CHW178-Safe Use of Bedrails Policy
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Safe Use of Bedrails Policy
1. Purpose
The purpose of this policy is to ensure that the use of bedrails at {{org_field_name}} is carried out safely, appropriately, and in line with the individual needs and risks of each resident. The policy is designed to meet the requirements of the Regulation and Inspection of Social Care (Wales) Act 2016, the Health and Safety at Work etc. Act 1974, the Manual Handling Operations Regulations 1992, the Medicines and Healthcare products Regulatory Agency (MHRA) guidance on bedrails, and current CIW expectations. Improper use of bedrails can cause serious injury or entrapment. This policy ensures that decisions about the use of bedrails are person-centred, risk assessed, regularly reviewed, and comply with best practice in promoting dignity, autonomy, and safety.
2. Scope
This policy applies to all staff at {{org_field_name}} involved in the assessment, provision, fitting, use, monitoring, cleaning, and maintenance of bedrails. It covers all residents who may require bedrails as part of their care plan and includes both permanent and temporary use. It also applies to agency staff, contractors, and external health professionals contributing to decision-making and care provision.
3. Related Policies
This policy should be read in conjunction with the following:
CHW07 – Person-Centred Care Policy
CHW08 – Dignity and Respect Policy
CHW09 – Consent to Care Policy
CHW11 – Safe Care and Treatment Policy
CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
CHW16 – Health and Safety at Work Policy
CHW18 – Risk Management and Assessment Policy
CHW24 – Management of Accidents, Incidents and Near Misses Policy
CHW39 – Mental Capacity and Deprivation of Liberty Safeguards Policy
CHW37 – Moving and Handling Policy
4. Policy Statement and Implementation
A. Person-Centred Assessment and Justification
Bedrails will only be used following a comprehensive, person-centred risk assessment that considers both the risks of falling from bed and the risks associated with using bedrails, such as entrapment, climbing over, agitation, or restraint. The assessment takes into account the person’s mobility, cognition, behaviour, sleep patterns, personal preferences, and overall health. Bedrails will not be used as a means of restraint or for staff convenience. Alternatives such as low beds, sensor mats, crash mats, and increased observation will always be considered first. The decision to use bedrails is recorded in the care plan with a clear rationale, consent (or best interest decision), and a schedule for review.
B. Risk Assessment Procedure
A bedrail risk assessment form is completed for any resident being considered for bedrails. The assessment includes evaluation of:
- Height and weight of mattress in relation to rail
- Gaps between bedrail bars and between mattress, bedframe, and rail
- Risk of the resident attempting to climb over the rails
- Compatibility with bed type and mattress
- Bed height and accessibility
- Presence of cognitive impairment, delirium, or agitation
- Medical conditions (e.g., seizures, strokes, Parkinson’s)
- Alternatives and less restrictive options
The assessment is reviewed monthly, or sooner if there is a change in health or behaviour, following a fall or incident, or if the person expresses discomfort or distress.
C. Consent and Mental Capacity
Residents with capacity are asked for their informed consent before bedrails are introduced. This includes discussion of the purpose, risks, and alternatives. Where a resident lacks capacity, a best interest decision is made in accordance with CHW39 – Mental Capacity and DoLS Policy. Family members or representatives are consulted, and advocacy services are offered. All decisions are recorded and signed, with clear documentation of the decision-making process.
D. Safe Installation and Compatibility
Bedrails are only installed by trained staff or maintenance personnel who understand manufacturer guidance and safety standards. Compatibility between the bed, mattress, and bedrail is essential. We do not mix components from different manufacturers. Where required, gap fillers, rail protectors, or extensions are used to eliminate entrapment risks. A visual inspection is carried out immediately following installation and signed off in the Bedrail Safety Log.
E. Daily Checks and Ongoing Monitoring
Bedrails in use are visually inspected daily by care staff as part of routine checks. This includes checking for movement, gaps, damage, wear to fastenings, and overall cleanliness. Any issues are reported immediately to the nurse in charge or maintenance team and the bedrail is taken out of use until repaired or replaced. Residents using bedrails are monitored regularly to assess comfort, positioning, and safety, particularly during repositioning, toileting, or overnight checks.
F. Alternatives and Least Restrictive Options
We actively explore and document alternatives to bedrails as part of the assessment process. These may include:
- Profiling beds that lower to floor level
- Floor sensor mats and call bells
- Crash mats beside beds
- Increased supervision or night checks
- Body positioning pillows or wedges
- Environmental modifications to support safety
The choice of intervention must reflect the least restrictive option that promotes the resident’s safety, comfort, and independence.
G. Incident Reporting and Review
All incidents involving bedrails, including entrapment, injury, or distress, are reported under CHW24 – Management of Accidents, Incidents and Near Misses Policy. Immediate action is taken to safeguard the individual and review the use of bedrails. A root cause analysis is conducted by the Registered Manager, and changes to the care plan or equipment are implemented. If a serious injury occurs, this is reported to CIW and the Health and Safety Executive (HSE) as required.
H. Staff Training and Competence
All staff involved in assessing, fitting, and monitoring bedrails are trained in their safe use as part of their induction and annual refresher training programme (CHW27). Training includes risk identification, installation procedures, legal and ethical considerations, and alternatives to restrictive practices. Competence is assessed through observation and supervision. Any staff member unsure about bedrail safety must escalate their concern to a senior colleague or the Registered Manager.
I. Equipment Maintenance and Procurement
Bedrails are sourced from approved suppliers and meet MHRA and British Safety Standards. They are cleaned routinely as part of our infection prevention procedures (CHW17) and subject to regular maintenance checks. Maintenance records are kept in the Equipment Safety Log, and bedrails are replaced at the first sign of wear, damage, or loss of function. Repairs are only carried out by authorised personnel. The Registered Manager and maintenance team ensure that all bed-related equipment is tracked, inspected, and serviced in accordance with our asset management schedule.
5. Policy Review
This policy will be reviewed annually or earlier in response to changes in legislation, equipment guidance, incidents involving bedrails, or CIW feedback. The Registered Manager is responsible for ensuring the safe use of bedrails is embedded in practice and that any updates to this policy are communicated to staff and reflected in training.
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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