A tool that ensures care is safe, clean and personal every time was adapted for learning disability settings, leading to improvements in care.

Jo Penney (UK) and Jim Blair (UK)

12 October, 2020


A tool that monitors whether care is safe, clean and personal every time originally evolved from the nursing assessment and accreditation system, and was recently adapted for use by a learning disability service in Guernsey. The tool includes questions about different standards of a department’s care; the answers are used to assign a colour to a department to denote its quality. Audits are carried out regularly, and where parts of the learning disability department have areas for improvement they have changed them quickly as a result. Staff feedback is positive and there are plans to formulate bespoke, autism-specific questions for a newly opened local centre.

Citation: Penney J, Blair J (2020) Adapting a care quality tool for use in learning disability services. Nursing Times [online]; 116: 12, early online publication.

Authors: Jo Penney is a quality improvement manager, States of Guernsey Health and Social Care; Jim Blair is learning disability adviser, States of Guernsey Health and Social Care, and associate professor of learning disability nursing (Hon), Kingston University and St George’s, University of London.

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The widely quoted idea of American firearms instructor and author Jeff Cooper that “safety is something that happens between your ears, not something you hold in your hands” is also at the core of what it means to have a safe culture in care. It is essential to continually reflect on how care can be improved to ensure it is safe, clean and personal every time (SCAPE); this article discusses a project to do this for learning disability care in the Bailiwick of Guernsey.

The idea of ensuring care is SCAPE was originally devised in 2008 by Salford Royal NHS Foundation Trust. It now forms part of the States of Guernsey’s (2016) Care Values Framework 2017-2020, which comprises six key principles that guide developments in health and social care in Guernsey (Box 1), fitting most comfortably within principle two: to deliver safe and effective, harm-free care.

Box 1. Key principles of Guernsey’s Care Values Framework

  • Promote a culture of courage and compassion
  • Deliver safe and effective, harm-free care
  • Support research, innovation and evidence-based practice
  • Build and strengthen care providers’ leadership at all levels
  • Have an empowered, accountable and skilled workforce
  • Deliver high-quality, effective and integrated care

Source: States of Guernsey (2016)

This article charts the use of a SCAPE tool, discussing the issues faced,  solutions and plans for the future.

What is SCAPE and why was it implemented?

SCAPE evolved from the nursing assessment and accreditation system (NAAS) framework, which measures the quality of nursing care delivered by individuals and teams. The framework was constructed to enable nurses to understand how they deliver care, identify what works well and where further improvements are needed; as far as possible, it matches Care Quality Commission standards and aligns with relevant national learning disability best practice.

Salford Royal NHS Foundation Trust incorporated an adapted version of the NAAS into a SCAPE tool; this helped it achieve an Outstanding rating from the CQC (2018). A SCAPE tool was developed, not just to be used in nursing or an acute hospital setting, but as a broader approach to explore how care is considered, delivered and evidenced in relation to quality (NHS Improvement, 2019). It focuses on how care impacts those who deliver and receive it. NHSI’s (2019) guide on ward and unit accreditation programmes mentions Salford’s SCAPE tool.

Quality of care is vital, but defining it is problematic because it means different things to different people and can vary depending on: gender; religious beliefs; education; ethnicity; cultural, spiritual, economic and social experiences – all of which help us define the world around us (Blair, 2010). In essence, high-quality care involves a degree of excellence; for a service to be deemed ‘high quality’, the stated aims of support, care and treatment must be achieved to a high standard and service users must be treated with dignity, respect and compassion. Those providing care must continually keep abreast of care developments and best practice.

The drive to embed such quality was at the core of Guernsey’s Adult Disability Services (ADS) – part of the island’s Health and Social Care. It adopted and adapted the SCAPE tool to ensure it was providing high-quality, evidence-based support to people with learning disabilities.

Adapting the SCAPE tool

There are approximately 250 adults with a learning disability known to the local ADS in Guernsey, out of a population of 63,276. ADS required a reliable, objective tool that would:

  • Provide evidence of care quality;
  • Enable practice developments and improvements;
  • Measure essential care and specialist learning disability care;
  • Be adaptable to suit various settings, including residential, the outreach teams, Community Learning Disability Team, short-break service and day services.

Guernsey operates an integrated Health and Social Care department: it does not fall under the remit of the NHS or CQC. As the Salford SCAPE tool was already being used by the island’s acute general hospital across a range of services, we decided to adapt it for use in the learning disability service.

The SCAPE tool uses a list of questions divided into different standards, each based on an area of a department’s work. The Guernsey acute hospital’s tool has 15 standards (Box 2); these were adapted for ADS. The tool is split into sections, with staff focusing on different sections, looking at documentation, observing practice, talking to service users and holding discussions with a manager; they mark ‘yes’, ‘no’ or ‘not applicable’ to each question. When the audit is finished, the scoring is analysed and the area given an overall status of red, amber or green; blue (excellent) can be achieved if certain criteria are met.

Box 2. SCAPE standards at Guernsey’s acute hospital

  • Organisation and management of the clinical area
  • Safeguarding patients
  • Pain management
  • Service-user safety
  • Environmental safety
  • Nutrition and hydration
  • End-of-life care
  • Medicines management
  • Person-centred care
  • Tissue viability
  • Elimination
  • Communication
  • Infection control
  • The Nursing and Midwifery Council’s (2018) code
  • Dementia care

SCAPE = safe, clean and personal every time. Source: States of Guernsey (2016)

Professionals were asked to volunteer if they wished to be involved in the project to adapt the acute hospital’s SCAPE tool. Two learning disability nurses joined a working group led by the practice development lead, along with a member of the quality and safety team that supported the learning disability service. As the tool was already in use in the acute hospital, the project lead joined existing SCAPE teams to see how it was used in practice; this gave useful insight into the changes required.

The working group revised the acute hospital’s SCAPE, removing all elements that were not relevant to learning disability practice; as an example, the word ‘patient’ was replaced with ‘service user’. Three new standards were also added that are specific to learning disability settings:

  • Epilepsy care and treatment;
  • Hospital care for people with learning disabilities;
  • Healthcare for people with learning disabilities.

The new epilepsy standard was based on the National Institute for Health and Care Excellence’s (2012) guideline but, at the time of development, no national standard could be found to provide guidance for a health action plan, hospital passport, annual health check or person-centred plan; these are widely used in learning disability services. Instead, evidence was used to direct best practice for these elements.

Guernsey’s acute hospital introduced ‘red questions’ to the SCAPE tool; if ‘no’ was answered to one of these, the standard would automatically score red no matter what the answers were to other questions in that section. These ‘red questions’ were changed for the new tool so it  focused on learning disability, for example:

  • Has the service user had a person-centred plan within the last year?
  • Has the service user attended an annual health check in the last 12 months?
  • Has a dysphagia risk-screening tool been completed for the service user and the declaration at the end been completed and signed? Are staff following the speech and language therapist/occupational therapist’s advice for dysphagia management?
  • If the service user has a behaviour support plan, does the service area complete a monthly fidelity check to enable it to analyse whether staff are correctly following it?
  • Do staff understand when the hospital passport should be used?

Departments in the acute or older adult settings were already using SCAPE; some had achieved blue status (Table 1) and these managers were invited to give presentations to all senior ADS staff. This allowed staff to ask how SCAPE would influence practice and how to prepare. The then-deputy chief nurse and quality and safety team member, who led on the acute hospital’s SCAPE and had extensive knowledge on the topic, also explained the process to senior staff in the learning disability service.

Table 1.  SCAPE result and corresponding status

SCAPE result                                                                                                Status

5+ red standards                                                                                           Red

2-4 red standards and/or                                                                              Amber

10+ amber standards                                                                                    Amber

1 red standard in total. Must also have <10 amber standards                     Green

3 consecutive green SCAPE audits                                                             Blue (area of

0 red standards in the latest audit                                                               excellence)

0-4 amber standards in the latest audit

SCAPE panel presentation for new Blue SCAPE status

SCAPE = safe, clean and personal every time

After initial changes were made to the tool, it was sent to all managers so they could discuss it with their teams and feed back any concerns or changes. The tool was then piloted during 2017, with one area using the official SCAPE process – all departments are given notice of the date and time of an upcoming audit but not told which department is being audited until 24 hours beforehand. After the pilot, some minor changes were made to the tool before it went live in 2018.

Implementing the new SCAPE tool

The tool was used throughout 2018, and 10 areas were audited across various settings:

  • Four residential homes;
  • A day service;
  • A short-break service;
  • Two outreach services;
  • A supported-living service;
  • A community learning disability team.

The audit team comprised the practice development lead, quality and safety representative (a learning disability nurse) and two volunteers; the volunteers differed each time to improve staff members’ understanding of the process, allow them to familiarise themselves with giving and receiving feedback, and enable them to learn about good practice from other departments. No one audited their own area or one with which they might have close ties (some areas share the same manager). Throughout 2018, the practice development lead or quality and safety representative were on the team to provide consistency and support less-experienced auditors. For the first two audits, an extra quality and safety representative with considerable experience of acute services SCAPE was used.

Overall, the tool was well received and a range of scores was achieved. All areas received an action plan of elements they could improve.

The tool was reviewed for 2019 and some staff suggested removing standards they felt were not relevant to their work, such as tissue viability. However, best practice was, again, followed and recent reports were presented to the service manager to consider as evidence to retain certain questions in the audit.

A section on positive behaviour support was added to the 2019 tool. This is a multidimensional framework used to understand a person’s challenging behaviour based on an assessment of their physical and social environment, and the broader context in which that behaviour occurs. Including stakeholder perspectives and involvement, it is used to create, implement and evaluate the effectiveness of a personalised and enduring support system that enhances quality-of-life outcomes for the person and other stakeholders (Gore et al, 2013; Dunlop and Carr, 2007).

In reviewing SCAPE, feedback was also sought from staff. Their comments illustrated the central role quality plays and the impact the tool was having on care:

SCAPE has enabled the adult disability service [to] keep up to date with best practice and standards, in line with the UK’s Care Quality Commission requirements. SCAPE has made us more aware of what quality care should look like and supports us in being reflective practitioners.” (Deputy service manager).

“[SCAPE] ensures all our services are universal and keeps standards high.” (Service manager).

The learning disability SCAPE tool continued to be used throughout 2019, with 10 areas audited. It was adapted to create a version to suit the community learning disability team, which includes topics such as wait times and outcomes, and was adjusted for 2020 to ensure it remained effective, robust and high quality.

Outcomes and future plans

SCAPE highlights aspects of care that can be improved, such as those in the following examples, which have been taken from the audits conducted in 2019:

  • At the beginning of the year, one area was shown to have a low uptake in reviewing positive behaviour support plans. When re-audited at the end of the year, it had 100% compliance in reviewing the plans for all open cases;
  • One area’s audit highlighted concerns about the environment. With support from senior management, additional resources and administrative staff were allocated to help with archiving and tidying. The area was redecorated and more sensory equipment purchased. When re-audited four months later, it achieved an improved status;
  • Audits revealed a lack of compliance in the accommodation, short-break and day-service teams completing dysphagia risk-screening tools for all service users. A red question was added to the SCAPE tool to cover this, and audits at the end of the year showed an increase in compliance; according to the 2020 audits, this has continued.

A bespoke autism hub opened in Guernsey in late 2019, so we plan to devise specific SCAPE questions to include best-practice autism support. It is also hoped many other areas outside of Guernsey will build on our experiences and use, adapt and develop the SCAPE tool to ensure effective, safe, dynamic and quality-driven care is delivered in all settings.

Guernsey has no care regulator so all services must be assured they are delivering safe, high-quality care – the learning disability SCAPE tool has made this possible. Safety and quality must be the bedrock of every care interaction and the heart of service evolution.

Key points

  • Ensuring care is safe, clean and personal every time evolved from the nursing assessment and accreditation system
  • A tool was developed that uses various approaches to measure care, then assigns the relevant health or care department a traffic-light status denoting its quality
  • A working group adapted the tool for use in learning disability settings, then piloted and implemented it
  • Areas that received a poor result have improved quickly, and staff feedback is positive


Blair J (2010) Service quality. In: Talbot P et al (eds) Key Concepts in Learning Disabilities. Sage.

Care Quality Commission (2018) Salford Royal NHS Foundation Trust: Inspection Report. London: CQC.

Dunlop G, Carr EG (2007) Positive behaviour support and developmental disabilities: a summary and analysis of research. In: Odom SL et al (eds) Handbook of Developmental Disabilities. Guilford Press.

Gore N et al (2013) Definition and scope for positive behaviour support. BILD, International Journal of Positive Behaviour Support; 3: 2, 14-23.

National Institute for Health and Care Excellence (2012) Epilepsies: Diagnosis and Management. London: NICE.

NHS Improvement (2019) Guide to Developing and Implementing Ward and Unit Accreditation Programmes. London: NHSI.

Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.

States of Guernsey (2016) The Care Values Framework 2017-2020. St Peter Port: States of Guernsey.

This article was originally published in the Nursing Times, December 2020 Vol 116 Issue 12. It is reproduced here with kind permission of the Nursing Times. For further articles on learning disabilities nursing visit: https://www.nursingtimes.net/roles/learning-disability-nurses/