satisfactory and a longer term solution was planned – the construction of a purpose-built hygiene room.

As a capital project, building a hygiene room took a considerable time to complete. Wrangles over funding, design and construction made for a fraught process, and two years passed in which the inadequate temporary arrangements had to be continued. The school appointed a support assistant to work with the boy on an individual basis; as specialist skills were required, this was not a job that could easily be shared with other staff.

When the hygiene room was finally completed, it became evident that there were points of design which left much to be desired: the changing table needed to be near to the shower head, and wasn’t; there was a heater at child level, and the support assistant preferred to work in a cold room rather than risk the child sustaining a burn; there was no washbasin, so the assistant found it hard to maintain the necessary cleanliness; and the door was fitted with a type of disability-friendly bolt which had to be used to prevent the door from swinging open. Points raised by the school were consistently met with the response that there was a standard template for such rooms and the council and contractors were bound by building regulations.

Against this background there emerged a new child protection conundrum: the knotty problem of privacy. The support assistant became apprehensive about shutting the door; she said that medical staff who worked with the boy on a peripatetic basis had told her that ‘under no circumstances’ should she be locked in a room with a child; it was, they suggested, poor child protection practice and following it could render her vulnerable to allegations of abuse.

On the other hand, staff supervising the older children who used the cloakroom space adjoining the new hygiene room began to object to the door being open. Other pupils could peer inside, and this might be damaging to the disabled student’s self-esteem and dignity.

It was also pointed out that even when locked, the design of the door was such as to make it simple to open from the outside without the need for a key. There developed, in effect, a stand-off between two factions taking opposing views, and both basing their arguments on their own perceptions of child protection.

In trying to resolve a situation such as this one, the first port of call is normally the local area safeguarding children board guidance, but not all go into this level of detail. In some areas, strong advice is given to schools recommending that two people are always present when intimate care (sometimes labelled ‘invasive procedures’) is needed. Some authorities require care logs to be kept and countersigned every time a child is (say) changed or tube-fed. In others, such as the policy given as an example on Teachernet, advice is framed more from the standpoint of respect for a child’s privacy: ‘Careful consideration will be given to each child’s situation to determine how many carers might need to be present when a child needs help with intimate care. Where possible, one child will be cared for by one adult unless there is a sound reason for having two adults present.’ Nationally, advice seems to be scant; as is frequently the case when one reaches the level of practical detail rather than principle, it falls to the institution to form its own judgement about the best way forward.

In this case, long consideration was given to the possibility of insisting that two people should be in attendance every time the boy went for a nappy change. This proved problematic on a practical level – very few mainstream schools have sufficient ‘spare’ support staff to allow a second person to be available on call at any part of the day. It was also questioned from a child protection standpoint too: what of his right to privacy? By increasing the number of spectators, would our primary aim be to serve his interests, or to assuage an adult’s fears of allegation?

Ultimately, the school’s decision was to put trust in its own selection procedures and instruct the lone support assistant to keep the door shut. This course of action would be supported by clarifying guidance with the medical agency and explaining school practice to parents. It was not on this occasion appropriate to be led by the child’s feelings on the matter as his developmental delay made them difficult to establish, although in other cases this would be a factor to take into consideration.

Below I discuss some of the wider issues brought up by this case study.

Applying the lessons in a wider context
The sorts of issues raised when we begin to examine details of organisation and routine as in the case study above show the tensions and trade-offs of child protection work in microcosm.

Possibly the single most important area to get right is recruitment and selection of staff.

If a school, or any other institution, makes the mistake of employing someone who is a danger to children, that danger persists however meticulous its policies and working procedures might be, while someone who is caring and trustworthy presents no problem under any circumstances. It is worth noting that ‘support assistant’ jobs are generally poorly paid and while there are of course many skilled unsung heroes doing such jobs every day, whose dedication and competence cannot be overestimated, it is also unfortunately the case that some applicants are far from suitable. Low rates of pay tend to attract young applicants who might have a sketchy or non-existent job history. To exacerbate matters, schools are frequently under pressure to appoint quickly to enable a child to start school, and under pressure from parents and LEA, and a perceived threat of prosecution under the Disability Discrimination Act, could be swayed to take a gamble on a candidate. Settings need to feel confident enough in their grasp of child protection principles to hold out against pressures and make appointments only when they are fully satisfied that they have found someone of appropriate calibre and credentials.

A second area to rectify is that of inter-agency working. It is possible that the situation outlined above could have been avoided if those who were responsible for funding, designing, and constructing the hygiene room had worked together from the outset, and had actively involved the school staff. It is hard to tell if anyone considered the child protection implications of the layout and door fittings. On a local procedural level, it would be helpful if all professionals working with children adhered to the same rules, so that when the medical worker commented that the door should not be locked, the educational worker would feel confident to concur or set right a misconception.

Third, there is a need to secure full parental approval for measures that are taken in school. This means being absolutely clear with parents/carers about working practices and to describe practices in detail. For example, rather than saying in general terms ‘We respect each child’s right to privacy’ it might be better to show them the actual room and say ‘This is where your child’s nappy will be changed by a trained professional who has been appointed after a thorough vetting process.’ Any misgivings can then be answered.

It would be hoped that most parents will accept that the professional is assuming the parental care role, and that few parents would insist that two adults should be present at any point of intimate care within the home environment. Devon County Council takes this a step further and recommends that ‘where a routine procedure is required an intimate care plan should be agreed in discussion with the child, school staff, parents and relevant health personnel. The plan should be signed by all who contribute and reviewed on an agreed basis.’

Fourth, it would be supportive and conducive to good practice to have clearer and realistic guidance about intimate care and child protection. It has, however, to be recognised that settings are in widely different circumstances, and have very dissimilar staffing ratios, so absolute prescription is unlikely to be an option. It might be more helpful if national guidance clarified what is not expected: that it is not necessary for two or more people to be in attendance when a child has a nappy changed, and a recognition that putting intimate carers on a rota – a stratagem used in some places to reduce the likelihood of over-reliant, potentially abusive relationships being formed – is impractical in many situations.

Finally, there is a leadership issue for schools, in that quality assurance is not secured solely through the initial appointment but has to be promoted through checks and longer-term development of human resources. Just as teaching quality is now assessed through regular observations and evidence drawn from a variety of sources, so also can be the quality of care. As well as direct observation of the interaction between child and support assistant, the judgements of others can be canvassed – teachers in the year group, parents, child.

Maintaining this vigilance over quality goes far beyond securing the confidence in staff that is required to underpin the stance taken in relation to the conflict between the need for privacy and the need to protect children from abuse and staff from allegation. More subtle abuses, such as those of negativity, emotional unavailability, or weak interpersonal skills, can also be picked up and dealt with appropriately, for example though training or change of role.

In fact, a further management function is that of staff deployment, and although, as noted above, swapping support assistants may not be possible from day-to-day or even month-to-month, it might be worth considering every year or two. To keep the same adult working with a child throughout seven years of primary schooling might not be ideal for a number of obvious reasons.

Philip Jones is a named person for child protection in a primary school.