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Safe Use of Bedrails Policy

1. Purpose

The purpose of this policy is to ensure that bedrails (also known as side rails or cot sides) are used safely, appropriately, and lawfully in all care settings supported by {{org_field_name}}. Bedrails are intended to reduce the risk of falls from bed, but if used incorrectly, they pose a significant risk of injury, entrapment, or even death. This policy outlines our approach to assessing, implementing, monitoring, and reviewing the use of bedrails in line with CQC Regulation 12 (Safe Care and Treatment), Regulation 13 (Safeguarding from Abuse and Improper Treatment), and Regulation 9 (Person-Centred Care). It also reflects guidance from the Medicines and Healthcare products Regulatory Agency (MHRA) and the Health and Safety Executive (HSE).

2. Scope

This policy applies to all staff involved in the care and support of individuals using bedrails in their own homes, supported housing, or any setting under the care of {{org_field_name}}. It includes healthcare professionals, care staff, maintenance workers, agency staff, and managers. It also applies to situations where equipment is provided by the NHS, local authority, or private suppliers, and where care staff are supporting individuals with or without nursing input.

3. Related Policies

• CH07 – Person-Centred Care Policy
• CH11 – Safe Care and Treatment Policy
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CH18 – Risk Management and Assessment Policy
• CH36 – Initial Assessment and Care Planning Policy
• CH37 – Moving and Handling Policy
• CH40 – Assisting with Personal Care Policy

4. When Bedrails May Be Considered

Bedrails may be considered to reduce the risk of an individual falling from bed and sustaining injury, particularly for those with impaired mobility, frailty, or disorientation during sleep. However, their use is not without risk and is not suitable for everyone. They should never be used as a form of restraint or for staff convenience. Factors to consider before use include:

• The person’s ability to move in bed and independently reposition
• History of bed-leaving behaviour, falls, or confusion
• The size and type of bed and mattress
• The risk of entrapment or climbing over the rails
• The person’s cognitive function and understanding of their environment

5. Risk Assessment and Decision-Making

Prior to using bedrails, a detailed individual risk assessment must be completed by a competent member of staff. This includes:

• Assessing the risks and benefits of using bedrails versus alternatives
• Considering the individual’s preferences, consent, or best interests if they lack capacity
• Reviewing environmental, physical, and cognitive factors
• Consulting with the multidisciplinary team and family where appropriate
  The risk assessment must be documented in the care plan and reviewed at least monthly or sooner if the person’s condition or environment changes.

6. Consent and Mental Capacity

Where a person has capacity, informed consent must be obtained and recorded prior to bedrail use. Where a person lacks capacity, a Mental Capacity Assessment must be completed, and a best interests decision made involving relevant parties, in accordance with the Mental Capacity Act 2005. Bedrails must never be used covertly or without appropriate legal and ethical justification. Deprivation of liberty safeguards may be considered if bedrails restrict the individual’s freedom of movement in conjunction with other restrictions.

7. Alternatives to Bedrails

Bedrails should not be the default option. Staff must consider and document whether safer alternatives are appropriate, such as:

• Bed sensors or alarms to detect movement
• Low-level beds with crash mats
• Profiling beds with tilt functions
• Increased staff checks or supervision at night
• Adjusting the sleeping environment to reduce risk of falls
  Any decision to not use bedrails, despite a risk of falls, must also be risk-assessed and clearly recorded.

8. Safe Installation and Equipment Checks

Bedrails must be compatible with the bed and mattress being used and installed according to manufacturer instructions. Equipment should meet BS EN 60601-2-52 standards and be free from defects. A bedrail safety check must be completed before first use and during each shift, including:

• Ensuring correct attachment and positioning
• Checking gaps between bedrail and mattress (no more than 60mm)
• Ensuring rail height is appropriate (at least 220mm above mattress surface)
• Confirming that rail locking mechanisms are secure
• Checking for wear and tear, rust, or loose parts
  Bedrails that are damaged, poorly fitting, or unsafe must be taken out of service immediately and reported.

9. Ongoing Monitoring and Reviews

Where bedrails are in use, care staff must monitor the person regularly and report any concerns including:

• Attempting to climb over rails
• Entrapment of limbs or bedding
• Skin damage or bruising
• Increased distress or agitation
  Reviews must take place at least monthly or sooner if any incident or concern arises. Each review considers whether bedrails remain appropriate and whether alternatives have become more suitable.

10. Reporting Incidents and Concerns

All incidents involving bedrail-related injuries, near misses, or entrapment must be reported to the Registered Manager {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}} immediately and documented using the organisation’s incident reporting procedures. Serious injuries or safety incidents may require reporting to the CQC under Regulation 18 – Notification of Other Incidents and to the MHRA if the equipment is faulty. Learning from incidents is shared with staff and used to improve safety practices.

11. Training and Staff Responsibilities

All staff involved in the assessment, installation, or use of bedrails receive training in:

• Risk assessment and decision-making
• Legal and ethical considerations
• Correct fitting and daily checks
• Infection prevention and cleaning of equipment
  Training is refreshed annually and evaluated through supervision and audits. Only trained and competent staff may fit or remove bedrails. Managers are responsible for ensuring compliance with policy and equipment standards across all services.

12. Cleaning and Infection Control

Bedrails must be cleaned regularly in line with CH17 – Infection Prevention and Control Policy. Staff must:

• Clean rails daily and between users with appropriate disinfectants
• Wear PPE when handling rails or bedding
• Report and isolate any equipment suspected to be contaminated or soiled
  Documentation of cleaning must be included in daily records.

13. Efficient Management at {{org_field_name}}

We manage bedrail safety efficiently through:

• A central register of all bedrail use and equipment checks
• Routine equipment audits by the health and safety lead
• Integration of bedrail safety into care planning and risk assessment processes
• Regular review of incidents and shared learning across teams
• Partnership with equipment providers and NHS therapists for ongoing guidance
  This ensures consistent compliance with CQC and safety requirements.

14. Policy Review

This policy will be reviewed annually or earlier if new guidance, incidents, or legislative changes occur. The Registered Manager is responsible for ensuring all staff are informed of updates and that procedures are implemented effectively to protect the health, safety, and dignity of the people we support.

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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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