Protecting People from Abuse and Harm: Minimising Restraints, Including Physical Controls, and Restrictive Practices in Care Homes (Scotland) Policy

Policy Statement

This policy sets out the values, principles and procedures underpinning this care home’s approach to issues of residents’ rights, associated risks and use of legitimate means of restraint, including physical restraint. The home’s restraint policies are integral to its overall approach to the safeguarding of vulnerable people.

The policy ensures that the respective human and citizens’ rights and responsibilities of people receiving care and staff regarding the use of restraints and actions that restrict freedom of movement and action are always upheld.

The home works on the basis that people receiving care have the same rights as anyone else in society, which must be fully respected. It would not seek to restrict people receiving care’s freedoms in any ways unless there were clear unacceptable risks to their safety and the safety of others without some form of restraint or restrictions being applied.

The policy applies to all those aspects of the service in which there are issues about the respective rights and responsibilities of people receiving care and providers concerning their freedom of action and movement. These include day-to-day care and relationships, and specific aspects such as accessibility to services outside the home such as health and social services and to community and citizen participation.

It specifically focuses on the inappropriate use of restraints and restrictions as breaches of human rights and possible criminal actions. The policy identifies when restraint could be justified and legally permissible and the procedures to be followed if staff must use restraint as a last resort.

The policy is written in line with a wide raft of legislation and statutory guidance, which includes the:

Human Rights Act 1998
Equality Act 2010
Adult Support and Protection (Scotland) Act 2007 (also taking into account the Adult Support and Improvement Plan 2019–2022)
Adults with Incapacity Act 2000
National Health and Social Care Standards My Support, My Life, particularly those found in section 3 “I have confidence in the people who support and care for me”. For example, standard 3.20 states “I am protected from harm, neglect, abuse, bullying and exploitation by people who have a clear understanding of their responsibilities”.
Mental Welfare Commission for Scotland (Best Practice Guidance) Rights, Risks and Limits to Freedom.

My Support, My Life states:

“Restrictions to my independence, control and choice involves any restriction to independent movement or freedom of choice, such as a physical barrier. In some exceptional circumstances, this could involve searches and physical or chemical restraint. If physical detention, restraint or searching is used, the individual concerned will usually be subject to a formal legal order authorising this”.

The policy should be read and used with other safeguarding policies, particularly the Support and Protection from Harm Overarching Policy.

Definition of Curbs, Restraints and Restrictive Practices

{{org_field_name}} accepts a definition of restraint as action intended to curb or restrict another person’s freedom of action. It recognises that restraint and restrictions can take many forms that prevent free movement and choice.

The use of restraint and restrictions can happen under many circumstances, which includes situations where the risks to a person’s safety are considered too high to be acceptable.

The most common situations, where legitimate restraint may be indicated, include those where there are needs to protect another person or other people from harming or injuring themselves or others physically or psychologically or to protect property and possessions.

Restraint can be reasonable and acceptable in a minority of situations but unreasonable and decidedly abusive and harmful to the person being restrained in many others.

Types of Restraints and Restrictions

{{org_field_name}} is committed to only using forms of restraint lawfully and where required to the minimum necessary to keep everyone safe from harm. This policy extends to the following forms of restraint.

Physical restraint — physical intervention to prevent, restrict, or subdue movements of the body, or part of the body of another person, including holding people chest down in prone positions (also referred to as “prone restraint”).
Psychological restraint — attitudes, discrimination or even social exclusion and punishment are all ways in telling someone repeatedly that they cannot leave or do something they want to do, including using unfriendly language and bullying, which people can exert pressure on an individual to comply, thus curtailing their freedoms.
Chemical restraint — the use of medicines and drugs specifically to control or subdue disturbed/violent behaviour. {{org_field_name}} will always follow initiatives to stop the overprescribing of psychotropic medicines as methods of behaviour control.
Mechanical restraint — the enforced use of mechanical aids such as bed rails, belts and cuffs specifically to control an individual’s movements.
Withdrawal, seclusion and segregation — environmental restraints that involve removing a person involuntarily from a situation; removing any aids and belongings that effectively restrict the person’s movements; confinement and isolation of a person, away from others, which prevents them from leaving, and where a person cannot mix freely with others temporarily or on a long-term basis.

Minimising Use of Physical Restraint

This home understands physical restraint to refer to the restriction of a person’s freedom without their permission. In the context of a nursing or care home, restraint could relate to the use of force or firm physical intervention:

in the event of a person receiving care or visitor becoming aggressive or behaving in a threatening manner
to prevent self-harm or injury to a person receiving care (for instance, by using bed rails, locking doors, restrictive clothing, etc)
to prevent a person receiving care from leaving the home in situations where staff are concerned as to the safety of that person receiving care.

Minimising Use of Restraints and Restrictions

{{org_field_name}} understands that restraint is illegal unless it can be demonstrated that for an individual not being restrained would conflict with {{org_field_name}}’s duty of care and that the outcome for the individual would be harmful.

{{org_field_name}} considers that physical restraint represents bad practice in care and should be avoided wherever possible. Staff will use physical restraint only as a last resort or in exceptional circumstances.

Restraint and restrictions will be used only where:

the form of restraint or restriction has been agreed as necessary following a risk assessment and has been entered in the person receiving care’s plan of care
the restraint is needed in an emergency (by definition unplanned) to prevent serious physical harm to the person receiving care, another person receiving care or other people, including care staff; in these situations care staff will follow the service’s policies in responding to behaviour that challenges and acts of aggression, violence and other emergencies
those involved in the intervention have received the appropriate training and supervision; this applies to any form of planned restraint and restrictive practice.

Any restraint or restriction must be in the welfare interests of the person and should be based upon the level of risk present, taking account of the person’s size, gender, age and medical conditions. It should be used for the minimum amount of time and with the least amount of intervention.

Any use of restraint must be carefully documented in the person receiving care’s records and reviewed. Alternative methods of care should be used wherever possible.

It is accepted that some people receiving care can be challenging at some time or another. Staff are always expected to deal with these events in a calm and professional manner. Whenever restraint is used full details must be entered in the person receiving care’s records and the management informed of the incident. Restraint should never be used as an easy option and all staff should be aware of the people receiving care’ legal and moral rights to freedom, dignity and autonomy.

Using Minimal Restraint in Situations of Aggression or Violence

Physical and verbal aggression by a person receiving care should be dealt with in line with the home’s health and safety policy and never met with counter aggression from staff. Physical interventions should be used only as a last resort by trained staff and to protect the rights and best interests of the person receiving care and should be the minimum consistent with making sure that all involved are kept safe from harm.

Care staff must only use minimum force when it is absolutely necessary to restrain someone. People receiving care who are acting in an aggressive or threatening manner must not be subject to undue restraint.

The law gives protection to people from being abused or attacked and, if a member of staff is attacked, they may use “minimum reasonable force” to defend themselves. Staff should remember that if they restrain a violent person and injure them because of the amount of force they use, they could be charged for assault. Because of this risk, staff must always follow the established procedure.

Restraints can have harmful effects on people’s physical and mental health by reducing their freedom of action and mobility. Restraining a person consistently can result in a decline in people’s levels of fitness, their ability to walk, sleep patterns and a general deterioration in their wellbeing.

Staff who deliberately use any form of illegitimate restraint or use restraint inappropriately will face disciplinary proceedings and dismissal if their actions clearly breach the home’s policies and their social care code of practice.

If it is proved that they have committed an act of misconduct causing harm to a vulnerable adult, they will be referred to the Disclosure Scotland PVA Barred List Service, which could prevent them from working with vulnerable adults.

Staff must not organise people receiving care’s rooms and other environments in such ways as to restrict their freedom of movement, for example, by deliberately seating them in chairs from which they cannot get up without help or permission.

Staff must make sure that mobility aids (or deprivation of), harnesses, straps, belts and cot sides are used solely for ensuring safety and not to control and restrain.

Staff must not restrict people receiving care’s freedom of movement and access by locking their bedrooms and other doors. Nor should anyone be locked in their room to control and restrain their behaviour.

Where some limitations need to be applied to keep people safe, they should follow only after a full risk assessment and management plan has been completed, and applied with the person’s consent or where the person cannot give their consent because of mental incapacity after a full incapacity assessment. Risk assessments should include the risks to the individual of being harmed from any intervention.

The home rejects the use of drugs and medication that are solely or mainly used to control and restrain behaviour. The home accepts that any medication that can have the effect of restricting or controlling behaviour should be prescribed only after full medical assessment and is regularly and rigorously reviewed.

Staff must not use threats of actual physical punishment or any form of intimidation, harassment or bullying to control and restrain people receiving care’s behaviour.

The home does not use any form of surveillance methods such as CCTV and other technological aids, which intrude into people receiving care’ privacy and dignity, to monitor and restrict their freedom of movement. Any use of such devices must be justified as necessary only to keep people safe.

Minimising Use of Restraints and Restrictions for Adults with Incapacity

{{org_field_name}} accepts that restraints and restrictions might form part of a care plan based on a risk assessment — usually as part of a wider process of decision-taking for people who might lack the mental capacity or who have been formally assessed as lacking the capacity to recognise any dangers to themselves or others.

The mechanism by which {{org_field_name}} enters into the process will invariably be a locally organised multidisciplinary meeting attended by all key professionals and with the full involvement of person receiving care and relevant others, including family members, independent advocates and welfare guardians where appointed.

In such cases, any decisions or actions taken in response to the risk assessment will be based on an assessment of their mental capacity, following the principles of the Mental Incapacity Act 2000, which briefly are that any action or decision taken:

must benefit the person, eg to keep them safe from harm, when otherwise they would suffer and be at risk of harm
should restrict the person’s freedom of action as little as possible while keeping them safe
should always consider the present and past wishes and feelings of the person, who might need support to communicate those feelings and wishes
should always consider wherever possible the views of the people who are closely involved in the person’s welfare
should encourage and promote the person to exercise whatever skills he or she has and to develop new skills as far as possible.

{{org_field_name}} understands that such decisions must be based on a judgment of what is in the welfare interests of the person, informed, where appropriate, by discussion with relatives and carers. Any action taken should be proportionate to the assessed level of risk and must respect the right of the person receiving care to confidentiality. Where the assessment indicates that an advocate is required, this should be provided.

Outcomes will be full recorded within the plan of care and regularly reviewed as a key aspect of it. The aim will always be to reduce the need for restrictive interventions with risk assessments being regularly updated.

It is recognised that such restraints and restrictions could amount to a person being deprived of their freedoms, hence it is important to work strictly to the procedures developed under the Adults with Incapacity Act 2000 with all the necessary safeguards to protect a person’s human rights.

Following any decision that a restriction on a person’s freedom is necessary to keep the person safe from harm, a plan will be agreed, and {{org_field_name}}, in partnership with the multidisciplinary team involved in the decision making, will then:

make regular checks to see if the restrictions continue to be necessary
adjust or remove them where they are no longer necessary
provide the person and their lawful representatives with information about the plans and their rights and entitlements
ensure the person’s cultural or faith-based and other protected needs continue to be met.

Inappropriate Forms of Restraint

Staff who deliberately use any form of illegitimate restraint or use restraint inappropriately will face disciplinary proceedings and dismissal if their actions clearly breach the agency’s policies and their social care code of practice.

Staff must not organise people receiving care’ environments in such ways as to restrict their freedom of movement against their wishes or without their consent, for example, by preventing them from getting out of bed, up and down stairs or preventing them from leaving their house.

Staff must make sure that mobility aids (or deprivation of), harnesses, straps, belts and cot sides are used solely for ensuring safety in line with care plans and not to control and restrain.

Staff must not restrict people receiving care’ freedom of movement and access by locking their bedrooms and other doors. Nor should anyone be locked in their accommodation to control and restrict their freedom of movement.

Where some limitations need to be applied to keep people safe, they should follow only after a full risk assessment and management plan has been completed, and applied with the person’s consent or where the person cannot give their consent because of mental incapacity after a full capacity assessment. Risk assessments should include the risks to the individual of being harmed from any intervention.

The service rejects the use of drugs and medication that are solely or mainly used to control and restrain behaviour. It accepts that any medication that can affect a person’s behaviour should be prescribed only after full medical assessment and is regularly and rigorously reviewed.

Staff must not use threats of actual physical punishment or any form of intimidation, harassment or bullying to control and restrain people receiving care’ behaviour.

The service does not support the use of any form of enforced or covert surveillance methods such as CCTV and other technological aids, which intrude into people receiving care’s privacy and dignity, to monitor and restrict their freedom of movement.

Where the service’s staff come across situations whereby they think unreasonable restrictions and restraints are being placed by other people or parties, including relatives, they should report the matter, which can then be assessed and escalated to the appropriate level for further enquiry and assessment. This might entail raising an alert with their local adults’ protection team. (See the Support and Protection from Harm Overarching Policy.)

When Minimum Restraint is Acceptable and Reasonable

The use of restraint is only acceptable when people’s safety is clearly at risk. Restraining interventions must then be appropriate to the situation and must be discontinued once the immediate danger has gone.

Staff actions should be directed at preventing the need for any form of restraint. If physical or any other form of restraint is needed it should be undertaken solely with the interests of keeping the person and other people safe.

The least restrictive form of intervention appropriate to the situation should always be used.

The home undertakes to provide its staff with appropriate guidance, supervision and training in those interventions that are seen to be acceptable and reasonable for the people receiving care.

Importance of Risks and Risk Assessments

Staff are expected to promote and enable people receiving care to exercise their rights and not seek to curb them or any of their civil liberties. To achieve this, it is recognised that staff must assess and manage any risks to people receiving care’ safety that may occur.

Any risks to personal safety requiring intervention that could be interpreted as restraint or restriction are assessed in consultation with the people receiving care and a risk management plan developed so that all parties are aware of the possible consequences and responsibilities for the actions taken.

The risk assessment is comprehensive, fully recorded and signed by all parties within the individual care plan. All significant parties including relatives, advocates and other professionals are made aware of the risk assessment and management plan.

Reporting and Recording

Any instance involving the restraint of a person receiving care should be reported immediately to the person in charge and fully recorded both as a critical incident and on the person receiving care’s individual file/care plan.

A full description of the incident must be given together with details of what took place and the reasons for the restraining actions.

It can be expected that the incident will be discussed in a meeting/supervision/case review to explore further the issues raised by the situation.

As far as possible, the aim will be to discover the lessons to be learned to minimise or prevent the need for such actions in the future.

In cases where there is evidence that the restraints used were unreasonable or inappropriate, the staff member(s) involved may be warned that they may face disciplinary action (or disciplinary action may need to be taken if there is strong enough evidence that abuse has occurred).

In these instances, the service will alert the local adults’ protection authority and notify the Care Inspectorate in line with its notification procedures.

Monitoring and auditing

All restraints and restrictions imposed on people receiving care are regularly reviewed through their care plans and their use is monitored and audited by senior management. The object is always to make sure that restraints and restrictions are kept to the minimum and only used when there are no reasonable alternatives.

Training

All new staff receive training in the service’s policies and procedures on restraint and restrictive actions as part of their mandatory training in adult protection, which is regularly updated and refreshed.

All staff receive training to update them about changes to the service’s restraints policies and procedures and receive specialist training in any aspect of restraint, including specific methods and techniques, as required by their roles and responsibilities.

{{org_field_name}}’s ongoing training so that staff can develop skills to manage and reduce unacceptable behaviour based on detailed problem analyses and the selection of individualised interventions appropriate to each case.

Staff are trained as required in a range of positive intervention strategies in line with the training standards produced by the Restraint Reduction Network (2020) as they apply to Scotland, all national guidance and resources produced by the Scottish Social Services Council.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Next Review Date: {{next_review_date}}

DS157. Protecting People from Abuse and Harm: Minimising Restraints, Including Physical Controls, and Restrictive Practices in Care Homes