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Supporting positive outcomes in children’s residential care

August 2024

Written by Dr Kat Deerfield and edited by Dr Eleanor Johnson and Dr Grace Krause

In this evidence summary, we highlight relevant and up-to-date research on how residential care can be delivered in a way that supports positive outcomes for children and young people.

The removal of private profit from children’s care is changing the landscape of residential care in Wales. This summary focuses on evidence about how best to deliver children’s residential care so that children and young people have positive experiences. We also highlight research that focuses on what children and young people say they want from their home life in residential care.

Introduction

Residential children’s care in Wales is changing. Welsh Government has announced plans to eliminate profit from the care of children who are looked after (Welsh Government, 2022). The end of for-profit provision has led to discussions about how best to provide residential care to children who are looked after. This evidence summary looks at the research on good practice in children’s residential care, exploring what factors are important for making these services work for children and young people.

There are lots of ways of running children’s residential care services. Different services will adopt specific approaches, frameworks, or models of care to guide their work. In research and practice, the terms ‘approach’, ‘framework’, and ‘model’ are used inconsistently, and sometimes interchangeably, and it can be difficult to know the differences between them (Macdonald et al., 2012). The term ‘model’ is used in a Social Care Institute for Excellence report on therapeutic approaches in children’s residential care in the general “sense of ‘approach’ or ‘programme’” (Macdonald et al., 2012). This is how we use the term ‘model’ in this evidence summary.

There are lots of models of children’s residential care with some research evidence about what makes each model work. Many of these models have to be purchased by organisations that use them. In some cases, details of the models are not publicly available, which can make it harder to find the research evidence the models are based on. Also, the amount of research supporting individual models varies a lot (Cordis Bright, 2018). In this summary, we look at evidence that’s relevant to care delivery regardless of which model is used. Rather than looking at specific models, we’ve focused on what different models of children’s residential care have in common. We explore the evidence on what elements of children’s residential care promote positive outcomes for children and young people, regardless of which model is being used. Lots of research on children’s residential care also focuses on specific treatment models or approaches to trauma-informed working. Our evidence summary on trauma-informed approaches (Cordis Bright and Taylor-Collins, 2024) looks at the research on this topic more broadly.

In this evidence summary, we explore the research on children and young people’s experiences of their home environment in residential care. It highlights the importance of creating a space where children and young people feel safe, comfortable, and at home.

Children’s residential care in Welsh legislation and guidance

In March 2023, there were 7,208 children looked after by local authorities in Wales, 10 per cent of whom lived in some form of children’s residential care (Welsh Government, 2023). There are several pieces of legislation that regulate the care of children who are looked after.

United Nations Convention on the Rights of the Child (UNCRC)

Wales made the UNCRC part of its domestic law in 2011 in the form of the Rights of Children and Young Persons (Wales) Measure 2011. The Measure clarifies that Welsh Government must have ‘due regard’ for the UNCRC in all its policies. The Convention states that all children have the right to have decisions made in their best interest and have the right to have a say in decisions that concern them.

Social Services and Well-being (Wales) Act 2014

The Act regulates provision for children who are looked after, including care and support planning and the placements in which they should be accommodated. The Act also regulates how cases should be reviewed and what arrangements should be made when young people leave care.

Health and Social Care (Wales) Bill 2024

The Health and Social Care (Wales) Bill 2024 intends to eliminate private profit from the care of children who are looked after. If implemented, from April 2026 all new providers of children’s residential care will be required to have not-for-profit status. Existing for-profit providers would need to transition to not-for-profit status by April 2027.

The Bill will have far-reaching consequences in terms of restructuring provision for children who are looked after. In 2022, over 80 per cent of care homes for children and young people in Wales were run by the private sector (Welsh Government, 2022). The move to not-for-profit care will therefore mean a significant change to the landscape of children’s residential care across the country.

Scotland has also made policy changes to remove profit from the care of children who are looked after, following the Independent Care Review (2020). This review emphasised that all profit should be reinvested into children’s care. Here in Wales, The Health and Social Care (Wales) Bill 2024 also aims to make sure that public money invested in the care of children who are looked after doesn’t profit individuals or businesses.

Moving to a not-for-profit system aims to improve outcomes by changing how money in the residential care system is spent. Welsh Government (2022) proposes that money spent on children’s services that currently ends up as profit will instead be reinvested to:

  • deliver better experiences and outcomes for children and young people
  • support service development and improvement
  • further the professional development of staff.

There are other considerations involved in a move away from for-profit provision. There’s evidence that some children feel uncomfortable being part of a ‘market’ system (Children’s Commissioner for Wales, 2021). There’s also mixed evidence about the quality of care provision. Some research suggests that the quality of provision by local authorities and private providers is similar (Competition and Markets Authority, 2022). But some research finds higher quality and better outcomes in not-for-profit provision (Ablitt et al., 2024). There’s evidence that not-for-profit residential care homes have lower staff turnover rates, fewer placement moves, and fewer out-of-area placements than homes managed by large companies (Ablitt et al., 2024).

What research says about models of children’s residential care

The shift to not-for-profit care creates opportunities to change and develop provision in a way that’s informed by research evidence. There are lots of models of residential care that have different perspectives and structures. Not all of these are supported by clear research evidence, so it can be hard to say how well every model works or how models compare to each other (Bailey et al., 2019; Cordis Bright, 2018). Rather than describing individual models, this summary focuses on the characteristics of residential care that can support positive outcomes for children and young people.

In our analysis of the research evidence on children’s residential care we’ve identified several positive features that are shared across multiple models. These include:

  • therapeutic approaches to supporting children and young people (Macdonald et al., 2012; Parry et al., 2023)
  • training and support for staff (Cordis Bright, 2018; Parry et al., 2023)
  • having an appropriate location and supporting children and staff’s connections with the local community, education, and parents and carers where appropriate (Montserrat et al., 2022; Sommerfeldt, 2022; Children’s Commissioning Consortium Cymru, 2024)
  • a safe and welcoming home environment (Allcock, 2019; Children’s Commissioning Consortium Cymru, 2024; Johnson, 2016; Sommerfeldt, 2022)
  • consistency and continuity of care (Cordis Bright, 2018; Park et al., 2020).

Therapeutic approaches in residential care

Children and young people living in residential care have often experienced complex trauma (Macdonald et al., 2012; Parry et al., 2023). They may also have complex emotional, behavioural, and mental health needs, sometimes because of previous neglect and trauma or disrupted relationships (Parry et al., 2023).

Therapeutic residential care refers to residential care that’s built on insights from psychology or models of delivering therapy. These models are often designed around goals like building competencies, understanding children’s behaviour better, or building stronger relationships (Macdonald et al., 2012). Some therapeutic residential care settings are also designed in a trauma-informed way. More information on what this means can be found in our evidence summary on trauma-informed approaches (Cordis Bright and Taylor-Collins, 2024).

Research shows that therapeutic residential care promotes a healing environment for children with needs requiring complex support, regardless of the specific model that a setting uses (Macdonald et al., 2012; McNamara, 2020). It can provide children and young people with an opportunity to heal from trauma and it aims to improve outcomes related to emotional well-being and mental health (Macdonald et al., 2012). More research is needed to explain the positive impact that therapeutic approaches can have on the lives of children living in residential care and which elements of these approaches are most important. A lot of research focuses on individual therapeutic models, without much clarity about what makes them different to each other or why one approach might be more appropriate than another in a particular situation (Bellonci and Holmes, 2021; James, 2011). Many of these models were developed and are owned by for-profit providers, and some of them are supported by more research evidence than others (Bellonci and Holmes, 2021; Cordis Bright, 2018).

Secure children’s homes use therapeutic approaches because children in these placements are likely to have experienced multiple and/or complex trauma. A secure children’s home is a type of children’s residential care that’s intended to be used when there’s a high risk that a child or young person will harm themselves or others. Children are also placed in these homes because of welfare concerns where other placements aren't considered safe enough (Williams et al., 2024). As of March 2024, 46 per cent of secure children’s home placements in England and Wales were made on welfare grounds. This means that there are concerns that a child needs to be protected from harm by others, rather than because a child is considered to be at risk of harming themselves or others (Department for Education, 2024).

Secure residential care is intended to be short term, because there are legal limits on restricting children’s autonomy. We don’t have enough evidence on the effectiveness of the therapeutic approaches used in these settings. Practitioners report that the short time frames of placements in secure residential care settings are a hindrance to therapeutic progress (Williams et al., 2024). They can also make it difficult to engage effectively with other agencies providing mental health and welfare support. Research also highlights the importance of suitable placement options being available, so that each child placed in a secure children’s home on welfare grounds can have their individual needs met (Williams et al., 2024).

Training and support for staff

There’s limited research available on the support and well-being of children’s residential care staff (Parry et al., 2021). But research does show that there’s a mutually beneficial relationship between positive outcomes for children living in residential care and the well-being of the staff working with them (Parry et al., 2021). This research finds connections between positive outcomes for children and job satisfaction and the likelihood of staff experiencing burnout.

The model of care used by a setting can also affect how staff are supported and trained. For example, a number of therapeutic models involve structured, ongoing supervision for staff. Evaluations of these models show that staff see supervision as a valuable source of support (Cordis Bright, 2018).

Our evidence summary on improved well-being and workforce retention provides further information on how employers in social care can support employee well-being (Urban Foresight and Deerfield, 2024).

Location, connection, and community

A key aim of the changes to children’s residential care is for more children and young people to remain closer to home, when it’s safe for them to do so. This means they can continue to be connected to any existing support networks (Welsh Government, 2021).

Connection to the community is a vital part of ensuring positive outcomes for children and young people living in residential care settings. Building these connections may have been particularly challenging in the last few years following measures imposed as part of the COVID-19 pandemic response. We don’t have much evidence on the impact of this on the experiences of children living in residential care in Wales. However, a Spanish study found that 11 to 14 year olds living in residential care gave lower satisfaction ratings for both ‘friends and classmates’ and ‘location of home’ in a 2020 survey compared to a 2014 survey. The research team suggested this change was related to the impact of measures limiting social interaction and children’s access to the local area more generally (Montserrat et al., 2022).

Research with children and young people shows that the location of a home and how it’s connected to the surrounding community is very important. Sommerfeldt (2022) found that children and young people were much more positive about homes that looked like ‘normal’ houses rather than ones that looked more institutional. If it stood out from other buildings in the community, it might be more obvious to others that they were living in a children’s residential home (Sommerfeldt, 2022).

Research by the Children’s Commissioning Consortium Cymru (2024) found that the best location for a home depends on each child’s individual needs and wants. For example, while some children don’t like living in a rural area because they feel isolated, others may feel unsafe living in an urban area. This research shows that it’s important to talk to young people to find out their needs and preferences. It also indicates that the best way of making sure that children’s individual needs are met wherever possible is to provide multiple types of placements in different areas.

Home environment

Research involving children and young people with experience of living in care homes emphasises the importance of the home environment. Many children’s views about good residential care focus on the material qualities of the home. This includes its size, layout, and whether it meets their needs for privacy or fulfils their desire to make choices about their own space (Sommerfeldt, 2022; Children’s Commissioning Consortium Cymru, 2024). Areas of concern for children and young people that are highlighted in the research include the need for:

  • privacy in bedrooms, and a clear difference between individual and communal spaces (Sommerfeldt, 2022)
  • enough space, but not so much that the home appears different to other homes in the community (Sommerfeldt, 2022; Children’s Commissioning Consortium Cymru, 2024)
  • privacy in bathrooms, with enough bathrooms for the number of children, young people, and staff (Children’s Commissioning Consortium Cymru, 2024)
  • no staff offices (Children’s Commissioning Consortium Cymru, 2024), or where these exist, a preference that staff spend most of their time in communal areas rather than in the office space (Sommerfeldt, 2022).

An important consideration for people working in children’s residential care is how to balance safety with privacy, comfort, and individual control over the home environment. This can be a difficult balance, but making sure children feel comfortable in their home is crucial to their well-being (Allcock, 2019; Johnson, 2016; Sommerfeldt, 2022). Williams et al. (2024) describe the positive experience of one young person involved in their study who was able to decorate their room to reflect their interests, despite needing constant supervision owing to safety concerns. This suggests that supporting children to have control over how their own space looks could be an important factor in achieving positive outcomes, even when there are safety concerns or increased security measures in place.

Trauma-informed spaces

Research highlights the importance of engaging with trauma-informed approaches when designing residential care spaces. Ames and Loebach (2023) suggest that trauma-informed design has the potential to reduce re-traumatisation and promote the resilience of children living in residential care.

Trauma-informed design refers to the combination of housing, health, and well-being support to promote and assist the healing process of those affected by trauma (West Waddy Archadia, 2023). This approach takes what we already know about trauma-informed care and applies it to the design of a place or environment. Many of the principles of trauma-informed design align with children and young people’s concerns about their home environment (Children’s Commissioning Consortium Cymru, 2024). They include making sure that:

  • there are clear distinctions between communal and private spaces
  • there is strong acoustic separation and that private spaces are as sound-proofed as possible
  • children and young people are allowed to decorate their private rooms according to their individual tastes and preferences.

Following these principles can provide children with safe spaces to undergo healing processes and support a sense of empowerment (West Waddy Archadia, 2023).

Consistency, continuity, and structure

Evidence suggests that there’s not one ‘best’ model of care amongst the many models of residential care that show positive outcomes for children and young people. While the research on models of care supports varying reasons for the effectiveness of each one, using a model can also in itself be a positive factor (Cordis Bright, 2018). This is because clearly defined models provide structure and support consistency and continuity of care (Cordis Bright, 2018).

It's common for children to be placed in residential care after they’ve lived in multiple placements. Placement moves are challenging for children and young people. They can cause feelings of distress and isolation, and moving may create difficulties with accessing support services (Park et al., 2020). Care Inspectorate Wales (2019) recommends that residential care should be seen as a positive option for some children in some situations, rather than being considered as a ‘last resort’ in all cases. For some children and young people, it’s the intervention that offers the best chance of care continuity. More work needs to be done to make sure residential care is used most effectively when it’s the best placement option for an individual. This includes challenging negative perceptions of residential care and making sure that the provision of support it offers is as good as it can be (Holmes et al., 2018).

However, research shows there are aspects of residential care that are challenging for many children. The structure and routine of life in residential care can conflict with their idea of ‘home’ and this may negatively impact their experiences (Sommerfeldt, 2022). At the same time, consistency in the approach taken by residential care staff can help improve children’s experiences of residential care (Sommerfeldt, 2022). These findings speak to the difficulty of striking a balance between structure and individual preferences in children’s residential care. Research with children and young people shows that continuity of staff and consistent relationships between children and staff are vitally important to creating that balance (Sommerfeldt, 2022).

Conclusion

The move to a not-for-profit system of children’s residential care will mean substantial changes to the residential care landscape across Wales. This provides an opportunity to think about children’s residential care in an evidence-based way. There are many different approaches to delivering residential care that support children and young people, but these approaches have some elements in common. It’s important to make sure that children’s residential care is informed by therapeutic principles, that it has a consistent structure, and that staff are given appropriate support. The location of a home, its connections to the community, and how its environment is designed are equally important considerations, which have been highlighted by children and young people. Recognising these things is an important part of working toward positive outcomes for all children and young people living in Wales.

Additional reading

Here is a list of the five most relevant resources to delivering children’s residential care that are either open access or freely available on the NHS Wales e-Library.

  1. Bailey, C., Klas, A., Cox, R., Bergmeier, H., Avery, J. and Skouteris, H. (2019) ‘Systematic review of organisation-wide, trauma-informed care models in out-of-home care (OoHC) settings’, Health and Social Care in the Community, 27 (3), pp. e10-e22, doi:10.1111/hsc.12621, available at https://doi.org/10.1111/hsc.12621.
  2. Holmes, L., Connolly, C., Mortimer, E. and Hevesi, R. (2018) ‘Residential group care as a last resort: Challenging the rhetoric’, Residential Treatment for Children and Youth, 35 (3), pp. 209-224, doi:10.1080/0886571X.2018.1455562, available at https://doi.org/10.1080/0886571X.2018.1455562.
  3. Mann, M., Lifford, K., O’Connell, S., Weightman, A., Searchfield, L., Lewis, R., Cooper, A. and Edwards, A. (2023) ‘A rapid review of what organisational level factors support or inhibit the scale and spread of innovations in children’s social care’, MedRxiv, 2023.04.03.23288061, doi:10.1101/2023.04.03.23288061, available at https://www.medrxiv.org/content/10.1101/2023.04.03.23288061v1.
  4. Parry, S., Cox, N., Andriopoulou, P., Oldfield, J., Roscoe, S., Palumbo-Haswell, J. and Collins, S. (2023) ‘Mechanisms to Enhance Resilience and Post-traumatic Growth in Residential Care: A Narrative Review’, Adversity and Resilience Science, 4 (1), pp. 1-21. doi:10.1007/s42844-022-00074-w, available at https://doi.org/10.1007/s42844-022-00074-w.
  5. Sommerfeldt, M. B. (2022) ‘“Sometimes I feel at home”: adolescents’ narratives of everyday life in residential care’, Journal of Children’s Services, 17 (1), pp. 33-44. doi:10.1108/JCS-12-2020-0086, available at https://doi.org/10.1108/JCS-12-2020-0086.
References - click to expand

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Allcock, A. (2019) Healing environments for children who have experienced trauma, IRISS, available at https://doi.org/10.31583/esss.20190506 (accessed: 2 April 2024).

Ames, R. L. and Loebach, J. E. (2023) ‘Applying trauma-informed design principles to therapeutic residential care facilities to reduce retraumatization and promote resiliency among youth in care’, Journal of Child and Adolescent Trauma, 16 (4), pp. 805-817, doi:10.1007/s40653-023-00528-y.

Bailey, C., Klas, A., Cox, R., Bergmeier, H., Avery, J. and Skouteris, H. (2019) ‘Systematic review of organisation-wide, trauma-informed care models in out-of-home care (OoHC) settings’, Health and Social Care in the Community, 27 (3), pp. e10-e22, doi:10.1111/hsc.12621.

Bellonci, C. and Holmes, L. (2021) ‘Debate: The greater the needs the lesser the evidence – therapeutic residential care for young people’, Child and Adolescent Mental Health, 26 (1), pp. 78-79, doi:10.1111/camh.12448.

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Parry, S., Cox, N., Andriopoulou, P., Oldfield, J., Roscoe, S., Palumbo-Haswell, J. and Collins, S. (2023) ‘Mechanisms to enhance resilience and post-traumatic growth in residential care: a narrative review’, Adversity and Resilience Science, 4 (1), pp. 1-21. doi:10.1007/s42844-022-00074-w.

Parry, S., Williams, T. and Oldfield, J. (2021) ‘Reflections from the forgotten frontline: “The reality for children and staff in residential care” during COVID‐19’, Health and Social Care in the Community, 30, pp. 212-224, doi:10.1111/hsc.13394.

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