How do we create excellence in intensive therapeutic residential care practice?

What creates high quality therapeutic residential care? This is the question often asked of agencies, of staff, of policy makers and of the young people themselves. There is no simple answer! Intensive therapeutic residential care is a complex operating environment. It cares for and supports young people with the most complex needs and interacts with a range of complex systems around young people.

It stands to reason then that leaders play a critical role in leading, managing, inspiring and supporting high-quality care.

In the UK, a review was recently undertaken by Oftsed (2020) to examine the qualities of a small number of consistently high performing residential care providers over a five year period. The key themes to arise from this review clearly point to the quality of its leadership and the support of its people.

I explore these themes below in the context of the ITC reforms in NSW.

1. The statement of purpose

The review found that in effective organisations there is a commitment to continually reviewing and aligning to the overarching vision and intent of the program. This speaks to an ongoing commitment to organisational congruence – that idea that ‘we walk the talk’ at every level of the organisation.

The NSW Ten Essential Elements refer to this as organisational congruence and commitment to a therapeutic approach – from direct care worker to Board member – and the need to create the organisational conditions, through policies, procedures, staff training and support to ensure that the therapeutic approach is enacted in practice with young people.

  • How is your organisation measuring organisational congruence and commitment to your therapeutic model?
  • What would you notice in your program that would demonstrate you are strongly aligned with your therapeutic approach?
  • What are some of the opportunities and barriers that require clear leadership to leverage or address?
2. Making good decisions about young people coming into care

The review noted the importance of client mix and the role of managers in taking a detailed and personal interest in the young people coming into the home.

The issue of client mix is clearly an area of much discussion and work within the Intensive Therapeutic Care system. As described in the NSW Ten Essential Elements, the importance of the overall mix of children and young people when assessing the suitability of a potential new young person in the therapeutic program is a critical element of the success of a therapeutic program.

  • What factors are you considering at the individual client level?
  • What factors are you considering in regard to other clients in the home?
  • What factors are you considering in regard to the staffing group?
  • What other organisational factors are taken into account?
  • How is risk and need factored into the decision-making process?
3. Visible leaders

The review noted the importance of managers that are very visible to staff and young people, providing a ‘hands on’ model of good practice and seeking regular feedback from young people and staff. Their capacity to observe practice and provide feedback significantly contributed to staff confidence and capacity.

In the context of NSW, this is achieved through the joint leadership of House Managers and Therapeutic Specialists in each home. The strength of this collaboration is key to the effectiveness of the practice in the home. The capacity of the leadership team to walk alongside staff, model responses to young people, seek and receive feedback and offer opportunities for reflection is critical to effective therapeutic care.

  • What processes do you have in place to support the collaborative leadership required between House Managers and Therapeutic Specialists?
  • How confident are your House Managers to be able to lead practice with staff in the therapeutic approach?
  • What support are House Managers receiving to build their own confidence and capacity?
4. Continuing professional development and support for managers and staff

The review found that effective leaders valued and prioritised their own professional development and have strategies in place to support the translation of knowledge into practice within the homes. Effective leaders also identified that staff were their most valuable assets. The importance of recruitment and retention was a feature of effective organisations with a focus on attracting the right staff and ensuring their access to regular training, supervision and support.

Within the NSW context, the Ten Essential Elements refer to trained staff and consistent rostering, highlighting the need for mandatory and ongoing training for all staff and the need for supervision and leadership training for managers in Intensive Therapeutic Care.

  • What strategies do you currently have in place to equip leaders with the skills and knowledge they need to be effective?
  • Do you have the balance right between training and supporting operational staff and managers?
  • What are managers and staff telling you about their experience of feeling supported and valued?
  • What supervision frameworks are you using for staff and managers in ITC? Have they been reviewed to fit the ITC operating environment?
  • What frameworks are you using for reflective practice and debriefing? What are staff telling you about how helpful they are?
  • How do you bring House Supervisors together for peer support and shared learning?
5. Leadership journey

The review also noted that nearly all the managers had ‘worked their way through the ranks’ in residential care, often with the same provider. Others spoke of the importance of good induction processes. Central was the ability of managers to understand the experience of a direct care worker, the rostered environment, difficult situations they sometimes found themselves in and what success looked like, no matter how small.

  • How able are your managers to stand in the shoes of the direct care staff?
  • How would you describe the culture in the home that is fostered by the House Manager? Is it hopeful, aspirational and celebrating small successes?


Organisations valuing people who value others

It seems to me that there is much to affirm and much to learn from the UK review in the context of the ITC reforms in NSW. At the centre of it all seems to be the congruence of organisations valuing people who value others, including young people. It should not be that surprising when we know that effective therapeutic care is first and foremost about relationship-based practice!

The change process in ITC

The UK review addresses many of the 10 Essential Elements that form the basis for the approach to therapeutic care in the ITC system in NSW. It also highlights the possible need to amplify more clearly the critical role of leadership within the elements.

Change takes time – we need to be persistent and be open to learning whilst doing

The ITC reforms in NSW are not yet 2 years old, with much of the system in place for far less time than that. As with any broad ranging reform, challenges, foreseen and unforeseen, are expected. Importantly, I think a take-home message from this review is that many of the key ingredients of the reform are sound – let’s not lose sight of that in the face of implementation challenges. Change takes time – implementation science tells us we need to be thinking in years. Continuous improvement and the capacity for reflection at all levels of the system – from direct workers to policy makers – will be the key to success.

Janise Mitchell
Director, Centre for Excellence in Therapeutic Care


Centre for Excellence in Therapeutic Care. (2019). Practice Guide: The 10 Essential Elements of Intensive Therapeutic Care in NSW.

Ofsted and Stanley, Y. (2020). Social care commentary: creating the environment for excellence in residential practice. Accessed 15 March 2020