D200. Restraints, Physical Controls and Restrictive Practices in Domiciliary Care

Policy Statement

This policy sets out the values, principles and procedures underpinning {{org_field_name}}’s approach to the wider issues of the rights of people using the service, associated risks and use of legitimate means of restraint, including physical restraint. {{org_field_name}}’s restraint policies are integral to its overall approach to the safeguarding of vulnerable people receiving care.

The policy ensures that the respective human and citizens’ rights and responsibilities of people receiving care and staff regarding the use of restraints and actions that restrict freedom of movement and action are always upheld.

{{org_field_name}} works on the basis that people receiving care have the same rights as anyone else in society, which must be fully respected. It would not seek to restrict the freedoms of people receiving care in any ways unless there were clear unacceptable risks to their safety and the safety of others without some form of restraint or restrictions being applied.

The policy applies to all those aspects of {{org_field_name}} in which there are issues about the respective rights and responsibilities of people receiving care and providers concerning freedom of action and movement. These include day-to-day care and relationships and specific aspects such as accessibility to health and social services outside the person’s home and to community and citizen participation.

It specifically focuses on the inappropriate use of restraints and restrictions as breaches of human rights and possible criminal actions. The policy identifies when restraint could be justified and legally permissible and the procedures to be followed if staff must use restraint as a last resort.

The policy is written in line with a wide raft of legislation, which includes the Human Rights Act 1998, the Equality Act 2010, the Mental Capacity Act 2005, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and current Department of Health and Social Care, Care Quality Commission (CQC) and NICE guidance (NG11 and NG93).

Where support is being provided for children, in addition to the above, {{org_field_name}} further adheres to the principles found in the Government’s guidance Reducing the Need for Restraint and Restrictive Intervention, published June 2019.

The policy should be read and used with other safeguarding policies.

Definition of Curbs, Restraints and Restrictive Practices

{{org_field_name}} accepts a definition of restraint as action intended to curb or restrict another person’s freedom of action. It recognises that restraint and restrictions can take many forms including: physical restraint, forced care, physical intervention, chemical restraint, environmental restraint, electronic surveillance, preventing free movement, medical restraint, seclusion and segregation.

The use of restraint and restrictions can happen under many circumstances, which includes situations where the risks to a person’s safety are considered too high to be acceptable.

The most common situations, where legitimate restraint may be indicated, include those where there are needs to protect another person or other people from harming or injuring themselves or others physically or psychologically or to protect property and possessions.

Restraint can be reasonable and acceptable in a minority of situations but unreasonable and decidedly abusive and harmful to the person being restrained in many others.

Physical restraint

{{org_field_name}} understands physical restraint to refer to the restriction of a person’s freedom without their permission. In the context of a domiciliary care service, restraint could relate to the use of force or firm physical intervention:

in the event of a person receiving care or family member becoming aggressive or behaving in a threatening manner, or losing control of their behaviour because of acute emotional distress
to prevent self-harm or injury to a person receiving care (for instance, by using bed rails, blocking doors, restrictive clothing, etc)
to prevent a person receiving care from leaving their home (eg if they live on their own) in situations where staff are concerned as to the safety of that person.

Caring for children

{{org_field_name}} recognises that children, particularly autistic children and those with learning disabilities or mental health conditions, are at increased risk of restraint and restrictive practices. This is traumatising and can have long-term consequences for the health and wellbeing of children and young people, as well as on the staff who carry out that intervention.

{{org_field_name}} also recognises that autistic children and those with learning disabilities are at risk of being overprescribed psychotropic or sedative medicines as a form of restraint. {{org_field_name}} will work to the guidelines for social care services published by the NHS England projects Stopping Over-Medication of People with a Learning Disability, Autism or Both (STOMP) and Supporting Treatment and Appropriate Medication in Paediatrics (STAMP).

To prevent the need for restraint or restrictions, {{org_field_name}} uses positive behaviour support (PBS) and other alternatives to de-escalate behaviours which might challenge staff.

Restrictive intervention will only be used when absolutely necessary, in accordance with the law and clear ethical values and principles which respect the rights and dignity of children and young people, and in proportion to the risks involved. It will never be used as a long-term solution.

(See also the policy Challenging Behaviour, Violence and Aggression — Children and Young People (England).)

Use of Restraints and Restrictions

{{org_field_name}} understands that restraint is illegal unless it can be demonstrated that for an individual not being restrained would conflict with its duty of care and that the outcome for the individual would be harm to themselves or for others.

{{org_field_name}} considers that physical restraint represents bad practice in care and should be avoided wherever possible. Staff will use physical restraint only as a last resort or in exceptional circumstances.

Restraint and restrictions will be used only where:

the form of restraint or restriction has been agreed as necessary following a risk assessment and has been entered in the person’s plan of care
the restraint is needed in an emergency to prevent serious physical harm to the person receiving care or other people
those involved in the intervention have received the appropriate training and supervision.

Any restraint or restriction must be in the best interests of the person. It should be based upon the level of risk present, taking account of the person’s size, gender, age and medical conditions. It should be used for the minimum amount of time and with the least amount of intervention.

It is accepted that some people receiving care can be challenging at some time or another. Staff are always expected to deal with these events in a calm and professional manner. Whenever restraint must be used, management must be informed of the incident, full details must be entered in a restraint incident reporting form and on the person’s care records.

Restraint should never be used as an easy option and all staff should be aware of the people receiving care’s legal and moral rights to freedom, dignity and autonomy.

Restraint used in situations of aggression or violence

Physical and verbal aggression by a person receiving care should be dealt with in line with {{org_field_name}}’s policies and it should never be met with counter aggression. Physical interventions should be used only as a last resort by trained staff and to protect the rights and best interests of the person receiving care and should be the minimum consistent with making sure that all involved are kept safe from harm.

Care staff must only use minimum force when it is absolutely necessary to restrain someone. People receiving care who are acting in an aggressive or threatening manner must not be subject to undue restraint.

Because of this risk, staff must always follow established procedures required by health and safety laws, which are set out in corresponding safeguarding staff policies. (See the Disrespectful Behaviour and Abuse of Staff, Including Aggression and Violence and Appropriate Response in Care Homes Policy.)

The law gives protection to people from being abused or attacked and, if a member of staff is attacked, they may use “minimum reasonable force” to defend themselves. Staff should remember that if they restrain a violent person and injure them because of the amount of force they use, they could be charged for assault. Because of this risk, staff must always follow the established procedure.

Planned and unplanned restraints and restrictions

{{org_field_name}} accepts that restraints and restrictions might form part of a care plan based on a risk assessment — usually as part of a wider process of best interests’ decision-taking for people who might lack the mental capacity to recognise any dangers to themselves or others.

It is recognised that such restraints and restrictions could amount to a person being deprived of their freedoms, thereby requiring safeguarding authorisation under the Court of Protection.

Inappropriate forms of restraint

Restraints can have harmful effects on people’s physical and mental health by reducing their freedom of action and mobility. Restraining a person consistently can result in a decline in people’s levels of fitness, their ability to walk, sleep patterns and general deterioration in their wellbeing.

Staff who deliberately use any form of illegitimate restraint or use restraint inappropriately face disciplinary proceedings and dismissal. If it is proved that they have committed an act of misconduct causing harm to a vulnerable adult, they will be referred to the Disclosure and Barring Service for inclusion on its barred list, preventing them from working with vulnerable adults.

Staff must not organise people’s environments in such ways as to restrict their freedom of movement against their wishes or without their consent, for example, by preventing them from getting out of bed, up and down stairs or preventing them from leaving their house.

Staff must make sure that mobility aids (or deprivation of), harnesses, straps, belts and cot sides are used solely for ensuring safety and not to control and restrain.

Staff must not restrict freedom of movement and access by locking people in bedrooms or other rooms in the house and must not agree to this if, say relatives request it.

Where some limitations need to be applied to keep people safe, they should follow only after a full risk assessment and management plan has been completed, and applied with the person’s consent or where the person cannot give their consent because of mental incapacity after a full best interests’ assessment.

{{org_field_name}} rejects the use of drugs and medication that are solely or mainly used to control and restrain behaviour. It accepts that any medication that can affect a person’s behaviour should be prescribed only after full medical assessment and is regularly and rigorously reviewed.

Staff must not use threats of actual physical punishment or any form of intimidation, harassment or bullying to control and restrain the behaviour of people using services.

{{org_field_name}} does not support the use any form of enforced or covert surveillance methods such as CCTV and other technological aids, which intrude into people’s privacy and dignity, to monitor and restrict their freedom of movement. It has a separate policy to cover situations where CCTV is already installed or has been installed by third parties, eg relatives, which could be with or without the agreement of the person receiving care as householder. (See policy on CCTV in Homes of People in Domiciliary Care.)

Where {{org_field_name}}’s staff come across situations whereby they think unreasonable restrictions and restraints are being placed by other people or parties, including relatives, they should report the matter, which can then be assessed and escalated to the appropriate level for further enquiry and assessment. This might entail raising an alert with their local safeguarding adults’ team. (See Safeguarding People Using a Care Service from Abuse or Harm in Care Homes (England) Overarching Policy.)

When restraint is acceptable and reasonable

The use of restraint is only acceptable when people’s safety is clearly at risk. Restraining interventions and restrictive practices must then be appropriate to the situation and must be discontinued once the immediate danger has gone.

Staff actions should be directed at preventing the need for any form of restraint or restrictions. If physical or any other form of restraint is needed it should be undertaken solely with the interests of keeping the person and other people safe.

The least restrictive form of intervention appropriate to the situation should always be used.

{{org_field_name}} undertakes to provide its staff with appropriate guidance, supervision and training in those interventions that are seen to be acceptable and reasonable for the person receiving care.

Risks and risk assessments

Staff are expected to promote and enable people receiving care to exercise their rights and not seek to curb them or any of their civil liberties. To achieve this, it is recognised that staff must assess and manage any risks to people’s safety that could occur.

Any risks to personal safety requiring intervention that could be interpreted as restraint or restriction are assessed in consultation with the person receiving care and other professionals involved in promoting their wellbeing and a risk management plan developed so that all parties are aware of the possible consequences and responsibilities for the actions taken.

The risk assessment is comprehensive, fully recorded and signed by all parties within the individual’s care plan. All significant parties including relatives, advocates and other professionals are made aware of the risk assessment and management plan.

Reporting and recording

Any instance involving the restraint of a person receiving care should be reported immediately to the manager in charge and fully recorded as a critical incident and on the individual’s file/care plan.

A full description of the incident must be given together with details of what took place and the reasons for the restraining actions.

It can be expected that the incident will be discussed in a meeting/supervision/case review to explore further the issues raised by the situation.

As far as possible, the aim will be to discover the lessons to be learned to minimise or prevent the need for such actions in the future.

In cases where there is evidence that the restraints used were unreasonable or inappropriate, the staff member(s) involved may be warned that they may face disciplinary action (or disciplinary action may need to be taken if there is strong enough evidence that abuse has occurred).

In these instances, {{org_field_name}} will alert the local safeguarding authority and notify the service regulator as safeguarding incidents.

Monitoring and auditing

All restraints and restrictions imposed on people receiving care are regularly reviewed through their care plans and their use is monitored and audited by senior management. The object is always to make sure that restraints and restrictions are kept to the minimum and only used when there are no reasonable alternatives.

Training

All new staff receive training in {{org_field_name}}’s policies and procedures on restraint and restrictive actions as part of their mandatory safeguarding training, which is regularly updated and refreshed.

All staff receive training to update them about changes to {{org_field_name}}’s restraints policies and procedures and receive specialist training in any aspect of restraint, including specific methods and techniques, as required by their roles and responsibilities.

{{org_field_name}} provides ongoing training so that staff can develop skills to manage and reduce unacceptable behaviour based on detailed problem analyses and the selection of interventions appropriate to each person’s needs.

Staff are trained in a range of positive intervention strategies in line with the training standards produced by the Restraint Reduction Network (2020), all national guidance and the resources produced by Skills for Care.

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

Reviewed on: {{last_update_date}}

Next review date: this policy is reviewed annually (every 12 months). When needed, this policy is also updated in response to changes in legislation, regulation, best practices, or organisational changes.

D200. Restraints, Physical Controls and Restrictive Practices in Domiciliary Care