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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

4.1 Person-Centred Assessment and Justification

Bedrails will only be used following a comprehensive, person-centred risk assessment which demonstrates that their use is necessary and appropriate for the individual and that the expected benefits outweigh the risks. The assessment must consider both the risk of the individual falling from bed and the risks created or increased by the use of bedrails, including entrapment, asphyxiation, climbing over the rail, falling from a greater height, agitation, distress, injury and restriction of the individual’s freedom of movement.

The assessment must take account of the individual’s mobility, physical size and anatomy, cognition, behaviour, level of consciousness, sleep patterns, medical conditions, communication needs, personal preferences and wishes, capacity to make the relevant decision and any other equipment being used with or around the bed.

Bedrails must never be used for staff convenience, as a punishment, or simply because they have previously been used. Alternatives and less restrictive options, including low or ultra-low beds, appropriate floor or crash mats, sensor or alarm systems, increased observation and other individually assessed measures, must be considered before bedrails are introduced and whenever their continued use is reviewed.

The service recognises that, depending on their purpose and effect, bedrails may constitute a restrictive practice or mechanical restraint. Where use of bedrails restricts an individual’s liberty of movement, their use must comply with Regulation 29 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended. The restriction must be necessary to prevent a risk of harm to the individual or another person and must be a proportionate response to that risk. The least restrictive effective option must always be used.

The decision to use bedrails, the reasons for that decision, the alternatives considered, the risks and benefits identified, the individual’s consent where they have capacity, and any decision made under the Mental Capacity Act 2005 where the individual lacks capacity must be clearly recorded in the individual’s personal plan and associated risk assessment. Where the arrangement amounts to a restrictive practice, this must also be identified and recorded as such and monitored in accordance with the service’s policy on control, restraint and restrictive practices.

4.2 Risk Assessment Procedure

A specific bedrail risk assessment must be completed before bedrails are first provided or used for an individual. The assessment must be person-centred and must consider the individual, the bed, mattress, bedrails, accessories, other equipment in the bed environment and the way in which all of these interact.

The assessment must include, as applicable:

• the individual’s height, weight, physical size, body shape and anatomy;
• the individual’s mobility and ability to reposition independently;
• whether the individual is able or likely to attempt to climb over, under, around or between the bedrails;
• cognition, confusion, delirium, agitation, distress, involuntary movements or behaviours which may increase the risk associated with bedrail use;
• medical or neurological conditions which may affect movement, awareness or risk, including seizures, stroke, Parkinson’s disease or other relevant conditions;
• the individual’s level of consciousness and any variation in consciousness;
• the type, make and model of the bed and bedrails;
• the manufacturer’s instructions and stated compatibility of the bed, mattress, rails and accessories;
• the dimensions and condition of the mattress, including its height, width, length, firmness and the extent to which its edge may compress;
• any mattress overlay, pressure-relieving mattress, alternating-pressure mattress, turning system or other equipment which may change the effective dimensions of the mattress or bedrail;
• the effective height of the bedrail above the mattress;
• gaps within the bedrail and gaps between the bedrail, mattress, headboard, footboard and mattress platform which may create an entrapment hazard;
• the security, condition and positioning of clamps, fixings, catches and other fittings;
• whether the rail can move away from the mattress or bed frame;
• the effect of different positions and configurations of a profiling or adjustable bed;
• whether the individual uses the rail to assist mobility or transfers and, if so, whether the particular rail is designed and approved for that purpose;
• other equipment or objects around the bed which may introduce or increase a risk;
• the risk of the individual falling from a greater height if they climb over the bedrail;
• the individual’s wishes, feelings and preferences;
• the individual’s mental capacity in relation to the decision to use bedrails;
• whether use of the bedrails may constitute a restrictive practice or deprivation of liberty;
• alternative and less restrictive measures; and
• the overall balance of benefit and risk from using or not using bedrails.

The risk assessment must be reviewed at least monthly and sooner whenever there is a significant change in the individual’s health, mobility, cognition, behaviour, physical size, condition or care needs; following a fall, entrapment, near miss or other incident; where the individual expresses discomfort or distress; or where there is evidence that the existing arrangement may no longer be safe.

The assessment must also be reviewed whenever any component of the bed system is changed, replaced, removed and refitted or adjusted, including the bed, mattress, mattress overlay, bedrails, rail accessories, pressure-relieving equipment or other equipment which may affect the safety of the bedrail arrangement. The compatibility and safe configuration of the complete bed system must be confirmed before the bedrails are returned to use.

The outcome of each assessment and review, including the rationale for continued use or discontinuation of the bedrails, must be documented in the individual’s records and reflected in their personal plan.

4.3 Consent, Mental Capacity and Lawful Authority

Where an individual has capacity to make the relevant decision, their informed consent must be obtained before bedrails are introduced. The individual must be given information in a manner they can understand about why bedrails are being considered, the intended benefits, the material risks associated with their use, available alternatives and their right to refuse or withdraw consent.

Mental capacity must be presumed unless there is a reason to doubt it. Where there is doubt about an individual’s capacity to make the specific decision about the use of bedrails, a decision-specific assessment of capacity must be undertaken and recorded in accordance with the Mental Capacity Act 2005 and its Code of Practice. Staff must take all practicable steps to support the individual to make the decision before concluding that they lack capacity.

Where the individual lacks capacity to make the relevant decision, any decision to use bedrails must be made and recorded in accordance with the Mental Capacity Act 2005 best interests requirements. The decision must consider the individual’s past and present wishes and feelings, beliefs and values, the views of relevant people who should be consulted, the risks and benefits of the available options and whether the purpose can be achieved in a less restrictive way.

Family members and other persons close to the individual should be consulted where appropriate as part of the best interests process, but they must not be treated as having authority to consent on the individual’s behalf unless they have the relevant lawful authority, for example a valid and applicable Lasting Power of Attorney for health and welfare or appointment as a deputy by the Court of Protection with authority covering the decision.

Where appropriate, the service must involve an Independent Mental Capacity Advocate in accordance with the requirements of the Mental Capacity Act 2005.

The service must separately consider whether the use of bedrails, alone or together with the individual’s other care arrangements, amounts to a deprivation of liberty. A best interests decision does not by itself provide authority for a deprivation of liberty. No individual may be deprived of their liberty for the purpose of receiving care and support without lawful authority.

Where the individual’s care arrangements may amount to a deprivation of liberty and the individual lacks capacity to consent to those arrangements, the Registered Manager must ensure that the appropriate lawful authorisation is sought in accordance with the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards, or any legal framework replacing them that is in force at the relevant time. Any request to a supervisory body in relation to the Deprivation of Liberty Safeguards must be notified to Care Inspectorate Wales in accordance with the applicable statutory notification requirements.

All capacity assessments, consultations, best interests decisions, consent, refusals, lawful authority and reviews must be clearly documented in the individual’s records and personal plan.

4.4 Safe Installation and Compatibility

Bedrails must only be fitted, adjusted or removed by staff, maintenance personnel or other persons who have received appropriate training and have been assessed as competent for the task they undertake.

The bed, mattress, bedrails and any accessories or additional equipment must form a safe and compatible system. Installation must be carried out in accordance with the relevant manufacturer’s instructions for use. Integral bedrails supplied or specifically approved for use with the bed should be used where appropriate.

Components from different manufacturers, third-party bedrails or accessories must not be combined unless the manufacturer’s information confirms compatibility or a competent person has established, documented and authorised that the proposed combination is safe and suitable for the particular individual and intended use.

Where the bedrail is a medical device or accessory within the scope of the UK Medical Devices Regulations 2002, as amended, the service must ensure that it carries the appropriate conformity marking required for lawful supply and use, including UKCA, CE or CE UKNI marking as applicable.

Before first use and following every installation, refitting, adjustment or change to the bed system, a competent person must confirm that:

• the bedrails are the correct type and size for the bed and individual;
• all clamps, fixings, catches and locking mechanisms are correctly positioned and secure;
• the rail cannot move in a way which creates an unsafe gap;
• the mattress is of the correct size, type and specification;
• mattress compression does not create an unacceptable entrapment gap;
• mattress overlays, pressure-relieving surfaces and other equipment have been taken into account;
• relevant gaps and openings do not create an unacceptable entrapment risk;
• the effective height of the rail above the mattress remains sufficient for its intended purpose;
• all bed positions and configurations which may be used have been considered; and
• the installation complies with the manufacturer’s instructions and the individual’s current bedrail risk assessment.

Bedrail bumpers, protectors, extensions, gap-reducing devices or other accessories must only be used where they are suitable for the particular bedrail system, permitted by the manufacturer’s instructions and individually risk assessed. They must not be assumed to remove an entrapment risk simply because they cover a gap.

Blankets, pillows, bedding, towels or other improvised materials must never be used to fill an unsafe gap between a mattress, bed and bedrail.

A documented safety check must be completed immediately following installation or alteration and recorded in the Bedrail Safety Log. The bedrail must not be brought into use where compatibility or safe installation cannot be confirmed.

4.5 Daily Checks and Ongoing Monitoring

Bedrails in use must be visually inspected daily by care staff as part of routine safety checks.

Daily checks must include:

• security and stability of the bedrail;
• movement or loosening of the rail;
• gaps between the rail, mattress and bed frame;
• damage, wear or deformation;
• condition of fastenings, catches and locking mechanisms;
• mattress position and condition;
• whether pressure-relieving equipment or other accessories have moved or altered the safe configuration;
• cleanliness of the rail and surrounding equipment; and
• any indication that the arrangement is causing discomfort, distress or increased risk to the individual.

Any defect, change or concern must be reported immediately to the nurse in charge, senior member of staff or Registered Manager and to the maintenance team where appropriate.

Where a defect or unsafe condition is identified, the bedrail must be taken out of use unless immediate removal would place the individual at greater risk. Where immediate removal is not safe, alternative control measures must be implemented without delay until the equipment can be made safe or replaced.

Individuals using bedrails must be monitored at a frequency based on their individual risk assessment and personal plan. Monitoring must include the individual’s comfort, position, access to the call bell where applicable, signs of distress or attempts to climb over or around the rail, and continued suitability of the bedrail arrangement.

Particular attention must be given during repositioning, personal care, transfers, toileting and overnight checks.

4.6 Alternatives and Least Restrictive Options

The service must actively consider and document alternatives to bedrails before they are introduced and whenever their continued use is reviewed.

Alternatives may include:

• profiling beds capable of being lowered close to floor level;
• low or ultra-low beds;
• appropriately assessed floor or crash mats;
• sensor mats or alarm systems;
• accessible call bells;
• increased supervision or individually assessed night checks;
• appropriate positioning equipment;
• environmental modifications;
• changes to furniture positioning;
• review of medicines or clinical factors contributing to falls risk, where appropriate; and
• other individually assessed measures which promote safety without unnecessarily restricting freedom of movement.

The choice of intervention must reflect the least restrictive effective option and must promote the individual’s safety, comfort, dignity, independence and personal outcomes.

The service must not assume that a bedrail is safer than an alternative. The relative benefits and risks of each reasonable option must be considered as part of the individual’s assessment.

Where a less restrictive measure can safely achieve the required outcome, that measure must be used in preference to bedrails.

4.7 Incident Reporting, Statutory Notification and Review

Any accident, incident, near miss, entrapment, suspected entrapment, fall, injury, equipment failure or significant distress associated with a bedrail must be reported immediately in accordance with CHW24 – Management of Accidents, Incidents and Near Misses Policy. Immediate action must be taken to protect the individual and any other person who may be at risk.

Where there is concern that the bedrail, bed, mattress or associated equipment may be unsafe, the affected equipment must be taken out of use where it is safe and appropriate to do so and must not be returned to use until it has been assessed by a competent person and its safety has been confirmed. Where removing the equipment itself could place the individual at increased risk, an immediate alternative risk-management plan must be implemented.

Following an incident or near miss, the individual’s condition must be assessed and appropriate medical or healthcare advice obtained without delay where required. The individual’s bedrail risk assessment and personal plan must be reviewed immediately and amended where necessary.

The Registered Manager must ensure that Care Inspectorate Wales is notified without delay, using the method required by CIW, of any event which is notifiable under Regulation 60 and Schedule 3 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

This includes any serious accident or injury to an individual which, in the reasonable opinion of a healthcare professional, requires treatment by that or another healthcare professional and has or may have resulted in:

• damage or impairment of the individual’s sensory, motor or intellectual functions which is permanent or likely to last for more than 28 days;
• a change to the structure of the individual’s body;
• prolonged pain or prolonged psychological harm;
• death; or
• shortening of the individual’s life expectancy.

Notifiable events must normally be notified to CIW within 24 hours and in all cases without delay, unless a different statutory notification period applies.

Where an incident involves actual or suspected abuse, neglect, improper treatment or unlawful restraint, the service’s safeguarding procedures must also be followed and appropriate safeguarding referrals and notifications made.

Where the incident meets the statutory reporting criteria under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, the required report must also be made to the Health and Safety Executive. An incident must not be reported to the Health and Safety Executive merely because it is serious; the applicable RIDDOR criteria must first be considered.

Where a bedrail or associated medical device has caused or contributed to an adverse incident, malfunction or near miss, the Registered Manager must ensure that the applicable medical-device incident reporting arrangements for Wales are followed and that the manufacturer or equipment provider is informed where appropriate.

The Registered Manager must ensure that the circumstances and causes of significant incidents are investigated proportionately. This must include consideration of the individual’s needs, the original decision to use bedrails, compatibility of the bed system, installation, maintenance, staff practice, supervision, training and whether a less restrictive alternative should now be used.

Any learning, remedial action, equipment changes, changes to the individual’s personal plan or risk assessment, and any wider service-level actions must be recorded and monitored to completion.

4.8 Staff Training and Competence

All staff whose duties include assessing, selecting, fitting, adjusting, checking, monitoring or maintaining bedrails must receive training appropriate to their role.

Training must include, as applicable:

• the purpose and limitations of bedrails;
• risks associated with bedrail use, including entrapment, asphyxiation, falls from height and climbing over rails;
• person-centred risk assessment;
• consideration of alternatives and least restrictive options;
• recognition of bedrails as a potential restrictive practice;
• relevant requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards;
• consent and best interests decision-making;
• manufacturer’s instructions;
• bed, mattress and bedrail compatibility;
• correct fitting and adjustment;
• identification of unsafe gaps;
• the effect of mattress compression and pressure-relieving equipment;
• daily safety checks;
• incident and near-miss reporting;
• escalation of equipment defects and safety concerns; and
• the staff member’s responsibilities under this policy.

Staff competence must be assessed before they undertake tasks independently and reviewed through supervision, observation, refresher training and following any identified concern or incident.

Staff must not fit, adjust or make decisions about bedrails where they have not been trained and assessed as competent to undertake that task.

Any staff member who is uncertain about the safety or suitability of a bedrail arrangement must immediately escalate the concern to a senior member of staff, nurse in charge where applicable, or the Registered Manager.

Training and competency records must be maintained in accordance with the service’s staff training and development arrangements.

4.9 Equipment Maintenance and Procurement

Bedrails, beds, mattresses and associated accessories must be procured from reputable and traceable suppliers and must be suitable for their intended purpose, the individuals who may use them and the beds and mattresses with which they are intended to be combined.

Where equipment falls within the definition of a medical device or medical-device accessory, it must comply with the applicable requirements of the UK Medical Devices Regulations 2002, as amended, including the appropriate UKCA, CE or CE UKNI conformity marking as applicable.

Before equipment is purchased, hired, accepted on loan or introduced into service, the service must obtain sufficient information to confirm:

• its intended use;
• the population for whom it is suitable;
• compatibility requirements;
• mattress and dimensional requirements;
• any restrictions or contraindications;
• instructions for installation and use;
• cleaning and decontamination requirements;
• inspection and maintenance requirements;
• expected service life where specified; and
• availability of replacement components and technical support where relevant.

Beds and bedrails must be entered onto the service’s equipment or asset register and be subject to an appropriate planned preventative maintenance programme. Maintenance, inspection and servicing must be undertaken at the intervals and in the manner specified by the manufacturer and additionally whenever damage, deterioration or malfunction is suspected.

Maintenance and safety inspections must include, where relevant, examination of:

• clamps, fixings and attachment points;
• catches and locking mechanisms;
• structural integrity of the rail;
• deformation, cracking, corrosion or excessive wear;
• loose, missing or damaged components;
• movement of the rail which could create an entrapment gap;
• mattress condition and compatibility;
• bedrail dimensions and effective height;
• compatibility of accessories and additional equipment; and
• any other matter identified in the manufacturer’s instructions.

Any bedrail, bed, mattress or associated component which is damaged, excessively worn, insecure, incompatible or otherwise suspected to be unsafe must be withdrawn from use unless immediate withdrawal would itself create a greater risk to the individual. In those circumstances, immediate risk-control measures must be introduced until safe replacement equipment is available.

Repairs, alterations and replacement of safety-critical components must only be undertaken by appropriately authorised and competent persons using components which are suitable for the particular equipment. Unauthorised modifications must not be made.

Following repair, servicing, replacement of components or reconfiguration of the bed system, compatibility and safe installation must be checked before the equipment is returned to use and the individual’s bedrail risk assessment must be reviewed where the change could affect their safety.

Cleaning and decontamination must be undertaken in accordance with the manufacturer’s instructions and the service’s infection prevention and control procedures.

All inspection, servicing, maintenance, repairs, defects and remedial actions must be documented in the Equipment Safety Log or asset-management system and retained in accordance with the service’s records-management requirements.

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.

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