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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Managing Adults’ Challenging Behaviour Policy

1. Purpose

The purpose of this policy is to ensure that all instances of challenging behaviour displayed by adults using the services of {{org_field_name}} are managed safely, respectfully, and in a person-centred, non-discriminatory manner that upholds the rights, dignity, and well-being of the individual. This policy is aligned with the Regulation and Inspection of Social Care (Wales) Act 2016, the Social Services and Well-being (Wales) Act 2014, and CIW guidance. It outlines our commitment to a proactive, positive behavioural support approach rooted in understanding the causes of behaviour and avoiding restrictive practices wherever possible.

2. Scope

This policy applies to all employees at {{org_field_name}}, including permanent, temporary, agency staff, management, and external professionals working in or visiting the service. It covers all situations where adults receiving care or support may display behaviour that is perceived as challenging, distressing, aggressive, disruptive, or self-injurious. It includes behaviour linked to dementia, mental health conditions, sensory needs, communication difficulties, trauma, learning disabilities, or environmental stress.

3. Related Policies

This policy should be read alongside the following:
CHW07 – Person-Centred Care Policy
CHW08 – Dignity and Respect Policy
CHW11 – Safe Care and Treatment Policy
CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
CHW18 – Risk Management and Assessment Policy
CHW24 – Management of Accidents, Incidents and Near Misses Policy
CHW27 – Staff Supervision, Training and Development Policy
CHW29 – Whistleblowing (Speaking Up) Policy
CHW39 – Mental Capacity and Deprivation of Liberty Safeguards Policy

4. Policy Statement

At {{org_field_name}}, we believe all behaviour is a form of communication and that people who display challenging behaviour should be met with compassion, curiosity, and skilled support. Our goal is to understand the underlying causes, minimise triggers, reduce risk, and support individuals to feel safe, valued, and in control. We use Positive Behaviour Support (PBS) as our core framework and work in partnership with individuals, their families, advocates, and professionals to implement effective support strategies.

5. Definition of Challenging Behaviour

Challenging behaviour may include physical aggression, verbal outbursts, self-harm, withdrawal, resistance to care, sexualised behaviour, property damage, or disruption. It is defined as behaviour that may put the individual or others at risk, interfere with daily activities, or result in distress to the person or those around them. We do not view individuals as ‘challenging’ but recognise the importance of adapting our care approach to meet their unique needs.

6. Understanding and Preventing Challenging Behaviour

Every individual has a detailed care plan and behavioural risk assessment that explores known triggers, past trauma, communication styles, health conditions, pain or discomfort, medication effects, sensory needs, and unmet emotional or social needs. Staff are trained to recognise early signs of distress and use de-escalation techniques such as distraction, reassurance, calm tone, providing space, or offering choices. The physical environment is assessed for noise, lighting, crowding, or overstimulation, and adapted to promote calmness. We support predictable routines, meaningful activities, and continuity of care to reduce anxiety and frustration.

7. Positive Behaviour Support (PBS) Planning

Where an individual displays behaviour which challenges frequently, presents a significant risk of harm, or may require the use of a restrictive practice, a person-centred Positive Behaviour Support Plan must be developed as part of, or clearly linked to, the individual’s personal plan.

The plan must be developed, so far as practicable, with the individual and, where appropriate and lawful, their representative, family members, placing authority, service commissioner and relevant health or social care professionals. The individual’s communication needs, wishes, feelings, preferences, cultural background, language needs, previous experiences and any known history of trauma must be taken into account.

The Positive Behaviour Support Plan must identify, where relevant:

• the individual’s known or likely triggers for distress;
• environmental, physical, psychological, communication, sensory, health and social factors which may contribute to the behaviour;
• early signs that the individual is becoming distressed;
• proactive strategies intended to prevent distress and reduce the likelihood of behaviour which challenges;
• the individual’s preferred communication and de-escalation approaches;
• reasonable adjustments required to support the individual;
• positive risk-taking arrangements;
• any agreed crisis-management strategies;
• any restrictive practice that may foreseeably be required as a last resort to prevent harm;
• the circumstances in which any planned restrictive practice may be considered;
• how staff must monitor the individual during and following any restrictive practice;
• the steps that will be taken to reduce and, wherever possible, eliminate the future use of restrictive practices; and
• the arrangements for post-incident support and review.

Any planned restrictive practice must be individually assessed, lawful, necessary to prevent a risk of harm, proportionate to that risk and the least restrictive effective option available. A planned restrictive practice must not be used automatically simply because it appears in an individual’s plan. Staff must consider the circumstances and risks present at the time of each incident.

The individual’s personal plan, including any Positive Behaviour Support Plan, must be reviewed whenever required and at least every three months. It must be reviewed sooner following a significant change in the individual’s needs, risks or circumstances or where the existing plan is not supporting the individual to achieve their personal outcomes.

Any use of a restrictive practice which was not provided for in the individual’s current personal plan must trigger an immediate review of the individual’s assessment, risk management arrangements and personal plan. Following any significant incident, the Registered Manager must determine whether an earlier multidisciplinary or professional review is required.

Staff providing care and support to the individual must have access to the current Positive Behaviour Support Plan, understand the parts relevant to their role and provide care and support in accordance with it.

8. Safe Interventions, Control, Restraint and Restrictive Practices

{{org_field_name}} is committed to preventing and reducing the use of control, restraint and other restrictive practices. Care and support will be planned and delivered using person-centred, rights-based and preventative approaches so that restrictive practices are avoided wherever possible.

For the purposes of this policy, restrictive practice includes any practice which restricts an individual’s freedom, movement or choice. This may include physical restraint, mechanical restraint, chemical restraint, environmental restraint, seclusion or enforced isolation, long-term segregation, coercive practices and other measures which prevent an individual from doing something they wish to do or compel them to do something they do not wish to do.

For the purposes of Regulation 29 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, a person controls or restrains an individual where they use or threaten to use force to secure an act which the individual resists, or restrict the individual’s liberty of movement, whether or not the individual resists, including through physical, mechanical or chemical means.

Care and support must not include an act intended to control or restrain an individual unless:

• it is necessary to prevent a risk of harm to the individual or another individual;
• it is a proportionate response to that risk;
• it is lawful in the individual circumstances;
• the least restrictive effective option available is used; and
• the intervention is carried out by staff who have been trained and assessed as competent in the particular method of control or restraint being used.

Restrictive practices must only be used as a last resort. They must never be used:

• as punishment;
• to humiliate or degrade an individual;
• for the convenience of staff;
• because an individual is perceived as difficult;
• to secure routine compliance where there is no relevant risk of harm; or
• to compensate for insufficient staffing, inadequate staff skills, poor care planning or other resource difficulties.

Before a foreseeable restrictive practice is included within an individual’s care arrangements, the service must undertake and record an individual risk assessment. The assessment must consider the nature and seriousness of the risk of harm, the individual’s physical and mental health, frailty, communication needs, sensory needs, history of trauma, known medical risks, capacity and consent where relevant, and whether less restrictive alternatives can safely achieve the required outcome.

Where an individual has capacity to make the relevant decision, their rights, wishes and decisions must be respected subject to the lawful limitations which apply where action is immediately necessary to prevent harm.

Where there is reason to doubt an individual’s capacity to make a particular decision, capacity must be assessed in accordance with the Mental Capacity Act 2005. Capacity is decision-specific and time-specific. Where the individual lacks capacity for the relevant decision, any act carried out under the Mental Capacity Act must comply with its statutory principles, including the requirement to act in the individual’s best interests and to consider whether the purpose can be achieved in a less restrictive way.

The use of physical, mechanical, chemical or environmental restriction must not amount to an unlawful deprivation of liberty. Where a deprivation of liberty may arise, the requirements set out in Section 9 of this policy must be followed.

Any planned restrictive practice must be clearly recorded within the individual’s current personal plan and Positive Behaviour Support Plan. The plan must specify the circumstances in which the intervention may be considered, the method which may be used, known contraindications and risks, monitoring requirements, and the measures being taken to reduce future use.

The fact that a restrictive practice is included within an individual’s personal plan does not authorise its routine or automatic use. At every occurrence, staff must be satisfied that the legal criteria for its use are met in the circumstances existing at that time.

During any restrictive intervention, staff must monitor the individual’s safety, physical condition, breathing, distress and well-being. The intervention must end as soon as it is no longer necessary or proportionate. Medical assessment or treatment must be obtained promptly where there is injury, breathing difficulty, loss of consciousness, significant physical distress, significant psychological distress or any other clinical concern.

Following every use of control, restraint or another restrictive practice:

• the individual must receive appropriate reassurance, support and an opportunity, in a form they can understand, to communicate their views about what occurred;
• any injury or deterioration in physical or emotional well-being must be responded to promptly;
• the incident must be reported to the appropriate manager;
• a record must be completed within 24 hours;
• the individual’s personal plan and risk assessment must be reviewed where required;
• any restrictive practice not already provided for in the individual’s current plan must trigger an immediate review; and
• safeguarding, CIW, police, health professional, commissioner or other notifications and referrals must be made where the relevant statutory criteria are met.

The service will actively monitor the frequency, type, duration, circumstances and outcomes of restrictive practices with the aim of reducing and, wherever possible, eliminating their use.

9. Safeguarding, Mental Capacity, Deprivation of Liberty and Statutory Notifications

Behaviour which challenges, or the use of a restrictive practice, does not automatically constitute a safeguarding matter. However, where there is an allegation, evidence or reasonable concern that an individual has experienced abuse, neglect or improper treatment, including unlawful restraint or an inappropriate deprivation of liberty, staff must act immediately in accordance with the service’s safeguarding policy and the Wales Safeguarding Procedures.

Where a safeguarding concern arises, staff must:

• take immediate action necessary to protect the individual and any other person at risk;
• report the concern immediately through the service’s safeguarding arrangements;
• preserve relevant information and evidence;
• make or support appropriate referrals to the local authority and any other relevant agency;
• record the allegation or evidence, the action taken and any referrals made; and
• ensure that the individual is informed and supported in a way appropriate to their communication needs, understanding and circumstances.

The Safeguarding Lead, {{org_field_safeguarding_lead_name}}, in their role as {{org_field_safeguarding_lead_role}}, will oversee the service response and liaison with {{org_field_local_authority_authority_name}} and other agencies where appropriate.

Mental capacity and consent

The Mental Capacity Act 2005 must be followed whenever there is reason to doubt an individual’s capacity to make a particular decision concerning their care, treatment or proposed restrictions. Capacity must not be assumed to be absent because of the individual’s diagnosis, disability, behaviour, age or appearance.

Any assessment of capacity must relate to the specific decision which needs to be made and the time at which it must be made. All practicable steps must first be taken to support the individual to make the decision themselves.

Where an individual lacks capacity to make the relevant decision, any decision or act undertaken on their behalf under the Mental Capacity Act 2005 must be in their best interests and consideration must be given to whether the required purpose can be achieved in a way which is less restrictive of the individual’s rights and freedom of action.

Deprivation of liberty

An individual must not be deprived of their liberty for the purpose of receiving care and support without lawful authority.

The service must comply with the Mental Capacity Act 2005, the Deprivation of Liberty Safeguards and applicable case law and national guidance.

Following the UK Supreme Court judgment of 2 June 2026 in A Reference by the Attorney General for Northern Ireland of a devolution issue under paragraph 34 of Schedule 10 to the Northern Ireland Act 1998 [2026] UKSC 16, staff and managers must not rely solely upon the former Cheshire West “acid test” when considering whether an individual is deprived of their liberty.

The assessment must consider the individual’s concrete circumstances as a whole. Relevant factors include:

• the nature and type of restrictions imposed;
• the duration of the restrictions;
• the effect of the restrictions upon the individual;
• the manner in which the restrictions are implemented;
• whether and how the individual objects;
• the individual’s expressed wishes and feelings;
• the degree and nature of supervision and control;
• whether the individual is free to leave;
• the relative normality of the arrangements;
• the purpose of the arrangements; and
• how closely the arrangements resemble detention rather than an ordinary restriction on movement.

No single factor is determinative.

For the purposes of Article 5 of the European Convention on Human Rights, valid consent to confinement is not identical to having legal capacity to make the relevant care and residence decision under the Mental Capacity Act 2005. An individual who lacks legal capacity for the relevant care and residence decision may nevertheless, depending upon the circumstances, be capable of expressing wishes and feelings which amount to valid consent for Article 5 purposes. Compliance alone must not be treated as consent.

Where there is doubt about whether an individual is objecting, whether valid consent exists, whether the restrictions amount to a deprivation of liberty, or whether Article 5 is engaged, the Registered Manager must seek appropriate professional advice and a referral must be made to the relevant supervisory body for consideration of a Deprivation of Liberty Safeguards authorisation, or to the Court of Protection where that is the appropriate legal route.

Existing restrictions and DoLS arrangements must be kept under review and unnecessary restrictions must be reduced or removed without delay.

CIW and other statutory notifications

The Registered Manager and Responsible Individual must ensure that notifications are made to Care Inspectorate Wales in accordance with Regulations 60 to 62, Schedule 3 and any other applicable notification requirement.

In relation to incidents falling within the subject matter of this policy, this includes, where applicable:

• any abuse or allegation of abuse involving the service provider, a member of staff or a volunteer;
• any allegation of misconduct by a member of staff;
• any serious accident or injury to an individual which meets the regulatory notification threshold;
• any incident which is reported to the police;
• any event which prevents, or could prevent, the provider from continuing to provide the service safely; and
• any request made to a supervisory body in relation to the application of the Deprivation of Liberty Safeguards.

Notifications to CIW must be made without delay unless a different statutory timescale applies and must be submitted through CIW Online in the manner required by CIW.

A restrictive-practice incident does not require notification to CIW merely because restraint occurred. The Registered Manager must determine whether the circumstances meet one or more statutory notification criteria. This does not affect the separate requirement for every incident of control or restraint to be recorded within 24 hours.

Where an incident also requires notification to the local authority, police, placing authority, service commissioner, health professional, safeguarding authority or another regulatory or professional body, the appropriate notification or referral must be made in accordance with the relevant legal and organisational procedure.

10. Staff Training, Competence and Support

All staff must receive training, information, supervision and support appropriate to their role and to the needs of the individuals for whom they provide care and support.

As part of induction, staff whose role involves supporting individuals who may display behaviour which challenges must receive Positive Behaviour Support training appropriate to their role. Staff must be made familiar with this policy, relevant personal plans, risk assessments and the service’s arrangements for reducing restrictive practices.

Relevant training must include, according to the staff member’s role:

• Positive Behaviour Support;
• person-centred and rights-based care;
• prevention and de-escalation;
• trauma-informed approaches;
• safeguarding adults;
• recognising abuse, neglect and improper treatment;
• communication and responding to communication needs;
• understanding physical, psychological, environmental, sensory and health factors which may contribute to distress;
• the Mental Capacity Act 2005;
• Deprivation of Liberty Safeguards;
• the current legal test for identifying a deprivation of liberty;
• the Welsh Government Reducing Restrictive Practices Framework;
• incident reporting and recording requirements; and
• post-incident support and learning.

No member of staff may use a method of control or restraint unless they have been trained in the method being used and have demonstrated the competence required to use it safely.

Where physical or other specialist restrictive interventions may foreseeably be required, the service provider must ensure that sufficient numbers of appropriately trained and competent staff are available to meet the assessed needs of individuals safely. Training must reflect the individuals supported by the service and the restrictive practices, if any, which staff may reasonably be expected to use.

Training in restrictive practices must emphasise prevention, de-escalation, human rights, proportionality, least restrictive practice, risks associated with restraint, monitoring during and following an intervention, when to obtain medical assistance, recording requirements and post-incident review.

Staff must receive refresher training at intervals appropriate to the subject, their role and the requirements of the training provider. Training must also be reviewed and updated following relevant changes in legislation, case law, national guidance, individual needs, identified practice concerns or learning from incidents.

Training concerning the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards must reflect the current legal position, including the UK Supreme Court judgment of 2 June 2026 concerning the definition of deprivation of liberty.

The Registered Manager must maintain records of relevant training and competence and must ensure that expired, inadequate or incomplete training is identified and addressed promptly.

Staff must receive appropriate supervision and opportunities for reflective practice. Following a significant incident involving behaviour which challenges or restrictive practice, appropriate support and debriefing must be offered to staff, and any identified learning, wellbeing or training needs must be addressed.

11. Documentation and Incident Management

All incidents involving behaviour which challenges must be recorded to the extent necessary to maintain an accurate record of the individual’s care, risks, well-being and the staff response.

Where an incident involves any form of control or restraint, a record of the incident must be completed within 24 hours of the control or restraint being used.

Records relating to control, restraint or restrictive practice must contain sufficient information to enable the service to establish what occurred and whether the intervention was lawful, necessary, proportionate and consistent with the individual’s personal plan.

The record must include, where relevant:

• the date, time and location of the incident;
• the circumstances and events preceding the incident;
• the individual’s presentation, communication and apparent needs;
• identified or possible triggers;
• de-escalation and less restrictive measures attempted;
• the risk of harm which made the intervention necessary;
• the type and method of restrictive practice used;
• the reason the particular intervention was considered necessary and proportionate;
• the names of staff involved and their respective roles;
• the duration of the restrictive practice;
• the individual’s response during the intervention;
• observations and monitoring undertaken during and after the intervention;
• any injury, pain, distress or other adverse consequence experienced by the individual or another person;
• any first aid, medical assessment or treatment provided or requested;
• when and why the intervention ended;
• the individual’s views and feelings following the incident, where these can be obtained;
• post-incident support provided to the individual;
• whether the restrictive practice was included within the individual’s current personal plan;
• any review or amendment required to the risk assessment, Positive Behaviour Support Plan or personal plan;
• any safeguarding referral;
• any CIW, police, commissioner, placing authority or other statutory notification;
• action taken by the Registered Manager following review of the incident; and
• any learning or measures identified to prevent recurrence and reduce future restrictive practice.

Every use of control, restraint or restrictive practice must be recorded, including where the intervention was already identified within the individual’s personal plan.

Any restrictive practice which was not included within the individual’s current personal plan must trigger an immediate review of the individual’s assessment, risks and personal plan.

Records must be accurate, contemporaneous as far as practicable, legible, attributable to the person making the entry, securely maintained and available for management, regulatory and safeguarding review where required.

The Registered Manager must review incidents to identify patterns, repeated triggers, increasing frequency or duration of restrictive practice, injuries, ineffective interventions or other concerns requiring professional assessment or changes in care and support.

Where incidents indicate a significant change in the individual’s care and support needs, the provider assessment, personal plan and associated risk assessments must be reviewed and relevant professionals, representatives and commissioners involved as appropriate.

12. Involving the Person and Their Representatives

The views and experiences of the individual are central to any plan for managing their behaviour. Where possible, individuals are involved in creating their own coping strategies, reviewing their care, and reflecting on incidents. Where appropriate, family members or advocates are engaged to ensure the person’s rights, preferences, and needs are understood and respected. We recognise that cultural background, communication needs, and previous experiences shape how behaviour is expressed and understood.

13. Monitoring and Quality Assurance

The Registered Manager will maintain oversight of incidents involving behaviour which challenges and the use of control, restraint and other restrictive practices. The Responsible Individual will maintain oversight in accordance with their statutory responsibilities.

Monitoring must include, where relevant:

• the number and frequency of incidents;
• the individuals affected;
• the type of restrictive practices used;
• the reasons for their use;
• duration;
• injuries or adverse outcomes;
• repeated triggers or patterns;
• whether interventions were planned or unplanned;
• safeguarding referrals;
• CIW and other statutory notifications;
• staff involved;
• compliance with the requirement to complete control or restraint records within 24 hours;
• compliance with personal plans and Positive Behaviour Support Plans;
• staff training and competence;
• the effectiveness of de-escalation and preventative strategies; and
• evidence that restrictive practices are being reduced wherever possible.

Repeated, increasing or disproportionate use of restrictive practices must be investigated. Appropriate action must be taken where monitoring identifies concerns about individual care, staff practice, training, staffing arrangements, care planning, environmental factors or compliance with this policy.

The Responsible Individual must ensure that the quality of care and support is reviewed as often as required and at least every six months in accordance with Regulation 80 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017.

As part of the Quality of Care Review, aggregated information concerning incidents, notifiable incidents, safeguarding matters and records of control, restraint and restrictive practice must be analysed for patterns, trends, risks and opportunities for improvement.

The outcome of monitoring must be used to:

• improve individual personal plans and Positive Behaviour Support Plans;
• reduce avoidable restrictive practice;
• identify staff training and supervision requirements;
• address deficiencies in practice;
• inform service-level risk management;
• identify whether additional professional input is required; and
• inform the Responsible Individual’s Quality of Care Review and recommendations for improvement.

Where monitoring identifies an immediate risk to an individual’s safety, rights or well-being, remedial action must be taken without waiting for the next scheduled audit or Quality of Care Review.

Relevant records must be available to Care Inspectorate Wales on request and evidence must be available to demonstrate that identified concerns, themes and learning have resulted in appropriate action.

14. Policy Review

This policy will be reviewed annually, or earlier in response to legislation changes, CIW guidance, incidents, or service feedback.

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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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