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CH183-Supporting Adults with Behaviour that Challenges, Distressed Behaviour and Restrictive Practice Policy

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Supporting Adults with Behaviour that Challenges, Distressed Behaviour and Restrictive Practice Policy

1. Purpose

The purpose of this policy is to provide a clear, lawful and person-centred framework for supporting adults in the care home whose behaviour may challenge others, place themselves or others at risk, or indicate distress, unmet need, pain, fear, trauma, confusion, sensory overload, communication difficulty or environmental stress.

{{org_field_name}} recognises that behaviour that challenges is not a diagnosis and must not be used to label, blame or stigmatise a person. Staff must view behaviour as a form of communication and must seek to understand the cause, function and context of the behaviour before deciding how to respond.

This policy sets out how the service will prevent avoidable harm, promote positive behaviour support, reduce the use of restrictive practice, safeguard people from abuse and improper treatment, and ensure that any intervention is lawful, necessary, proportionate, the least restrictive option, time-limited, recorded, reviewed and in the person’s best interests where they lack capacity.

This policy supports compliance with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, CQC Fundamental Standards, the Care Quality Commission (Registration) Regulations 2009, the Mental Capacity Act 2005, Deprivation of Liberty Safeguards, the Human Rights Act 1998, the Equality Act 2010, the Care Act 2014, the Data Protection Act 2018 and UK GDPR, and relevant national guidance including CQC guidance on restraint, safeguarding, safe care and treatment, consent, staffing, good governance and statutory notifications.

2. Scope

This policy applies to all adults living at, staying at, visiting or receiving care and support from {{org_field_name}} within the care home. It applies to all staff employed or contracted by the service, including the Registered Manager, deputy managers, nurses, care staff, support staff, ancillary staff, activities staff, agency workers, bank staff, volunteers, students and any person working on behalf of the service.

The policy also applies when staff support people away from the care home, including during appointments, activities, community access, hospital visits, social outings or transport arranged as part of the person’s care.

This policy must be followed whenever a person presents with behaviour that challenges, distressed behaviour, risk of harm to self or others, verbal or physical aggression, refusal of care that may create risk, behaviour linked to cognitive impairment, dementia, delirium, learning disability, autism, mental health needs, acquired brain injury, trauma, pain, sensory needs, communication difficulty, substance withdrawal, environmental distress or any other identified or suspected need.

This policy does not authorise any staff member to use unlawful restraint, punishment, seclusion, intimidation, coercion, degrading treatment, blanket restrictions or any intervention that is not necessary, proportionate, least restrictive and properly documented.

3. Related Policies

This policy must be read alongside the following policies to ensure a comprehensive understanding of roles, responsibilities, and interrelated procedures:

4. Policy Statement and Responsibilities

Understanding Behaviour

Behaviour that challenges or distressed behaviour must be understood as communication. Staff must not describe people as “challenging”, “aggressive”, “difficult”, “attention seeking” or “non-compliant” in a way that labels or blames the person. Records must describe what was seen and heard, the context, possible triggers, risks, staff responses and outcomes in factual, respectful and non-judgemental language.

Staff must consider whether the behaviour may be caused or worsened by pain, infection, constipation, hunger, thirst, fatigue, medication side effects, delirium, dementia, sensory overload, trauma, anxiety, depression, psychosis, communication difficulty, unmet cultural or spiritual needs, lack of choice, loneliness, boredom, environmental noise, changes in routine, staff approach or restrictions that the person does not understand.

Where behaviour changes suddenly, increases in frequency or severity, or appears out of character, staff must treat this as a possible sign of physical or mental ill-health and escalate promptly to the nurse in charge, senior carer, Registered Manager, GP, NHS 111, emergency services or relevant clinical professional, depending on the level of risk.

Definitions

For the purpose of this policy, “behaviour that challenges” means behaviour that places the person or others at risk, causes distress, limits the person’s quality of life, affects their ability to receive care safely, or may lead to restrictive responses if not properly understood and supported.

“Restrictive practice” means any practice that limits a person’s movement, liberty, choice, privacy, access to people, access to activities, access to possessions, or ability to make everyday decisions. Restrictive practice may include physical restraint, mechanical restraint, chemical restraint, environmental restraint, observation, restriction of movement, locked doors, removal of items, restrictions on contact, or restrictions on access to parts of the home.

“Physical restraint” means the use of physical contact by staff to prevent, restrict or subdue movement.

“Mechanical restraint” means the use of equipment or devices to prevent, restrict or subdue movement, where the primary purpose is behavioural control rather than therapeutic support.

“Chemical restraint” means the use of medication primarily to control behaviour or restrict movement, rather than to treat a diagnosed physical or mental health condition. Medication must never be used for staff convenience or as punishment.

“Environmental restraint” means restricting a person’s movement or choices through environmental controls, such as locked doors, coded keypads, blocked exits, removal of mobility aids, restricting access to rooms or using furniture or equipment to limit movement.

“Restriction” means any limitation placed on a person’s freedom or choice. Not all restrictions amount to restraint, but all restrictions must be lawful, necessary, proportionate, least restrictive, risk assessed, documented and reviewed.

Assessment and Planning

A Behaviour Support Plan must be developed for any person who presents with, or is at foreseeable risk of, behaviour that challenges, distressed behaviour, aggression, self-injury, refusal of essential care, repeated distress, or any behaviour that may lead staff or others to consider restrictive practice.

The Behaviour Support Plan must be based on a person-centred assessment and, where appropriate, functional assessment of behaviour. The assessment must consider the person’s life history, diagnosis, communication needs, sensory profile, mental health, cognition, physical health, pain, medication, sleep, nutrition, hydration, continence, trauma history, cultural and spiritual needs, relationships, environment, daily routine, preferences, strengths, known triggers and early warning signs.

The plan must be developed with the person wherever possible and, where appropriate, with their family, representative, advocate, attorney, deputy, GP, community mental health team, dementia team, learning disability team, speech and language therapist, occupational therapist, psychologist, pharmacist or other relevant professionals.

The Behaviour Support Plan must include:

Behaviour Support Plans must be reviewed at least monthly where there is active or recurring risk, after every significant incident, after any use of restraint or restrictive intervention, following any safeguarding concern, following any relevant medication change, following hospital admission or discharge, following a change in mental or physical health, and at least every six months where the risk is stable and low.

Prevention and Proactive Support

The focus of care must be on preventing behavioural crises through consistent, supportive interactions and an environment that promotes well-being. Staff are expected to:

Staff must also consider whether reasonable adjustments are required under the Equality Act 2010. This may include adapting communication, routines, staffing approach, lighting, noise levels, personal care routines, mealtimes, activities, visiting arrangements, personal space, sensory input, or the pace and timing of care.

Where the person has dementia, autism, a learning disability, mental health needs or communication difficulties, staff must use approaches that are appropriate to the person’s needs and must involve specialist professionals where routine care planning is not sufficient to reduce distress or risk.

De-escalation Techniques

Staff must use proactive and non-restrictive approaches wherever possible. De-escalation must be person-specific and based on the person’s care plan, communication needs, known triggers and preferred support. Staff must remain calm, respectful and non-threatening, use simple language, reduce demands, offer choices, allow personal space, avoid confrontation, remove audiences where safe to do so, reduce noise or stimulation, and give the person time to process information.

Staff must not shout, threaten, punish, ridicule, intimidate, argue, use unnecessary touch, block exits unless there is an immediate safety reason, or use language that could shame or humiliate the person. Staff must avoid power struggles and must not insist on non-urgent care where continuing would increase distress or risk.

Where there is immediate risk, staff must summon assistance, protect other people in the least restrictive way possible, remove potential hazards where safe, maintain a safe distance, and escalate to the nurse in charge, senior carer, Registered Manager, emergency services or relevant health professional as appropriate.

Restrictive Practice and Safe Intervention

Restrictive practice must only be used as a last resort to prevent immediate or foreseeable harm, and only where the intervention is lawful, necessary, proportionate, least restrictive, time-limited and in the person’s best interests where they lack capacity. Restrictive practice must never be used as punishment, for staff convenience, because of staffing shortages, to enforce compliance, or as a substitute for appropriate assessment, care planning, communication support or clinical intervention.

Staff may only use restrictive intervention where:

Where restrictive practice is foreseeable, the Behaviour Support Plan must identify who may authorise it, which roles may apply it, what techniques may be used, what must not be used, how the person must be monitored, when the intervention must stop, and when senior staff, professionals, safeguarding, emergency services or CQC must be notified.

During any restraint or restrictive intervention, staff must continuously monitor the person’s physical and emotional wellbeing, including breathing, colour, pain, distress, signs of injury, consciousness, fatigue and any known health condition that increases risk. Any concern about the person’s wellbeing must result in the intervention stopping as soon as safe and urgent medical assistance being sought where required.

Prone restraint, pain-based techniques, holds that restrict breathing, seclusion, blanket restrictions, unnecessary locked-door restrictions, punitive restrictions, degrading treatment and any intervention not approved by the service are prohibited.

Any restrictive practice that may amount to a deprivation of liberty must be considered under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Where the person lacks capacity to consent to the care arrangements and is under continuous supervision and control and is not free to leave, the Registered Manager must ensure that a DoLS application or review is made to the supervisory body as required.

Chemical Restraint and PRN Medication

Medication must not be used to control behaviour for staff convenience, to punish a person, to compensate for inadequate staffing, or to replace positive behaviour support. Any medication prescribed for anxiety, agitation, distress, behaviour that challenges, sleep or mental health symptoms must have a clear clinical rationale, prescribing instructions, review date and monitoring arrangements.

PRN medication must only be administered in accordance with the person’s medication care plan, PRN protocol, consent or best-interest decision, and prescriber instructions. The PRN protocol must state the reason for use, early interventions to try first, dose, maximum dose, minimum interval, expected effect, side effects to monitor, when to seek medical advice, and how effectiveness will be reviewed.

Where medication appears to be used primarily to restrict movement, sedate the person or manage behaviour rather than treat a diagnosed condition, this must be treated as potential chemical restraint and escalated to the Registered Manager, prescriber, pharmacist and safeguarding lead for review.

Training and Competence

Staff must not be expected or permitted to use de-escalation, breakaway, restraint or restrictive intervention techniques unless they have received training appropriate to their role and have been assessed as competent. Training must be refreshed at intervals set by the provider, the training organisation, risk assessment, legislation or CQC expectations, and sooner where incidents, supervision, audit or competency concerns identify a need.

Mandatory training relevant to this policy includes:

Agency, bank and temporary staff must receive sufficient induction and information about people’s Behaviour Support Plans, risk assessments, communication needs and known triggers before providing care. They must not use restrictive interventions unless the Registered Manager is satisfied that they are trained, competent and authorised to do so.

The Registered Manager must maintain records of staff training, competency assessment, supervision, refresher training and any restrictions on staff practice.

Reporting, Recording and Reviewing Incidents

All incidents involving behaviour that challenges, distressed behaviour, aggression, self-injury, refusal of essential care, restraint, restriction, injury, safeguarding concern, police involvement or emergency services involvement must be recorded promptly, factually and respectfully in the care record and incident reporting system.

Records must include:

The person must be offered reassurance, support and the opportunity to express their views after the incident in a way they can understand. Staff involved must be offered debrief, support and reflective discussion.

The Registered Manager or delegated senior person must review all significant incidents, all incidents involving restraint or restriction, all repeated patterns of distress, and all incidents resulting in injury or safeguarding concern. Reviews must identify lessons learned, whether the care plan remains effective, whether staffing, environment, training, communication, health needs or professional input require action, and whether notifications or safeguarding referrals are required.

CQC must be notified without delay where required by the Care Quality Commission (Registration) Regulations 2009, including serious injury, allegations of abuse, incidents reported to or investigated by the police, events that stop the service running safely and properly, deaths, and outcomes of DoLS applications where applicable.

Duty of Candour

Where an incident involving behaviour that challenges, distressed behaviour, restraint, restriction or staff response results in a notifiable safety incident, {{org_field_name}} will follow the Duty of Candour procedure. This includes informing the relevant person as soon as reasonably practicable, providing a truthful account of what is known, offering an apology, explaining what further enquiries will take place, providing reasonable support, keeping written records and sharing the outcome of any investigation where appropriate.

Staff must report any incident that may meet the Duty of Candour threshold to the Registered Manager immediately.

Safeguarding and Rights

People must be protected from abuse, neglect, unlawful discrimination, degrading treatment, unnecessary or disproportionate restraint, inappropriate deprivation of liberty and any form of improper treatment. Any use of force, control, coercion, intimidation, punishment, seclusion, humiliation, neglect, rough handling, misuse of medication or restriction that is not lawful, necessary, proportionate and least restrictive must be treated as a potential safeguarding concern.

Staff must report safeguarding concerns immediately in line with the Safeguarding Adults Policy. The Registered Manager or safeguarding lead must take action without delay to protect the person, preserve evidence where necessary, seek medical assistance where required, notify the local authority safeguarding team, inform CQC where required, and involve the police where a crime may have been committed.

The person’s human rights must be respected at all times, including their rights to dignity, liberty, family life, privacy, communication, protection from inhuman or degrading treatment, and non-discrimination. Any restriction on rights must be lawful, necessary, proportionate, recorded and reviewed.

Person-Centred Care, Consent and Mental Capacity

Staff must seek the person’s consent before providing care or support. Consent must be voluntary, informed and specific to the care or intervention proposed. Staff must not assume that a person lacks capacity because they have dementia, a learning disability, autism, mental health needs, communication difficulties or because they make a decision that others consider unwise.

Where there is reason to believe that the person may lack capacity to make a specific decision about care, support, risk, restriction or intervention, a decision-specific mental capacity assessment must be completed in accordance with the Mental Capacity Act 2005. Where the person lacks capacity, any decision or intervention must be made in their best interests, using the least restrictive option and involving the person as far as possible, together with family, representatives, attorneys, deputies, advocates or professionals as appropriate.

Where the person has no appropriate family or representative and the decision meets the criteria for Independent Mental Capacity Advocate involvement, an IMCA referral must be made.

Where care arrangements may amount to a deprivation of liberty, the Registered Manager must ensure that a DoLS application, review or urgent authorisation is considered and completed in accordance with legal requirements.

Dignity and Respect

We are committed to treating all individuals with dignity, even when their behaviour is challenging. This includes preserving privacy, avoiding labels or stigmatisation, and ensuring that interventions respect the person’s identity, culture, and personal choices​.

Staff must avoid language or practice that labels, blames, shames or infantilises the person. Behavioural incidents must never be discussed in public areas or in front of other residents, visitors or staff who do not need to know. Personal care must not be continued during distress unless delay would create significant risk, and staff must consider whether a different staff member, timing, approach, communication method or environment would better protect the person’s dignity.

Multi-Disciplinary Collaboration

{{org_field_name}} will work collaboratively with the person, family members, representatives, advocates, GPs, pharmacists, mental health teams, dementia services, learning disability teams, autism specialists, speech and language therapists, occupational therapists, physiotherapists, psychologists, social workers, safeguarding teams, commissioners and other relevant professionals.

The Registered Manager must seek professional advice where behaviour is new, increasing, unexplained, high risk, associated with injury, linked to possible physical or mental illness, results in restrictive practice, or is not improving through the current Behaviour Support Plan.

Where a person has repeated incidents, repeated use of PRN medication, repeated restraint, safeguarding concerns or escalating distress, the service must arrange a multi-disciplinary review to identify causes, reduce restrictions and agree a revised support plan.

Governance, Audit and Continuous Improvement

The Registered Manager must ensure that incidents involving behaviour that challenges, distressed behaviour, restraint, restriction, safeguarding concerns, injuries, PRN medication used for distress, police involvement and CQC notifications are monitored and audited.

Audits must consider frequency, location, time of day, staff involved, triggers, injuries, use of restraint or restriction, use of PRN medication, safeguarding referrals, complaints, care plan updates, staff training needs, staffing levels, environmental factors and whether the person’s quality of life has improved.

Findings must be shared with senior staff and, where appropriate, the provider, nominated individual, safeguarding lead, clinical professionals and commissioners. Actions must be recorded, allocated, monitored and reviewed to ensure improvements are made.

The service will use incident learning, supervision, reflective practice, resident and family feedback, complaints, safeguarding outcomes, audits and professional advice to reduce restrictive practice and improve people’s safety, dignity, choice and wellbeing.

5. CQC Notifications and External Reporting

The Registered Manager is responsible for ensuring that statutory notifications are submitted to CQC without delay where required. This includes, but is not limited to, serious injury to a person using the service, allegations of abuse, incidents reported to or investigated by the police, events that prevent or threaten to prevent the service from running safely and properly, deaths, unauthorised absences where applicable, and outcomes of DoLS applications where applicable.

Safeguarding concerns must be referred to the local authority safeguarding team in line with local safeguarding procedures. Where a crime may have been committed, the police must be contacted. Where there is immediate risk to life, serious injury or urgent medical need, emergency services must be contacted immediately.

The service will keep clear records of all external referrals and notifications, including the date, time, person submitting the referral, organisation notified, reference number where available, advice received and follow-up actions.

6. Policy Review

This policy will be reviewed at least annually and sooner where there are changes in legislation, CQC guidance, statutory guidance, national best practice, safeguarding requirements, organisational practice, serious incidents, repeated incidents, complaints, audit findings, CQC feedback or learning from safeguarding enquiries.

The Registered Manager and Nominated Individual are responsible for ensuring that the policy is reviewed, approved, implemented and communicated to all relevant staff. Staff must be informed of changes and, where required, receive updated training or supervision before revised procedures are implemented.

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}}
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