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Adaptations for Behaviours that Challenge

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A GUIDE TO ADAPTATIONS FOR CHILDREN AND YOUNG PEOPLE WITH BEHAVIOURS THAT CHALLENGE ENDORSED BY APR 2021 WRITTEN BY DAVE ELDRIDGE

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FOUNDATIONS About Us Foundations is the National Body for Home Improvement Agencies in England This means that we re contracted to oversee a national network of nearly 200 Home Improvement Agencies HIAs and handyperson providers across the country It s a role we ve held since 2000 and since 2015 we ve also been supporting local authorities to improve how they deliver Disabled Facilities Grants DFGs whether they use a HIA or not Our vision is a thriving range of Home Improvement Agencies Sharing the benefits that adaptations can bring to families is a core aim of our 2021 workplan supporting people to live safe independent and happy lives in the home of their choice We want to see recognition of the role of using RRO flexibilities for children Foundations role on informing policy and with complex needs and the cost design is twofold On the one hand we advise benefit of large adaptations compared and support government in delivering on part to the alternative particularly on the of its commitments to vulnerable older and wider system disabled people in their own home At the same time we help local authorities to adopt housing assistance policies and commission services sensitive to local priorities and needs Contact Us info foundations uk com www foundations uk com 2

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CONTENTS Introduction 4 Executive Summary 1 Behaviours That Challenge 5 8 1 1 Autistic Spectrum Disorders 1 2 Learning Disabilities 1 3 Pica 1 4 The Autism Act 2 Methodology 12 3 DFG Legislation and Guidance 13 3 1 Definition of Disabled 3 2 DFGs and Young People with Behaviours That Challenge 3 3 What Work Can Be funded with a Mandatory DFG 3 4 Assessments 3 5 Funding of Equipment 3 6 Discretionary Housing Assistance Policies 3 7 Other Relevant Legislation 4 Cost Benefit 28 5 General Design Guidance 30 6 Conclusion 37 7 Further Information 38 8 Further Case Studies 40 3

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INTRODUCTION To provide advice on how the funding can be Introduction used To include case studies and examples Everyone wants to be able to live safely independently and well in a place they of good practise in order to support the call home However for some people their effective use of the DFG and discretionary home needs to be adapted to enable these housing assistance policies so that children aspirations to be met Each local housing and young people with behaviours that authority has a budget to help meet the cost of challenge are able to continue to live at such adaptations home where that is in their best interests and the interests of their family This guide has been developed by Foundations the national body for Home Improvement Note Although the focus of this guide is Agencies HIAs to provide advice and on adaptations which might be needed for information for local authorities and Home someone living with their family it will also be Improvement Agencies dealing with requests for relevant to people with autism and or learning adaptations for people with behaviours which disabilities who are living in their own home challenge by providing advice and guidance for example in a supported living scheme for staff carrying out assessments and for staff or living independently with care and support determining applications for funding It will also provided It should be noted that where an be useful for occupational therapists and staff in adaptation involves some degree of restriction other agencies working with children and young of a person s independent movement there people with behaviours that challenge whose may need to be consideration of the Deprivation home may need to be adapted as well as their of Liberty Safeguards DoLs and a necessary families and carers consideration in the person s best interest Note It has been announced that DoLs will be replaced by Liberty Protection Safeguards in Guide Aims April 2022 The aims of the Guide are Guide endorsed by To provide some background and context to behaviours that challenge To outline the rules and regulations relating to Disabled Facilities Grants DFG and discretionary housing assistance policies 4

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EXECUTIVE SUMMARY anxiety because their underlying sensory needs Physical accessibility issues are easily understood in a way that autism related needs are not Mother of a 22 year old with autistic spectrum disorder quoted in Making Homes That Work 1 are not being addressed Understanding the reason for the behaviours and how to create a safe sensory environment is key to responding to the needs of the individual and providing effective support Research has highlighted the importance of an appropriate and safe environment at home for children with autism and their families Whilst many people with autism and or learning disabilities can live with Executive Summary and Key Points their families independently or with support some people their families and their caregivers may face profound challenges due to an The definition of disability with regard to inadequate or inappropriate home environment eligibility to apply for a Disabled Facilities Grant is drawn widely and clearly encompasses Disabled Facilities Grant funding can make a people with autism and or learning disabilities substantial difference in such circumstances However the vast majority 89 of adaptations funded through a DFG are to meet the needs of people with a physical disability Funding can be used where the criteria for a mandatory disabled facilities grant are met This may include adaptations designed to minimise the risk of danger where a disabled person has Many families of children and young people behavioural problems which causes them to act with autism and or learning disabilities face in a boisterous or violent manner damaging the significant difficulties in continuing to provide house themselves and perhaps other people care and support to enable their family Other adaptations specifically mentioned member to continue to live in the family home in the current DFG guidance include the particularly when the child or young person provision of specialised lighting toughened has behaviours that challenge This may or shatterproof glass or the installation of be because for a person with autism and guards around certain facilities such as fires or with severe learning disabilities living in a or radiators as may be cladding of exposed world designed for neurotypical people can surfaces and corners to prevent self injury be difficult and may cause them distress or 1 Braddock G Rowell J 2011 Making Homes that Work Creative Housing Solutions LLC and Rowell Brokaw Architects PC 5

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EXECUTIVE SUMMARY Local authorities also have substantial Behaviours that challenge have a discretion under the Regulatory Reform Order RRO to fund additional works which fall specific purpose or function and it is outside the mandatory purposes for which important to focus on the underlying a statutory DFG can be given Discretionary reasons rather than the behaviours assistance can also be provided to meet themselves Understanding the reason the cost of works which exceed the current for the behaviours and how to create maximum DFG of 30 000 As the Guide a safe sensory environment is key to notes although in some situations the cost responding to the needs of the individual of necessary adaptations can be significantly and providing effective support above this limit research by the School of Multi disciplinary multi agency Law at Leeds University and the children s neurological charity Cerebra has shown that the assessment and intervention planning is financial benefits for the wider health and social essential to ensure that the needs and care system are substantial and can avoid the rights of children and young people with considerable cumulative costs of providing autism and or learning disabilities are fully residential care where the person s parents can understood and that any adaptations no longer provide care in the family home to their home are appropriate and proportionate to meeting their needs and The Guide shows that effective and creative in particular their sensory needs use of DFG budgets can make a significant The purposes for which a mandatory impact on the lives of people with autism and or learning disabilities as well as on the lives DFG can be given cover a wide range of their families and carers Such an approach of situations which may help to create can also make sense financially By helping to a better environment for someone with avoid unnecessary admissions to residential autism and or learning disabilities in care appropriate use of DFG budgets not only particular to make the environment safe delivers better outcomes for people with autism for the person and those people who live and or learning disabilities and their families with them but can do so whilst at the same time delivering Flexible and creative use of the powers better value for money for local authorities under the Regulatory Reform Order can Key Points enable local authorities to develop specific 6

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EXECUTIVE SUMMARY discretionary grants to meet the needs of children and young people with autism Acknowledgements and or learning disabilities With thanks to all those who have provided It is essential to see DFG funding as part comments and suggestions during the writing of an integrated approach to meeting of this Guide including colleagues in Ministry of the needs of children or young people Housing Communities and Local Government with autism and or learning disabilities the Royal College of Occupational Therapists Although in some cases the cost of including members of the Royal College of adaptations can be significant by helping Occupational Therapists Specialist Section to avoid unnecessary admissions to Housing and members of the Access residential care appropriate use of DFG Committee for Leeds budgets not only delivers better outcomes for people with autism and or learning disabilities and their families but can do so whilst at the same time delivering savings We ve seen that very little of the Disabled Facilities Grant budget goes towards austism and behaviours that challenge we wanted to shine a light and show what is possible for health and social care budgets Paul Smith Director Foundations 7

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1 BEHAVIOURS THAT CHALLENGE behaviour and its underlying causes It should 1 Behaviours That Challenge be noted that because such behaviour arises from a response to the world around them One of the most widely used definitions of rather than being intrinsic to either autism and the term behaviours that challenge is that or learning disabilities the alternative term of Emerson who defines it as culturally distressed behaviour is also sometimes used abnormal behaviour s of such an intensity to describe such responses frequency or duration that the physical safety of the person or others is likely to be placed in For people with autism and or with learning serious jeopardy or behaviour which is likely disabilities living in a world designed for to seriously limit use of or result in the person neurotypical people can be difficult and may being denied access to ordinary community cause them distress or anxiety because facilities 2 The term behaviours that challenge their underlying sensory needs are not being describes the behaviour as challenging to addressed It is these sensory issues which services rather than the problem being within may sometimes result in people with autism the person this person presents us with and or people with learning disabilities a challenge in how to support him her as displaying behaviour which may challenge opposed to this person is being very difficult people who live with them or services which This encourages carers and professionals to support them find effective ways of understanding a person s 2 pdf https www challengingbehaviour org uk learning disability files Formal Definitions of Challenging Behaviour 8

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1 BEHAVIOURS THAT CHALLENGE Behaviours might include Common causes of behaviours that challenge Causing self harm or self injury e g head include Pain or health reasons a reaction to banging eye poking hand biting something that hurts e g banging head on Causing harm to others e g hair pulling wall may be expressing that the person has hitting head butting earache Destructive behaviours e g throwing things breaking furniture tearing things up Social attention everyone needs attention and behaviours that challenge may be a damaging the home good way of getting other people s attention Eating inedible objects e g pen lids even if it is negative e g being told off bedding To get something a child may learn Flight behaviours e g absconding behaviours that get them things they want climbing hiding withdrawal e g food objects etc Distress behaviours e g screaming Escape a child may seek to avoid things stripping urinating defecating vomiting they don t like e g seeing the dentist spitting repetitive behaviours It should be noted that there is no definitive list Sensory sometimes people enjoy the because it is any behaviour that is challenging feeling that certain behaviours give them to those around the person or that has a i e rocking humming etc A response to perceptions of sensory negative impact for the person overload or sensory deprivation Behaviours that challenge have a specific purpose or function and it is important to The nature of the home environment can have focus on the underlying reasons rather than an adverse impact on people with behaviours the behaviours themselves Understanding the that challenge Research has highlighted reason for the behaviours and how to create a the importance of an appropriate and safe safe sensory environment is key to responding environment at home for children with autism to the needs of the individual and providing and their families 3 An inadequate environment effective support In many cases the behaviour which doesn t provide this can directly provides a way for a person to control what is influence the decision to place someone with going on around them and to get their needs autism and or with learning disabilities in a met It may also be to block out pain or to care setting As George Braddock of Creative communicate high levels of distress Housing Solutions noted you cannot fix a 3 Pengelly S Rogers P Evans K 2009 Space at home for families with children with autistic spectrum disorders British Journal of Occupational Therapy 72 9 378 383 9

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1 BEHAVIOURS THAT CHALLENGE problem behaviour in a broken environment 4 which can result in confusion anxiety and Ensuring that the needs and rights of children withdrawal For others sensory input is hardly and young people with autism or learning felt leading them to crave additional input disabilities are fully understood and that any Sensory seeking refers to those people with adaptations to their home are appropriate and autism who crave additional sensory input This proportionate to meeting their needs and in might involve sensory seeking behaviours such particular their sensory needs usually requires as head banging against hard surfaces multi disciplinary multi agency assessment and intervention planning Moreover early Whilst many people with ASD can live with their intervention is paramount to ensure the families independently or with support some environment is adapted before the child people their families and their caregivers may young person or their family members are at face profound challenges due to an inadequate significant risk of harm or inappropriate home environment 1 1 Autistic Spectrum Disorders 1 2 Learning Disabilities The term learning disability refers to a range Autism is a spectrum condition All people with of disabilities including mild moderate severe autistic spectrum disorders ASD share certain and profound multiple learning disabilities and difficulties but being autistic will affect them as with autistic spectrum disorders learning in different ways People often struggle with disability affects people in different ways sensory processing and integrating sensations People with mild or moderate learning the neurological process of interpreting and disabilities can often lead independent lives managing the sensory input they receive and with low levels of support However someone it can be hard to make sense of sights sounds who has a severe or profound multiple learning smells tactile and other sensory information disability may Have little or no speech For some individuals with ASD sensory input Find it very difficult to learn new skills can be completely overwhelming They have Need support with daily activities such as difficulties dealing with noisy environments dressing washing eating and keeping safe This is often described as sensory sensitivity Have difficulties with social skills or sensory avoiding and refers to those people Need life long support with ASD who are prone to sensory overload May also have physical disabilities 4 Braddock G Rowell J ibid 10

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1 BEHAVIOURS THAT CHALLENGE It is harder for children with learning disabilities provide statutory guidance to local authorities to to develop the communication and social skills implement the autism strategy locally The first which other children use to get what they need autism strategy Fulfilling and Rewarding Lives or want This may mean that they present with was published in 2010 and a new strategy behaviours that may challenge others and they Think Autism 6 was published in 2014 are unlikely to grow out of those behaviours on their own and will need skilled support in In 2018 the government announced that the order that their needs can be met in a different autism strategy was to be extended to include way children Statutory guidance published in 20157 stated that people should live in their own 1 3 Pica homes with support to live independently if that is the right model for them Section 7 3 Pica is a medical term which refers to the persistent eating of non nutritive or non The Think Autism governance refresh food items Cases of pica are reported in published in 20188 grouped the existing many different groups including in people with nineteen strategic objectives into five domains learning disabilities and or who have autism Domain 5 Participation in Local Community although pica is itself a separate diagnostic includes access to an appropriate range of condition Pica is reported to be often more accommodation options which for many young severe in autistic people or people with a people with autism will mean continuing to learning disability Pica can be compulsive very live in the family home NICE guideline NG939 dangerous and preventing it can also be very published in 2018 recommends support in the difficult5 community for children and young people with behaviours that challenge as an alternative to 1 4 The Autism Act residential placements away from home and to reduce the potential need for such placements The 2009 Autism Act places a duty on the Section 1 6 2 government to produce and regularly review an autism strategy with an associated duty to 5 https network autism org uk knowledge insight opinion james frankish and pica 6 https www gov uk government publications think autism an update to the government adult autism strategy 7 https assets publishing service gov uk government uploads system uploads attachment_data file 422338 autism guidance pdf 8 https assets publishing service gov uk government uploads system uploads attachment_data file 696667 think autism strategy governance refresh pdf 9 https www nice org uk guidance ng93 11

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2 METHODOLOGY of adaptations for people with behaviours that 2 Methodology challenge Additional design guidance is based This Guide is based on the mandatory on advice from the Foundation for Challenging framework for Disabled Facilities Grants set Behaviour and is drawn from Foundations down in the Housing Grants Construction website The cost benefits of adaptations for and Regeneration Act 1996 as subsequently people with behaviours that challenge is based amended through relevant Orders and on a research report published by the School General Consents It also includes details of Law at Leeds University and the children s of the Regulatory Reform Order 2002 which neurological charity Cerebra can be used to enhance the provisions of the HGCRA 1996 Reference is also made to other The Guide has benefitted from comments and legislation such as the Autism Act 2009 It has suggestions from families with a direct interest also drawn extensively on existing reports and in adaptations for people with behaviours studies all of which are referenced throughout that challenge and from professionals and the Guide organisations working with people with autism and or learning disabilities and delivering Case studies from practitioners and adaptations to meet their needs organisations working with people with autism and or learning disabilities and their families have been used to demonstrate how the legislation can be used to enable the funding 12

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3 DFG LEGISLATION AND GUIDANCE the legislation applies to adaptations in any 3 DFG Legislation and Guidance tenure the cost of adaptations to the homes of council tenants is met from the local housing Local housing authorities have a statutory duty authority s Housing Revenue Account and not to provide a Disabled Facilities Grant DFG to from the DFG budget provided by MHCLG disabled people to help meet the cost of a range Detailed guidance about how the Act should be of adaptations to their homes The legislative applied was published by the Home Adaptations framework for Disabled Facilities Grants is set Consortium HAC in 2013 and revised in down in the Housing Grants Construction 201510 and Regeneration Act HGCRA 1996 The purposes for which a DFG must be approved The purpose of a DFG is to enable disabled subject to the eligibility of the applicant and to people to continue to live independently safely the test of resources are defined in Section and well in their own home DFG legislation 23 of the HGCRA as amended The basic distinguishes between the applicant who is the legislation has been further expanded in a person who has a legal interest in the property number of Orders and Consents to be adapted and the disabled person for whose benefit it is proposed to carry out any Funding to meet the cost of DFGs is allocated relevant works The disabled person can be of by the Ministry of Housing Communities and any age Local Government MHCLG according to a national formula It should be noted that whilst 10 tium The HAC Guide describes the key principles Adams S 2013 Home Adaptations for Disabled People A Good Practice Guide Home Adaptations Consor 13

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3 DFG LEGISLATION AND GUIDANCE underpinning the DFG legislation and of a DFG is included in Section 100 1 of the states that the focus is on identifying and HGCRA and states that a person is disabled if implementing an individualised solution to enable a person living within a disabling home environment to use their home more effectively Their sight hearing or speech is substantially impaired They have a mental disorder or impairment rather than on the physical adaptation of any kind itself The social model of disability They are physically substantially disabled recognises that whilst people have physical sensory learning ability and psychological by illness injury impairment present since differences these do not have to result in birth or otherwise disability unless society fails to take account of these and makes the necessary adjustments to The HAC Guide contains further guidance ensure the inclusion of the individual regardless about the definition of disabled and refers to of those difficulties Section 1 6 This is the definition in the Equality Act 2010 which further elaborated in Section 1 8 The starting states that a person has a disability for the point and continuing focus of those seeking purposes of this Act if s he has a physical or to provide a high quality adaptations service mental impairment specifically referencing will be the experience of the disabled person people with autism in Section 7 47 8 which and their carers The appropriateness and has a substantial and long term adverse effect acceptability of the adaptation outcome should on their ability to carry out normal day to day be measured by the extent to which it meets activities the needs identified by that disabled person sensitively efficiently and cost effectively As the practice guidance issued in 2000 to the Children Act 1989 noted when houses are well 3 2 DFGs and Young People with Behaviours That Challenge adapted for a particular child the family s life can be transformed 11 The Disabled Facilities Grant Review12 carried out in 2018 noted that the number of grants 3 1 Definition of Disabled going to young people under the age of 20 is relatively small Over the last 10 years the The definition of disabled for the purposes percentage of grants for this age group has 11 https dera ioe ac uk 15599 1 assessing_children_in_need_and_their_families_practice_guidance_2000 pdf 12 Mackintosh S Smith P Garret H Davidson M Morgan G Russell R 2018 Disabled Facilities Grant DFG and Other Adaptations External Review University of the West of England 14

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3 DFG LEGISLATION AND GUIDANCE ranged between 6 6 and 8 5 Whilst these and mental health issues was not recorded trends reflect broader levels of disability in the UK it is likely that within this age group the As the DFG Review notes the DFG was focus is predominantly on young people with originally devised to solve physical impairment physical disabilities since as was also noted problems There needs to be better guidance in the Review the majority of DFGs 89 about the use of the DFG for mental health have been awarded to people with physical issues Better guidance is also needed for disabilities children s cases which are increasingly likely to be about learning disability autism spectrum The only information about the nature of disorders or behavioural issues p53 impairments comes from a Freedom of Whilst the number of adaptations for children Information request in 2017 It is simply a and young people with behaviours that snapshot in time and does not provide much challenge is still relatively small anecdotal detail It shows that most grant recipients evidence from occupational therapists indicates were identified as having a physical disability that the number of such referrals is growing as their primary impairment and only 11 Such cases are also likely to be complex and were recorded as having another principal the needs of the young person will change impairment Of that other group dementia and develop over time Teenage years and the sensory impairment and learning disability transition to adulthood may present additional were the main issues identified The number challenges of grant recipients who had multiple conditions 15

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3 DFG LEGISLATION AND GUIDANCE Section 23 1 b in such circumstances when 3 3 What Work Can Be Funded with a Mandatory DFG on appeal the court found that the purpose of providing a separate bedroom for D was to make the dwelling as safe as was reasonably practicable was a relevant purpose 13 A mandatory DFG must be awarded subject to a test of resources which does not apply to applications for children and young people It should also be noted that the HGCRA Section aged 19 or under who are in ordinary non 23 30 states that if in the opinion of the local advanced full time education for any relevant housing authority the relevant works are more works which meet one of the purposes laid or less extensive than is necessary to achieve down in the HGCRA Section 23 and which are any of the purposes set out in subsection 1 deemed both necessary and appropriate and they may with the consent of the applicant reasonable and practicable to carry out treat the application as varied so that the relevant works are limited to or as the case The list of relevant purposes for which a DFG may be include such works as seem to the must be considered is included in Appendix authority to be necessary for that purpose B Although typically these have focused on meeting the needs of people with physical It is the responsibility of the Housing Authority to disabilities many of the purposes will also decide if the relevant works are necessary and be relevant for people with behaviours which appropriate to meet the needs of the disabled challenge This may be particularly the case occupant However the HGCRA states that for adaptations which are identified that meet a local housing authority which is not itself a the purpose described in Section 23 1 b of social services authority shall consult the social making the dwelling safe for the disabled services authority S23 3 to determine what occupant and other persons residing with him works meet this criterion The Housing Authority her For example the provision of an additional must also confirm that it is reasonable and bedroom where a sibling may be at risk from practicable to carry out the relevant works As the behaviour of another sibling with behaviours is described in the assessment framework in which challenge may be considered necessary the Royal College of Occupational Therapist s and appropriate and therefore eligible for DFG publication Adaptations Without Delay 14 funding A legal case involving Calderdale adaptations for young people with complex Council helped to clarify the relevance of needs are likely to require specialist intervention 13 https www foundations uk com media 6350 calderdale appeal pdf 14 https www rcot co uk adaptations without delay 16

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3 DFG LEGISLATION AND GUIDANCE with the support of a professional occupational two 15 The occupational therapist s assessment therapist to identify the appropriate solution s should include a broad consideration of all the options working with the family to explore The HAC Guide states that when carrying out these in full This may mean for example assessments for people with learning disabilities considering ways to make the home generally or people with ASD that assessors and staff more accessible and safer in order to allow developing specifications should rely upon the a young person to move around and explore advice of specialist colleagues Section 7 42 safely rather than restricting adaptations to one and 7 48 and should also involve the person area Where a specialist sensory assessment needing the adaptation and their family and is required it may be possible to fund this from carers in the assessment discussions and the the DFG so long as the assessment is being decision making process Section 7 47 carried out by an occupational therapist with the necessary experience Any DFG funding for 3 2 Assessments such fees would not however be paid until after a DFG application had been approved Assessments for adaptations for a young person with behaviours that challenge should An assessment of what work is both necessary be holistic and involve multi disciplinary and appropriate should also consider the professional input in addition to contributions needs of parents and any siblings living at from the young person wherever possible home as behaviours that challenge can have and those who know the young person best a significant impact on the ability of the whole Although the needs of a child may change as family to continue to support a family member they grow early intervention is paramount to with behaviours that challenge This may be ensure the environment is adapted before the particularly relevant with regard to adaptations child young person or their family members which support someone with disruptive sleep are at significant risk of harm and there is patterns as this can and frequently does affect no minimum age below which an adaptation the whole family As the HAC Guide notes cannot be considered assessment of disabled children should take into account the developmental needs of the NICE Guideline NG 11 notes that when child the needs of their parents as carers assessing the need for adaptations the and the needs of other children in the family assessment will consider the person their Section 7 18 environment and the interaction between the 15 https www nice org uk guidance ng11 chapter 1 Recommendations 17

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3 DFG LEGISLATION AND GUIDANCE Creating A Safer Environment Assessment Background After looking at a range of options a Safespace was recommended for Thomas Thomas lives with his mum Moira and his The aim was to reduce the risk of injury and older sister in their family home Throughout promote good sleep hygiene by providing a his childhood Thomas experienced difficulty safe calming low sensory environment The sleeping and as he entered puberty this became flexible sides of the Safespace meant that more problematic At the age of 13 Thomas Thomas would be safe from hard surfaces and who has autism began to express increased reduce the risk of injury anxiety and present behaviours that challenge These included self injurious behaviours such Outcome as banging hard surfaces with his hands This meant he was no longer safe in an ordinary Following the installation of the Safespace room Thomas was prescribed Melatonin to funded with a DFG Thomas s sleep pattern help him settle at night and his family tried a significantly improved as he felt much more range of techniques to help him Despite this relaxed and was able to focus on going to he continued to struggle Thomas and his sleep without any distractions During the family were all suffering from sleep deprivation day he was also able to use the space to de and there was an increased risk of self harm escalate and self calm if he felt overwhelmed as Thomas entered his teenage years Moira The Safespace helped both Thomas and Thomas s mum explained Thomas would bang his family to effectively manage behaviours on the walls and the neighbours would just that challenge and improve the quality of life bang back for the whole family It also gave Thomas more independence as he transitioned into adulthood 18

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3 DFG LEGISLATION AND GUIDANCE bed soft washable flooring sensory lighting Reducing Risk radiator covers to prevent climbing and injury enclosing the television adapting all light Background switches and the fitting of a motion sensor The Abouzeid family were experiencing daily The works were funded with a Disabled challenges with one of their children who had Facilities Grant and with funding for equipment complex needs His behaviour was generally from the Council s equipment budget destructive and he was also at risk of falls from Outcome escalating behaviour involving climbing on household objects The family were concerned that their son s behaviour was becoming Following completion of the work Mrs Abouzeid more difficult to manage and that the risks to said The works have made a real difference him and other family members were likely to to our lives It was important that our son was increase as he grew older and stronger safe and the family were too and the grant has now given him a safe space to go when he has Assessment a crisis We thought it would be very clinical and like a hospital room but it isn t it s just like Following an assessment the following works a normal bedroom and one that will carry him were recommended by the occupational into adulthood safely there s not a surface in therapist upholstered washable walls a there he could hurt himself on secondary window an upholstered and safe 19

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3 DFG LEGISLATION AND GUIDANCE Further advice about relevant works which adaptation there may need to be consideration may be eligible for DFG funding is provided of any requirements under the Deprivation of in the HAC Guide Annexe C This includes Liberty Safeguards DoLs Note it has been adaptations designed to minimise the risk announced that DoLs will be replaced by Liberty of danger where a disabled person has Protection Safeguards in April 2022 behavioural problems which causes them to act in a boisterous or violent manner damaging the house themselves and perhaps other people Where such a need has been identified the DFG is available to carry out appropriate adaptations to eliminate or minimise that risk Annexe C Section 19 Other adaptations specifically mentioned include the provision of specialised lighting toughened or shatterproof glass or the installation of guards around certain facilities such as fires or radiators as may be cladding of exposed surfaces and corners to prevent self injury Annexe C Section 21 It should be noted that where an adaptation involves some degree of restriction of a person s independent movement there may need to be consideration of the person s best interest This could be relevant where for example a young person is prone to climbing out of windows and it is proposed to change window or door locking mechanisms to ensure their safety In such cases there may be a need to consider the balance of risks of the adaptations being carried out or not It should be noted that where the person concerned is 16 or over and lacks the capacity to give informed consent depending the nature of the 20

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3 DFG LEGISLATION AND GUIDANCE Provision of Additional Bathroom Toilet Facilities Assessment Background Christopher aged 19 lived with his parents The Council s occupational therapist and two siblings Christopher s parents recommended a second bathroom to be provided significant levels of care and support funded from a DFG in order to make the to enable him to continue to live in the family property safe for other members of the home Christopher was autistic and his family It was also noted that the stress that behaviours could sometimes be challenging Christopher s parents and siblings were including being physically aggressive towards other members of the family Christopher used to spend lengthy periods in the bathroom experiencing together with occasional violent confrontations meant there was a risk that the caring arrangement might breakdown which could last for up to three hours This which could result in Christopher needing to was a point of tension and stress as other members of the family could not always access the bathroom On occasions Christopher would physically assault other members of the family when he wanted to access the bathroom move to a supported living arrangement with an increase in care costs an outcome which neither Christopher nor the family wanted Outcome but could not because others were using it The family applied for a DFG for a second A DFG for a second bathroom was agreed bathroom This has enabled all members of the family to have safe access to bathroom and toilet facilities and reduced the risk of a breakdown of the caring arrangement 21

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3 DFG LEGISLATION AND GUIDANCE of a deep bath together with zonal lighting One Adapting a Bathroom set was in the toilet area the second over the wash basin and the third over the bath Joe s Background mum purchased 3 sets of different coloured light bulbs to compartmentalise each area Joe a 17 year old with complex needs lived with his mother in a 2 storey property The referral had been to look at alternative ways of Outcome bathing as the bathroom was upstairs but when Joe had a bath his vigorous movements caused Following completion of the adaptations funded the bath to overflow Moreover Joe s mum with a DFG Joe was able to continue to have was finding it difficult to get him in to the bath a bath and the use of the different lighting and she thought a level access shower would meant that mum could take more of a hands be more manageable for her and would also off approach and let the environment guide the minimise the risk of flooding activity Assessment The occupational therapist s assessment identified 2 key points a Joe really like to have a bath as it was an activity that he enjoyed and it helped to improve his mood b Joe s mum was finding it increasingly difficult to guide him into the bathroom to carry out activities of personal care especially as he was becoming bigger and stronger It was also observed that the frequent flooding of the bathroom floor was beginning to cause damage to the ceiling below The occupational therapist recommended the installation of a sealed floor and the provision 22

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3 DFG LEGISLATION AND GUIDANCE Multiple DFGs for the Same Household the property is too small The occupational Background additional bedroom above However the grant therapist recommended a two storey extension to provide a ground floor bathroom with an surveyor initially advised that the Council could The family home is a very small 2 bedroomed only consider a single DFG which would leave shared ownership property The family cannot a significant shortfall in costs which the family afford to move to a more suitable property and were unable to meet the local Council will not permit the family to Outcome apply for social housing waiting list as they have too much equity The family includes twins with different needs the first has a lower limb Each child was assessed separately for a DFG amputation and has spinal rods and the second as the assessments are made on the need of has ASD each individual not the household as a whole The statutory maximum grant is 30 000 per application so two separate recommendations Assessment can lead to two applications and two grants of The first twin was assessed as needing a up to 30k It should also be noted that land downstairs toilet and shower The sibling charges under the General Consent are also with ASD was assessed as needing his own per application so this approach could result in bedroom as he attacks his twin Swapping two separate land charges of up 10k each or dividing bedrooms was not an option as 23

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3 DFG LEGISLATION AND GUIDANCE 3 3 Funding of Equipment between them to decide how particular adaptations should be funded As the Circular The provision of equipment is usually the went on to note the key aspect is that there responsibility of social services and in some is an agreement between the respective areas it is common practice that the cost authorities to ensure that such adaptations of equipment which can be installed and are progressed quickly and to ensure that removed fairly easily with little or no structural the needs of the disabled person is the modification is funded by the social services overriding factor It should also be noted that authority It is also the case that Regulation 2 the legislation does not set out a minimum of the Community Care Delayed Discharges value for a DFG and there is no reason why a etc Act Qualifying Services England mandatory DFG for less than 1 000 should not Regulations 2003 provides that any community be approved especially where as is the case care equipment and minor adaptations for the for an adaptation for a disabled child or young purposes of assisting with nursing at home or person no test of resources is applied aiding daily living which a person has been 3 4 Discretionary Housing Assistance Policies assessed to need and for which he or she is eligible should be provided free of charge by the social services authority provided the cost is 1 000 or less It is therefore sometimes The Regulatory Reform Order 2002 gives assumed that equipment cannot be funded by a local authorities a general power to introduce DFG since the DFG is a capital grant However polices for assisting individuals with renewals the HAC Guide states that the provision of repairs and adaptations to their homes through some equipment will clearly contribute to the grants or loans In 2008 the government made purposes for which a DFG can be given a number of changes to the way the DFG was commonly the use of stairlifts Other equipment administered and the ways in which it could be particularly in the context of assistive used These changes included the relaxation technology and monitoring equipment may form and removal of the ring fence in 2010 part of a wider package of care contributed to allowing DFG monies to be used more flexibly by health and social care services Section and as part of wider strategic projects to keep 2 14 people safe and well at home so long as the spending still meets the definition of capital Earlier guidance on the DFG DOE Circular expenditure From 2008 09 the scope for use 17 96 advised that ultimately it is for housing of DFG funding will be widened to support authorities and social services authorities any local authority expenditure incurred under 24

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3 DFG LEGISLATION AND GUIDANCE the Regulatory Reform Housing Assistance illustrates the potential impact of such policies England and Wales Order 2002 RRO This will enable authorities to use specific DFG Discretionary housing assistance policies funding for wider purposes which may be more could also include other provisions which may appropriate for individuals than current DFG meet the cost of adaptations for people with arrangements allow 16 Over 90 of councils in behaviours that challenge For example this England have now developed a discretionary could include financial assistance with sound housing assistance policy proofing or sensory calming measures As with all discretionary powers housing Such policies may include general provisions authorities must exercise their power to which will be of benefit to people with fund additional adaptations rationally and behaviours which challenge A typical element reasonably It is unlawful for an authority to in such policies is the option to approve operate a blanket policy of refusing to make any discretionary assistance in excess of the discretionary payments to fund adaptations statutory maximum of 30 000 in England for each individual case must be considered a mandatory DFG This can be of considerable on its merits DOE Circular 05 2003 states benefit in considering adaptations where the that Authorities must also avoid fettering cost of the relevant works is likely to exceed their discretion to provide assistance noting 30 000 which is often the case for adaptations that whilst they can refuse an application for to meet the needs of people with complex assistance which falls outside their agreed needs Discretionary grants can also be policy they cannot refuse an application introduced to meet needs that are not included that is outside policy without there being a in the list of purposes for which a mandatory mechanism in place to determine such cases DFG can be given For example the provision The mechanism should ensure that exceptional of a sensory room may have a substantial cases that fall outside policy are individually impact on supporting the self management considered on a sound and informed basis and of the behaviour of a young person with ASD approved where appropriate Section 4 5 but is not a relevant purpose for which a mandatory grant can be given However such provision could be included in a discretionary assistance policy The case study on page 27 16 Disabled Facilities Grants The Package of Changes to Modernise the Programme https webarchive nationalarchives gov uk 20080305201417 http www communities gov uk documents housing pdf dfgpackagechange 25

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3 DFG LEGISLATION AND GUIDANCE 3 5 Other Relevant Legislation As a result of the Care Act 2014 Section 2 of the Chronically Sick and Disabled Persons Act CSDPA no longer applies to adults It does however continue to apply to children This requires local authorities to arrange practical assistance in the home and any works of adaptation or the provision of additional facilities designed to secure greater safety comfort or convenience for a disabled person Guidance issued by the Department for Communities and Local Government in 2006 states that local authorities have a duty to ensure that the assistance required by disabled people is secured This includes those cases where the help needed goes beyond what is available through DFG or where a DFG is not available for any reason or where a disabled person cannot raise their assessed contribution para 2 8 17 The RCOT Guide to Home Adaptations and the Care Act notes that Section 2 of the CSDPA is capable of covering the provision of major adaptations 18 17 Delivering housing adaptations for disabled people a good practise guide 2006 Department of Communities and Local Government 18 Mandelstam M 2016 Home Adaptations The care Act 2014 and related provision across the United Kingdom College of Occupational Therapists Specialist Housing Section 26

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3 DFG LEGISLATION AND GUIDANCE Provision of a Sensory Room the disabled person or others living with them then it would have met one of the purposes of the DFG and the cost could have been met by Background a mandatory DFG so long as it was deemed to A local authority was asked to support the cost be necessary and appropriate Alternatively this of adaptations for a child with a diagnosis of provision could have been funded from the DFG autism The child had a poor sleep pattern budget if it had been included in a discretionary and had behaviours that challenge including assistance policy self harming and hitting others including his siblings The family had requested additional space for a sensory room as the bedroom was too small for additional equipment and there were no other rooms which could be used for this Assessment An assessment had been completed by the Council s Behavioural Advisory Team and Children and Young People Support Team who supported the need for additional space Outcome The local authority decided that a mandatory DFG could not be awarded because a sensory room was not included in the mandatory DFG provision The case was subsequently closed by the occupational therapist as no funding could be identified However if the reason for the sensory room had been identified as making the home safer for 27

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4 COST BENEFIT 4 Cost Benefit noted that whilst the cost of the adaptations was met from housing budgets primarily the DFG In 2017 the School of Law at Leeds University budget with additional discretionary funding the and the children s neurological charity Cerebra consequent significant savings benefited health studied the cost effectiveness of home and social care budgets 19 adaptations averaging 60 000 each for six disabled children The adaptations were This reinforces the need to take a wider primarily designed to provide additional safe approach to identifying costs and the savings space including safe garden space The generated by expenditure on adaptations principal cost benefit was that the adaptations Adaptations should be seen as one element had avoided the need for the young people to of an integrated approach to the delivery of be taken into care services supporting wellbeing and independent living involving housing health and social care It was calculated that up to 14 years of local services Whilst the cost of adaptations may authority funds for care placements had been be substantial as in the example cited on the saved due to the adaptations The adaptations following page with potential costs of residential also reduced the pressure of caring on parents care exceeding 40 000 pa the alternative cost and had a significant impact on the well being to the public purse of a care placement can be of the young people s siblings The report also much more 19 Clements L and McCormack S 2017 Disabled Children and the Cost Effectiveness of Home Adaptations and Disabled Facilities Grants A Small Scale Pilot Study Cerebra and the School of Law Leeds University 28

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4 COST BENEFIT I don t think I had any Where adaptation costs are likely to be sleep for about two years because I was having to come into Hannah s bedroom and stop her harming herself from banging against the walls and furniture so I was like a zombie during the day Since having a Safespace I ve been able to get two part time jobs They are totally flexible so if Hannah isn t well I don t have to go to work but I could have never of taken those on if I was feeling before like it did before the Safespace Colin Sheffield significant it may be appropriate to develop a whole systems business case demonstrating future health and social care cost savings as part of an approach to agree joint funding for the proposed adaptations Ian and Karen s son Joshua aged 11 was awarded statutory and discretionary funding totalling 165 000 Significant adaptations included additional safe play space for their son padding to prevent injuries and a big bedroom allowing someone to sleep next to Joshua helping prevent self harm A safe outside play area was also provided Ian who left his job to look after his son said Joshua s school visits would include some costly overnight stays if we didn t have adaptations It is exhausting caring for Joshua We are struggling now with his behaviour and he will get bigger We look after Joshua because we love him but doing so reduces public spending and it s a strong argument for more families with autistic children to have funds to adapt their homes accordingly From the Cerebra Leeds University research study 29

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5 GENERAL DESIGN GUIDANCE 5 1 General Design Guidance The following elements which particularly focus on sensory issues may need to be considered when assessing adaptations required to meet the needs of someone with behaviours which challenge Acoustics Control acoustics to minimise background noise echo and reverberation to suit the individual and level of focus required Think about how to minimise the impact of the sound of repeated behaviours such as head banging 30

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5 GENERAL DESIGN GUIDANCE Lighting Adjustable and appropriate light levels which can provide a more calming relaxed environment e g ambient warm lighting which avoids harsh bright blue light Lighting may need to be robust and difficult to access e g downlighters recessed into ceilings and may need to be waterproof 31

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5 GENERAL DESIGN GUIDANCE Spacial Sequencing Design spaces in a logical order based on use to support routine and predictability Use oneway circulation so people can move between activities as seamlessly as possible with minimal distraction Compartmentalisation Organise a space or building into compartments with clear functions and sensory qualities which help define the use Separate spaces using furniture floor covering floor level or lighting 32

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5 GENERAL DESIGN GUIDANCE Escape Space Provide space for respite from the overstimulation of the environment This might be a small partitioned area a Safespace or crawl space in a quiet section of a room or building Make the sensory environment neutral and customisable 33

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5 GENERAL DESIGN GUIDANCE Transitions Using transition zones helps the individual recalibrate their senses as they move from one level of stimulus to the next These spaces may be anything from a distinct node that indicates a shift to a full sensory room Sensory Zoning Organise spaces according to their sensory quality This means grouping spaces into highstimulus and low stimulus areas with transition zones aiding the shift from one zone to the next 34

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5 GENERAL DESIGN GUIDANCE Safety Safety is especially key for people who may have an altered sense of their environment Alterations might include using hot water safety fittings and avoiding sharp edges and corners Inclusive Non institutional design with consideration to colour schemes patterns or not textures finishes and themes so as to create homely spaces that do not over stimulate and can provide differentiation between spaces if required as above 35

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5 GENERAL DESIGN GUIDANCE Foundations website https www foundations and neurodiversity fields It is expected to be uk com dfg adaptations adaptation design published in April 2021 guides by disability challenging behaviour includes advice from the Challenging Behaviour Neurodiversity a term which refers to variation Foundation with design considerations for in the human brain regarding sociability adaptations for people with ASD and behaviours learning attention mood and other mental that challenge functions and encompasses people with autism or learning disabilities is currently referenced It should also be noted that the Building in the current BS8300 Design of an accessible Standards Institute BSI in its role as the UK and inclusive built environment National Standards Body is developing a new project to create the first set of guidance for the design of the built environment to include the needs of people who experience sensory and neurological processing difficulties and or differences This includes neurodivergent neurodegenerative and other neurological conditions which may affect sensory processing and mental wellbeing The fast tracked standard PAS 6463 Design for the mind Neurodiversity and the built environment Guide will provide information for designers planners specifiers facilities managers and decision makers on particular design features which can make public places more inclusive for everyone in particular by reducing the potential for sensory overload anxiety or distress It will address sensory design considerations including lighting acoustics flooring and d cor The standard will be developed by a steering group of experts in the built environment transportation planning 36

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6 CONCLUSION 6 Conclusion also make sense financially As was stated at the beginning of this guide By helping to avoid unnecessary admissions everyone wants to be able to live safely to residential care appropriate use of DFG independently and well in their own home budgets not only delivers better outcomes for However for many people with autism and people with autism and or learning disabilities or learning disabilities their home environment and their families but can do so whilst at the can be disabling and can present significant same time delivering better value for money for difficulties for a person with major sensory local authorities processing issues These challenges have been compounded by the additional pressures created by the covid pandemic when people are having to spend more time than previously at home What this guide has shown is that effective and creative use of DFG budgets can make a significant impact on the lives of people with autism or learning disabilities as well as on the lives of their families and carers Such an approach can 37

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7 FURTHER INFORMATION Useful Resources 7 Further Information Home Adaptations for Disabled People A Useful Websites detailed guide to related legislation guidance Newlife Foundation https newlifecharity and good practice Home Adaptations co uk Consortium Safespaces https www safespaces co uk Adaptations without delay A guide to planning and delivering home adaptations differently Contact a Family https www contact org uk Royal College of Occupational Therapists Fledglings https fledglings org uk Making Homes That Work A Resource Guide for Families Living with Autism Spectrum Disabled Living Foundation https www dlf Disorder Co occurring Behaviours George org uk Braddock Creative Housing Solutions LLC John Rowell Rowell Brokaw Architects PC The Challenging Behaviour Foundation 2011 https www challengingbehaviour org uk Autism Friendly Design National Autistic National Autistic Society https www autism Society org uk Managing Behaviour that Challenges and 38

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7 FURTHER INFORMATION Creating Safe Environments Heather Scott Anne Eddison Presentation to the RCOT Specialist Housing Section February 2016 Living in the Community Housing Design for Adults with Autism Helen Hamlyn Centre Royal College of Arts 2010 39

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8 FURTHER CASE STUDIES from their mother but also the wider multi Enabling Settled Sleep disciplinary information and support from other agencies including a specialist health visitor a Background paediatrician an educational psychologist and a paediatric Occupational Therapist Peter and Paul are twins with autism who are non verbal and presented with behaviours that Outcome challenge including aggressive tendencies towards each other anxiety and an inability to cope with sensory over stimulation Their Following provision of the Safespace equipment primary carer was their mother a single parent funded with a DFG the twins developed with two other children who also lived in the much better sleep patterns their aggressive family home All were suffering from extreme tendencies were reduced and their sensory sleep deprivation and there was a serious anxieties were able to be effectively managed risk of family breakdown putting the caring Social care was able to reduce costly specialist arrangement at risk child minder provision and their mother and their siblings experienced a significantly improved quality of life Assessment The twins were assessed as needing a bedroom adaptation involving the provision of two Safespace type products within the bedroom for each boy The purpose was to enable both boys to have separate spaces to sleep safely within the bedroom This would limit the risks of self harm should they wake up in the night and also provide an environment which promotes calmness minimising stimulation and noise to support self soothing The assessment and subsequent recommendations took into consideration not only the observable needs of the boys during the assessment visit and information gathered 40

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8 FURTHER CASE STUDIES Provision of Wet Floor Shower Closomat and Air Cooler for Bedroom His mother and sister felt unable to cope with Oliver s outbursts as he has grown older and bigger but wanted him to remain at home if solutions could be found Background Assessment Oliver is a teenager with autism who lives with his mother and sister in a maisonette with no A multi disciplinary assessment took place at access to private safe outdoor space The school with his mother sister teacher and staff maisonette had a small bathroom with a bath from his respite placement to discuss how to which they did not use as the room was so meet his needs It was observed that he enjoys cold because the existing sash window would playing in the wet room at his special school not close and the Housing Association would and they report it calms him and he would not replace fix it or replace it His mother was seek out time there when he was becoming struggling to wash him in a small raised shower dysregulated His mother reported he dislikes cubicle being hot and becomes more agitated He has recently had a residential placement where Oliver is non verbal and can be extremely he continued to use the shower room to calm violent when he becomes anxious He cannot which in turn reduced his angry outbursts manage PECS or any other communication An air cooler for his bedroom was also system His only interest at home was the iPad suggested as a way to calm him in his bedroom but when it ran out of power he would get as the Safespace could be hot especially in the angry as he was unable to understand why summer He had no other activity to participate in and would become anxious and lash out smashing Outcome walls and occasionally injuring his mother Lack of space and problems with regulating A wet floor shower room was provided so his room temperatures exacerbated his anxiety mother could assist wash him with greater Previously a Safespace had been installed ease but also so he had a place to go when so that Oliver would have somewhere to go he felt agitated and dysregulated to play and when he became agitated This was partially calm himself This has given him another successful and assisted him to go to sleep activity at home and has significantly reduced although he often wakes after a few hours his aggressive outbursts Because the water 41

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8 FURTHER CASE STUDIES temperature is thermostatically controlled Oliver s mother did not have to worry about him scalding himself and the newly installed UPVC double glazed window was safe if he hit against it A closomat was also provided to reduce the need for his mother to wash him after bowel movements The adaptations have enabled him to remain at home and for his mother and sister to feel safer The cost of the adaptations was 17 200 00 including fees By contrast the cost of a residential placement if Oliver had been unable to continue to live at home would have been at least 3 500 00 per week meaning that the payback time for the adaptations was less than five weeks 42

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9 APPENDIX 9 Appendix persons residing with him Housing Grants Construction and Regeneration Act 1996 Section 23 c facilitating access by the disabled occupant to a room used or usable as the principal family room Disabled Facilities Grants purposes for which grant must or may be given d facilitating access by the disabled occupant 1 The purposes for which an application to or providing for the disabled occupant a for a grant must be approved subject to the room used or usable for sleeping provisions of this Chapter are the following a facilitating access by the disabled occupant e facilitating access by the disabled occupant to and from to or providing for the disabled occupant a i the dwelling qualifying houseboat or room in which there is a lavatory or facilitating caravan or the use by the disabled occupant of such a ii the building in which the dwelling or as the facility case may be flat is situated f facilitating access by the disabled occupant b making to or providing for the disabled occupant a i the dwelling qualifying houseboat or or room in which there is a bath or shower or ii the building both or facilitating the use by the disabled safe for the disabled occupant and other occupant of such a facility 43

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9 APPENDIX g facilitating access by the disabled occupant 3 1 Subject to the provisions of Chapter 1 of to or providing for the disabled occupant a Part 1 of the Act an application for a disabled room in which there is a wash hand basin or facilities grant must be approved where the facilitating the use by the disabled occupant of application is for the purpose specified in such a facility paragraph 2 2 The purposes are h facilitating the preparation and cooking of a facilitating access to and from a garden by a food by the disabled occupant disabled occupant or b making access to a garden safe for a i improving any heating system in the dwelling disabled occupant qualifying houseboat or caravan to meet the Images needs of the disabled occupant or if there is no existing heating system there or any such system is unsuitable for use by the disabled Unsplash occupant providing a heating system suitable Cover p 33 Credit to photographer Nathan to meet his needs Dumlao p 2 Credit to photographer Jay Mullings j facilitating the use by the disabled occupant of a source of power light or heat by altering p 7 p 18 p 29 Credit to photographer Roy McNally the position of one or more means of access p 12 Credit to photographer Caleb Woods to or control of that source or by providing p 19 Credit to photographer Tanaphong additional means of control Toochinda k facilitating access and movement by p 20 p 37 Credit to photographer Kelly the disabled occupant around the dwelling Sikkema qualifying houseboat or caravan in order to p 21 Credit to photographer Matthew Tkocz enable him to care for a person who is normally p 22 Credit to photographer Thomas resident there and is in need of such care Despeyroux p 23 Credit to photographer Ralston Smith The following purposes were added in p 27 p 34 Credit to photographer Markus the Disabled Facilities Grants Maximum Spiske Amounts and Additional Purposes p 28 Credit to photographer Jennifer Araujo England Order 2008 p 30 Credit to photographer Dan Smedley 44

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9 APPENDIX p 31 Credit to photographer Abdullah Ahmad p 32 Credit to photographer Hugues de Buyer Mimeure p 35 Credit to photographer Sigmund p 38 Credit to photographer Sandy Millar p 43 Credit to photographer Paul Siewert Back Credit to photogrpaher Lukas Skoe Creative Commons p 13 Credit to photographer Alex Peppehill Houses on Beresford Street in Moss Side after redevelopment as part of the Infusion Homes development is licensed under CC BY ND 2 0 Safespaces p 26 p 40 Credit to Safespaces Please note that all case studies have been anonymised and names have been changed All photos have been used with permission 45

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Trading as Foundations Collective Enterprises Limited Company no 02131825 Astral PS Limited Company no 07818356 22 Norfolk Street Glossop Derbyshire SK13 8BS 0300 124 0315 info foundations uk com info filt org uk Foundations April 2021