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CH66-Positive Behaviour Support and Managing Aggression Policy

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Positive Behaviour Support and Managing Aggression Policy

1. Purpose and Scope

This policy outlines our approach to promoting positive behavior and safely managing aggression in our care home. It applies to all staff, volunteers, and caregivers supporting adult service users (including older adults with dementia) in our CQC-registered facility. Our goal is to ensure that service users receive care in a manner that promotes dignity, respect, safety, and person-centered support while meeting the Care Quality Commission (CQC) requirements for safe and effective care. By following this policy, we aim to enhance quality of life for residents, prevent incidents of challenging behavior, and respond safely and ethically when aggression does occur.

2. Policy Statement and Values

We are committed to a Positive Behaviour Support (PBS) approach in all aspects of care. PBS is “a person-centred framework for providing long-term support to people … who have, or may be at risk of developing, behaviours that challenge”. This approach recognizes that “behaviour that challenges usually happens for a reason and may be the person’s only way of communicating an unmet need. PBS helps us understand the reason for the behaviour so we can better meet people’s needs, enhance their quality of life and reduce the likelihood that the behaviour will happen”. In line with this philosophy, our staff will strive to understand the underlying causes of distress or aggression (such as pain, confusion, fear or frustration in a person with dementia) and address those needs proactively rather than reactively.

Our values and principles include: person-centered care, respect for each individual’s rights and dignity, and a commitment to least restrictive practices. We uphold that every service user has the right to a good quality of life, including: participation in community life, meaningful relationships, personal choice and autonomy, opportunities to develop skills, and being treated with dignity and respect. We promote a culture that sees behaviour as communication, not as something to punish. All staff are expected to interact with service users in a non-judgemental, respectful, and caring manner at all times. As the MAPA® approach (Management of Actual or Potential Aggression) emphasizes, we respond to people with respect and dignity while supporting them to stay safe.

This policy is aligned with national best-practice guidance. We adhere to the Department of Health’s Positive and Proactive Care (2014) guidance, which requires providers to use recovery-based, person-centered approaches and PBS principles when supporting people who present challenging behaviours. This applies equally to those with learning disabilities or autism and to older people with dementia who may become confused or agitated. We also follow relevant NICE guidelines on managing violence and aggression in care settings to anticipate and reduce the need for restrictive interventions. Our approach supports compliance with key CQC Fundamental Standards: ensuring person-centred care (Regulation 9), safe care and treatment including risk management (Regulation 12), safeguarding from abuse and avoiding inappropriate restraint (Regulation 13), good governance through incident monitoring (Regulation 17), and staff training and competency in PBS and de-escalation (Regulation 18). All staff and managers are responsible for upholding this policy and its values in daily practice.

3. Definitions

Positive Behaviour Support (PBS): Positive Behaviour Support is a person-centred and evidence-informed approach to understanding behaviour that may challenge or indicate distress. It seeks to understand the reasons for the behaviour, including environmental, physical, psychological, communication and social factors, and to improve the person’s quality of life while reducing the likelihood of behaviours that may place the person or others at risk.

Behaviour that Challenges: Behaviour that challenges means behaviour which may place the person or other people at risk of harm, significantly affect the person’s quality of life, or interfere with the delivery of safe and appropriate care. This may include verbal or physical aggression, self-injury, damage to property or other behaviour associated with distress. Staff must consider that behaviour may communicate an unmet need, pain, fear, anxiety, frustration, confusion, sensory distress or another underlying cause.

Management of Actual or Potential Aggression (MAPA®): MAPA® is the training framework used by {{org_field_name}} for the prevention and management of situations involving actual or potential aggression. It includes prevention, communication, de-escalation and, where staff have received the relevant practical training and have been assessed as competent, approved physical intervention techniques. Staff must not use a physical intervention technique solely because it is described in this policy. Staff may use only techniques for which they have current training and demonstrated competence.

Restraint and Restrictive Intervention: For the purposes of this policy, restraint or restrictive intervention includes an act intended to control or restrain a service user where a person:

Restrictive practices may therefore include physical restraint, mechanical restraint, restrictions on movement or access, and chemical restraint. Any restrictive practice must be necessary, proportionate to the identified risk of harm, used for the shortest time necessary and represent the least restrictive practicable option.

Physical Restraint: Physical restraint is the use of direct physical contact or force to prevent, restrict or subdue movement. Physical restraint must never be used for punishment, retaliation, convenience, intimidation or simply to secure compliance.

Mechanical Restraint: Mechanical restraint is the use of a device or equipment for the purpose of preventing, restricting or subduing a person’s movement where the purpose or effect is restrictive. Equipment used solely for a therapeutic, mobility, positioning or safety purpose is not automatically mechanical restraint; its purpose, necessity, the person’s consent or capacity, and its practical effect must be considered.

Chemical Restraint: Chemical restraint means the use of medication primarily for the purpose of controlling or restricting a person’s behaviour or movement rather than solely for the appropriate treatment of a diagnosed or identified medical condition. Medicines must never be administered as a means of punishment, convenience or inappropriate behavioural control. Any use of medication that may constitute chemical restraint must comply with the person’s medicines plan, prescribing instructions, consent or Mental Capacity Act requirements, and the principles of necessity, proportionality and least restriction.

Deprivation of Liberty: A deprivation of liberty is different from an individual act of restraint and must be considered in accordance with Article 5 of the European Convention on Human Rights, the Mental Capacity Act 2005 and current case law. Following the UK Supreme Court judgment of 2 June 2026, whether arrangements amount to a deprivation of liberty must be determined through a multifactorial assessment of the person’s individual circumstances. No single factor is determinative. Relevant factors include the type, duration, effects and manner of implementation of restrictions; the degree of supervision or physical control; the person’s freedom to leave; any use of sedating medication; social isolation; whether the person objects; the relative normality of the arrangements; and the person’s current wishes and feelings. Where there is doubt as to whether arrangements amount to a deprivation of liberty or whether the person validly accepts those arrangements, advice must be sought and the matter referred for consideration under the applicable Deprivation of Liberty Safeguards process.

4. Assessment and Individualised Support Planning

Effective Positive Behaviour Support begins with an individualised assessment of the person and the circumstances in which behaviour that challenges or indicates distress occurs. Where a service user displays, or is assessed as being at risk of displaying, behaviour that may result in harm, {{org_field_name}} will complete an appropriate assessment and develop an individualised Behaviour Support Plan and associated risk assessment.

The assessment must consider, where relevant:

The Behaviour Support Plan must identify proactive strategies designed to meet the person’s needs and reduce the likelihood of distress. It must also provide clear guidance about early intervention, de-escalation and the appropriate response if risks increase.

Where a restrictive intervention is foreseeable, the person’s assessment and plan must additionally record:

Capacity must be presumed unless established otherwise. Capacity is decision-specific and time-specific and must not be determined solely because a person has dementia, a learning disability, autism, mental illness, communication difficulty or because the person makes a decision which staff consider unwise.

Where there is reason to doubt a person’s capacity to make a particular decision concerning care, treatment or restrictive arrangements, capacity must be assessed in accordance with the Mental Capacity Act 2005 and the assessment and outcome recorded.

Where the person lacks capacity to make the relevant decision, any act undertaken on their behalf must comply with the Mental Capacity Act 2005 best-interests requirements. Staff must consider the person’s past and present wishes and feelings, beliefs and values and, where appropriate and practicable, consult those required by the Mental Capacity Act 2005. Any restriction must be the least restrictive practicable option.

Where restraint is relied upon under sections 5 and 6 of the Mental Capacity Act 2005 in relation to a person who lacks capacity, staff must reasonably believe that restraint is necessary to prevent harm to that person and that the restraint is a proportionate response to the likelihood and seriousness of that harm. The Mental Capacity Act does not by itself authorise a deprivation of liberty except where the statutory legal framework expressly provides authority.

The person must be involved as fully as possible in the development and review of their Behaviour Support Plan. Where appropriate, and subject to confidentiality, consent and the applicable legal authority, family members, representatives, advocates and relevant health and social care professionals will also be involved.

Behaviour Support Plans and associated risk assessments are living documents. They must be reviewed regularly and whenever there is:

5. Proactive Prevention Strategies

Primary prevention is our first priority. “Primary prevention uses proactive strategies that are designed to meet the person’s needs to minimise the occurrence of incidents of behaviour that challenges”. This means we focus on creating an environment and daily routine where challenging behaviours are less likely to occur. Staff will get to know each resident well – their personal history, preferences, and the things that make them happy, anxious, or upset. We use this knowledge to adjust our care and environment in a way that keeps the person as content and engaged as possible. Key proactive strategies include:

Meeting Basic Needs: Ensure the person’s physical needs (comfort, pain management, hunger, thirst, toileting, rest) are met promptly. Many aggressive outbursts in dementia can be prevented by timely attention to such needs.

Environment and Routine: Adapt the environment to reduce excess stress or confusion. For example, maintain a calm atmosphere with appropriate lighting and noise levels, provide familiar objects or decorations that are comforting, and establish a consistent daily routine. If certain times of day or activities are known triggers, adjust them (e.g. offer alternative activities or more support during those times).

Meaningful Activity and Engagement: Provide regular stimulation and engagement tailored to the person’s abilities and interests. Boredom and lack of stimulation can lead to frustration. Activities (music, reminiscing, walking, simple household tasks, social interaction, etc.) that are meaningful to the individual can prevent frustration and reduce incidences of challenging behavior.

Communication and Understanding: Use effective communication strategies, especially for individuals with dementia or limited verbal ability. This may involve using simple language, visual cues, gentle tone, and allowing extra time for the person to process. Staff should watch for non-verbal cues of distress and respond early. We also validate the person’s feelings – for instance, if a resident is upset due to a delusion or confusion, staff will acknowledge their emotions and provide reassurance rather than arguing or correcting them.

Building Trusting Relationships: All staff should approach residents with warmth, empathy and patience to build trust. A person who feels safe and understood is less likely to become frightened or agitated. Consistency in caregivers where possible helps maintain trust and predictability.

Individualised Avoidance of Triggers: The Behaviour Support Plan will list any known triggers for each person’s agitation or aggression. Staff must be aware of and, when possible, avoid or minimize these triggers. For example, if a resident becomes anxious in loud crowds, we will arrange quieter one-to-one activities instead of group outings; if a certain topic upsets them, staff will be mindful to steer conversation in a comforting direction.

By focusing on quality of life and preventative care, {{org_field_name}} aims to reduce the frequency and intensity of behaviours that challenge. Positive reinforcement of good behavior, encouragement, and celebration of the person’s abilities are also important. We treat every day as an opportunity to support the person’s wellbeing, independence, and sense of control, thereby proactively reducing the potential for aggression or frustration.

6. Early Intervention and De-escalation Techniques

Despite our best preventive efforts, there may be times when a service user begins to show signs of distress or escalating agitation. All staff are trained to recognize early warning signs of potential aggressive or challenging behavior. Early signs could include changes in body language (e.g. pacing, restlessness, clenched fists, tense posture), verbal cues (raised voice, shouting, or increased confusion), or changes in mood (like sudden anxiety or anger). Recognising these signs allows staff to intervene early with de-escalation techniques before the situation reaches a crisis point.

When early signs are noted, staff should remain calm and follow the person’s Behaviour Support Plan strategies for secondary prevention (sometimes called secondary strategies or early intervention). Key de-escalation techniques and approaches include:

Calm, Empathic Communication: Speak in a slow, gentle, reassuring tone. Use simple, clear words. Show empathy by acknowledging the person’s feelings (e.g., “I can see you’re upset – I want to help”). Often, just feeling heard can reduce a person’s anger.

Provide Space and Time: If safe, give the person a bit of space rather than crowding them. Ensure other residents or unnecessary staff distance themselves to reduce stimuli. Sometimes, a person just needs a few moments alone (with supervision from a safe distance) to regain composure. Always ensure they are still being observed from a distance for safety.

Active Listening and Distraction: Listen to what the person is trying to communicate. Let them express frustration if possible. Where appropriate, gently redirect or distract to a positive topic or activity. For example, offer a cup of tea, or invite them to a quieter area to look at a familiar photo album. Distraction and changing the environment are proven reactive strategies to defuse escalation.

Offer Choices: Often challenging behavior escalates when a person feels out of control. Offering a small choice can restore a sense of control (e.g., “Would you like to sit in the garden or your room?” or “Which of these outfits would you prefer to wear?”). Even if the choices are minor, the act of choosing can reduce aggression.

Boundary Setting in a Non-Threatening Way: If the person’s behavior is beginning to endanger others (e.g., verbal threats), staff should set gentle, clear limits. For example, “I want to help you, but I cannot do that if you hit me.” This must be done without raising voice or making punitive statements – the goal is to help the person understand the situation, not to force compliance through fear.

Call for Assistance Early: There is no stigma in calling another staff member or a senior for help if a situation is escalating. A fresh face or additional support can sometimes ease tension (as long as it doesn’t overwhelm the person). All staff carry alert devices/know the procedure to summon help in our care home if needed, so they can get backup promptly while continuing to calmly engage the service user.

Throughout an incident, staff demeanor is crucial. Staff must maintain a supportive, composed stance – be aware of their own body language (non-threatening posture, open palms, soft eye contact). We never respond to aggression with aggression. Shouting, scolding, or rushing toward a person will only escalate things further and is strictly against our approach. Instead, staff focus on de-escalation – the goal is to help the person calm down and regain control as soon as possible, while ensuring everyone’s safety. If the person begins to de-escalate (signs like slower breathing, willing to talk, reduced tension), staff should reinforce and support this by quietly praising their cooperation or offering comfort. Given our client group (people with dementia and other cognitive impairments), it’s especially important to be patient and not take any aggressive words or actions personally – they are a product of the condition or distress, and our role is to be the calming presence.

7. Use of Restrictive Interventions and Restraint

{{org_field_name}} is committed to minimising restrictive practices. Restraint or another restrictive intervention must only be used where it is lawful, absolutely necessary to address an identified risk of harm and proportionate to that risk.

Restrictive intervention must not be used:

Staff must continue to use prevention, communication and de-escalation wherever these can be used safely. Where an emergency develops so quickly that de-escalation is not practicable, or where attempted de-escalation has not reduced the risk, staff may take necessary and proportionate action to prevent harm in accordance with this policy, their training and the applicable legal framework.

Necessity and Proportionality

Before and throughout any restrictive intervention, staff must consider whether the intervention remains necessary and proportionate.

The level of restriction must be the minimum required to manage the identified risk. The intervention must end as soon as the circumstances that made it necessary have ended or a less restrictive measure can safely be used.

The fact that an intervention is included within a training programme does not in itself make its use lawful. Staff remain responsible for considering the individual circumstances, the person’s assessed needs, consent or capacity, relevant legal authority, risk of harm and whether the intervention is necessary and proportionate.

Physical Intervention

Physical intervention must be used only by staff who have received appropriate training and have been assessed as competent in the technique being used, except where an unforeseen emergency requires immediate reasonable action to prevent harm and trained assistance is not available.

Staff must not improvise or deliberately modify taught restraint techniques.

Any prohibited technique identified within the organisation’s approved training programme must not be used. Staff must not deliberately use techniques intended to cause pain, punish the person or restrict breathing.

During physical restraint:

Any person who becomes unresponsive, develops breathing difficulty, appears medically unwell or suffers a significant injury during restraint must receive immediate appropriate emergency assistance.

Mechanical Restraint

Mechanical restraint must not be introduced or used as a routine behaviour-management measure. Where equipment or a device has a restrictive purpose or effect, its use must be individually assessed and must have an appropriate lawful basis. The assessment must consider necessity, proportionality, consent or capacity, alternatives, risks, monitoring and whether the arrangements contribute to a deprivation of liberty.

Chemical Restraint and Medication

Medication must not be used primarily to sedate, control or restrict a person for punishment, staff convenience or as a substitute for appropriate care, staffing, environmental adjustment or de-escalation.

Where medication is prescribed on an “as required” basis in relation to distress, agitation or behaviour that challenges, the person must have clear individualised guidance setting out:

The administration of medication must comply with the Medicines Policy, prescribing instructions, Regulation 12 requirements and applicable consent and Mental Capacity Act requirements.

Consent, Mental Capacity and Restraint

Where a person has capacity to make the relevant decision, their refusal of care or treatment must be respected unless another lawful authority permits intervention.

Where a person lacks capacity to make the relevant decision, staff must act in accordance with the Mental Capacity Act 2005. Restraint under sections 5 and 6 of the Mental Capacity Act 2005 requires a reasonable belief that restraint is necessary to prevent harm to the person and that the restraint is proportionate to the likelihood and seriousness of that harm.

Any action taken in the person’s best interests must consider less restrictive alternatives and must not amount to an unauthorised deprivation of liberty.

Deprivation of Liberty and DoLS

A service user must not be deprived of their liberty for the purpose of receiving care or treatment without lawful authority.

Following the UK Supreme Court judgment of 2 June 2026, staff and managers must not rely solely on the former “continuous supervision and control and not free to leave” acid test when determining whether arrangements amount to a deprivation of liberty.

The Registered Manager or delegated competent person must consider the person’s individual circumstances through a multifactorial assessment, including:

A person’s wishes and feelings are relevant to determining whether they validly accept the arrangements, even where the person lacks capacity under the statutory Mental Capacity Act test to make the relevant care or residence decision. Any conclusion that the person validly accepts the arrangements must be based on the current legal test and must not be assumed simply because the person is passive or does not actively resist.

Where there is serious doubt about valid consent, where the person objects or fluctuates between acceptance and objection, where restrictions are significant, or where there is otherwise reason to believe Article 5 may be engaged, the Registered Manager must seek appropriate advice and make or facilitate the appropriate referral to the local authority for consideration under the Deprivation of Liberty Safeguards.

The Deprivation of Liberty Safeguards remain the applicable administrative authorisation process for adults aged 18 and over in care homes and hospitals in England where the statutory criteria are met.

Conditions attached to a DoLS authorisation must be understood, recorded and complied with. Changes in the person’s circumstances, restrictions, wishes, feelings or capacity must prompt consideration of whether a review is required.

Safeguarding

Any restraint or restrictive intervention which appears unnecessary, disproportionate, degrading, punitive, deliberately painful, outside the person’s lawful care arrangements, or otherwise potentially abusive must be reported immediately to the senior person on duty and dealt with under the Safeguarding Adults Policy.

The Registered Manager must ensure that safeguarding concerns are referred without delay to the appropriate local authority safeguarding adults service and other relevant authorities where the applicable threshold is met.

8. Post-Incident Procedures, Reporting, Notifications and Debriefing

Any significant incident involving aggression, behaviour that challenges, restraint or another restrictive intervention must be followed by appropriate immediate care, recording, management review and learning.

Immediate Safety and Health Assessment

Once the immediate risk has been controlled, staff must:

Where physical restraint has been used, the person’s condition after the intervention must be specifically assessed and recorded.

Informing Senior Staff

The senior person on duty must be informed as soon as practicable of a significant incident.

The Registered Manager or designated senior person must be informed without delay where:

Incident Record

The staff involved must make an accurate, complete and contemporaneous record as soon as practicable and in accordance with the Incident Reporting Policy.

The record must include, where applicable:

Records must use objective and respectful language and distinguish factual observation from opinion.

Post-Incident Review and Debrief

The incident must be reviewed by an appropriate manager or competent senior person.

The review must consider:

Staff involved in a significant incident must be offered appropriate post-incident support and the opportunity for reflective debriefing.

Follow-Up with the Service User

As soon as appropriate following the incident, the person must be offered support and an opportunity, using communication appropriate to their needs, to express their experience, wishes and feelings.

Where the person cannot participate in a conventional verbal debrief, staff must still consider their emotional presentation, behaviour, non-verbal communication and any indication that the incident has caused distress or affected their trust in staff.

Where appropriate and lawful, an advocate, representative or relevant family member may be involved.

Review of the Behaviour Support Plan and Risk Assessment

Following a significant incident or use of restraint, the Behaviour Support Plan and associated risk assessments must be reviewed promptly.

The review must identify whether:

Safeguarding Referrals

Any allegation, evidence or reasonable concern that the person has been subjected to abuse, neglect, improper treatment, unnecessary or disproportionate restraint or an unauthorised deprivation of liberty must be acted upon without delay in accordance with the Safeguarding Adults Policy.

The concern must not be withheld from the local authority safeguarding adults service merely because an internal investigation is also taking place.

Where a crime may have been committed, the police must be contacted as appropriate.

CQC Statutory Notifications

The Registered Manager or other registered person must ensure that CQC is notified without delay of incidents that are notifiable under the Care Quality Commission (Registration) Regulations 2009.

In relation to incidents covered by this policy, notifiable matters include, where the statutory criteria are met:

CQC notifications must be made using the method or form required by CQC.

The Registered Manager must also ensure compliance with the CQC notification requirements relating to Deprivation of Liberty Safeguards requests and court applications. Where a standard DoLS authorisation has been requested, the required CQC notification must be made once the outcome is known or the request is withdrawn, in accordance with Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

A safeguarding referral, police report, internal incident form or communication with a commissioner does not replace a CQC notification where a separate statutory notification is required.

Statutory Duty of Candour

The statutory duty of candour must be considered separately from the requirement to report an incident to CQC.

Not every incident of aggression, distress or restraint is automatically a notifiable safety incident for the purposes of Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Where an incident meets the statutory definition of a notifiable safety incident applicable to the provider, {{org_field_name}} must comply with the requirements of Regulation 20.

This includes:

The “relevant person” must be identified in accordance with Regulation 20. Staff must not automatically assume that a family member is the person to whom statutory candour information must be provided.

The organisation’s Duty of Candour Policy must be followed in all cases where the statutory duty may apply.

Learning and Management Oversight

Incident reports, restraint records, safeguarding concerns and post-incident reviews must be monitored by management for themes, recurrence and emerging risks.

Identified learning must result in appropriate action, which may include:

9. Staff Training and Competency

{{org_field_name}} will ensure that staff have the qualifications, competence, skills, training and experience necessary to support service users safely and in accordance with their roles.

Induction and Behaviour Support Training

Staff whose role involves contact with service users must receive appropriate induction and training relevant to the needs of the people they support.

Training must include, as appropriate to the role:

Statutory Learning Disability and Autism Training

In accordance with the statutory requirements applying to CQC-registered providers, {{org_field_name}} must ensure that every person working for the purpose of the regulated activities receives training on learning disability and autism that is appropriate to their role.

The provider will determine the level and content of training required for each role, ensure completion is recorded and monitor compliance.

Staff must not be regarded as competent to support autistic people or people with a learning disability merely because they have completed generic dementia, safeguarding or behaviour-management training.

MAPA® or Equivalent Restrictive Intervention Training

Only staff whose duties require practical restrictive-intervention skills will be authorised to use trained physical intervention techniques.

Relevant staff must receive suitable MAPA® or equivalent training from appropriately competent trainers. Training must cover:

Practical training must be appropriate to the needs, age, frailty and clinical characteristics of the people supported by the service.

Staff may only use techniques for which they have been trained and assessed as competent.

Training Updates and Competency

Training must be refreshed or updated at intervals determined by:

Where {{org_field_name}} requires annual MAPA® refresher training as part of its approved programme, staff must comply with that organisational requirement.

Completion of a training course alone does not establish ongoing competence.

Managers must obtain appropriate assurance that staff can apply their knowledge safely in practice. Competency must be reviewed where there is:

Where a member of staff is not competent to undertake an intervention safely, they must not be assigned to undertake that intervention until competence has been demonstrated.

Supervision and Staff Support

Supervision must provide staff with opportunities to:

Staff must be encouraged to report unsafe, inappropriate or excessive use of restraint and must know how to use the organisation’s safeguarding and whistleblowing procedures.

10. Governance, Monitoring and Review

The Registered Manager and provider must maintain effective governance arrangements to ensure that Positive Behaviour Support, restrictive interventions and the management of aggression comply with legal and regulatory requirements.

Incident Monitoring

Incidents involving aggression, behaviour that challenges, restraint or other restrictive practices must be recorded and subject to appropriate management oversight.

Management monitoring must consider:

Patterns, concerns or deterioration must result in documented action.

Restrictive Practice Monitoring

{{org_field_name}} must maintain sufficient records to identify and monitor the use of restrictive practices.

Monitoring must not be limited to physical restraint. Where applicable, oversight must include:

Records of individual restraint incidents must include sufficient information to determine whether the intervention was necessary, proportionate, lawful and used for the shortest necessary period.

Frequent, increasing, unusual or potentially unlawful restrictive practice must be investigated promptly.

Restraint Reduction

Management must use information from incidents, audits and individual reviews to identify opportunities to reduce restrictive intervention.

Where repeated restraint is being used, the Registered Manager must ensure that the person’s assessment, care plan, Behaviour Support Plan, risk assessment, physical health, medication, communication needs and environmental factors are reviewed.

Repeated restraint must not become accepted as routine practice simply because it is included in a care plan.

Mental Capacity and Deprivation of Liberty Oversight

The Registered Manager must maintain oversight of restrictive arrangements involving people who may lack capacity.

Governance arrangements must provide assurance that:

Care Plan Reviews

Behaviour Support Plans and associated risk assessments must be reviewed regularly and following significant incidents or changes.

Management must assure itself that records are accurate, current, person-centred and consistent with actual practice.

Safeguarding Oversight

The Registered Manager must maintain oversight of incidents that may constitute abuse, neglect or improper treatment.

Any allegation or evidence of unnecessary, disproportionate, degrading or otherwise unlawful restraint must be acted upon immediately under safeguarding procedures.

Internal management action must not delay an external safeguarding referral where one is required.

CQC Notification Oversight

The Registered Manager must have systems to identify events that require notification to CQC and to ensure notifications are made within the statutory timescale.

This includes ensuring that incidents requiring notification under Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 are notified without delay.

Evidence of the decision whether or not to notify CQC must be retained where appropriate.

Training and Competency Oversight

Management must monitor:

Staff who are not trained or competent for a particular intervention must not be assigned to carry it out.

Feedback and Complaints

Feedback or complaints about restraint, behaviour support or restrictive practice must be reviewed for safeguarding implications and organisational learning.

People using the service must be supported to raise concerns and must not be disadvantaged for doing so.

Records and Audit

Records relating to incidents, restraint, safeguarding, capacity, best interests, DoLS, staff competency and statutory notifications must be accurate, complete and contemporaneous.

Management audits must identify omissions, inconsistencies and emerging risks and must result in recorded corrective action.

Policy Review

This policy must be reviewed at least annually and sooner where required because of:

Material changes must be communicated to relevant staff and training or competency assessment provided where necessary.

11. References and Guidance

This policy must be read and implemented with reference to the current versions of the following legislation, regulations and statutory or regulatory guidance:

Relevant internal policies include:

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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