Safeguarding People from Abuse and Harm: Minimising Restraints, Including Physical Controls, and Restrictive Practices in Domiciliary Support (Wales) Policy

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 {{org_field_name}}, 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 the service in which there are issues about the respective rights and responsibilities of people receiving care and providers concerning their freedom of action and movement. These include day-to-day care and relationships and specific aspects such as accessibility to services outside the person’s home such as health and social services 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 to comply with Regulation 29: The Appropriate Use of Control and Restraint, which is part of the safeguarding standards under the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017. The service has developed its policy in line with this regulation, which states as follows.

Care and support must not be provided in a way which includes acts intended to control or restrain an individual unless those acts:
a. are necessary to prevent a risk of harm posed to the individual or another individual
b. are a proportionate response to such a risk.
Control or restraint must not be used unless it is carried out by staff who are trained in the method of control or restraint used.
The service provider must have a policy on the use of control or restraint and ensure that any control or restraint used is carried out in accordance with this policy.
A record of any incident in which control or restraint is used must be made within 24 hours.
For the purposes of this regulation, a person controls or restrains an individual if that person:
a. uses, or threatens to use, force to secure the doing of an act which the individual resists
b. restricts the individual’s liberty of movement, whether or not the individual resists, including by the use of physical, mechanical or chemical means.

The service also accepts as policy Regulation 30, which forbids the use of any corporal punishment in any Wales social care setting.

The policy is also in line with local authority safeguarding responsibilities under the Social Services and Well-being (Wales) Act 2014.

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 included in Regulation 29: The Appropriate Use of Control and Restraint, which states “a person controls or restrains an individual if that person (a) uses, or threatens to use, force to secure the doing of an act which the individual resists, or (b) restricts the individual’s liberty of movement, whether or not the individual resists, including by the use of physical, mechanical or chemical means”.

Restraint is action intended to curb or restrict another person’s freedom of action. The service 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 some situations but unreasonable and tantamount to abuse in others.

Types of Restraints and Restrictions

{{org_field_name}} is committed to only using forms of restraint lawfully and where required to the minimum necessary to keep everyone safe from harm. This policy extends to the following forms of restraint..

Physical restraint — physical intervention to prevent, restrict or subdue movements of the body, or part of the body of another person, including holding people chest down in prone positions (also referred to as “prone restraint”).
Psychological restraint — attitudes, discrimination or even social exclusion and punishment are all ways in telling someone repeatedly that they cannot leave or do something they want to do, including using unfriendly language and bullying, which people can exert pressure on an individual to comply, thus curtailing their freedoms.
Chemical restraint — the use of medicines and drugs specifically to control or subdue disturbed/violent behaviour. {{org_field_name}} will always follow initiatives to stop the overprescribing of psychotropic medicines as methods of behaviour control.
Mechanical restraint — the enforced use of mechanical aids such as bed rails, belts and cuffs specifically to control an individual’s movements.
Withdrawal, seclusion and segregation — environmental restraints that involve removing a person involuntarily from a situation; removing any aids and belongings that effectively restrict the person’s movements; confinement and isolation of a person, away from others, which prevents them from leaving, and where a person cannot mix freely with others temporarily or on a long-term basis.

Minimising the Use of 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.

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 harmful.

This service 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.

Any use of restraint must be carefully documented in the person’s care records and reviewed. Alternative methods of care should be used wherever possible.

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 is used full details must be entered in the person’s record and the management informed of the incident. Restraint should never be used as an easy option and all staff should be aware of the legal and moral rights to freedom, dignity and autonomy of the person receiving care.

Using Minimal Restraint used in Situations of Aggression or Violence

Physical and verbal aggression by a person receiving care should be dealt with in line with the service’s health and safety policy on aggression and violence and never met with counter aggression from staff. 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 the 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, 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.

Applying the Least Restrictive Principle Under the Mental Capacity Act 2005

Whenever {{org_field_name}} or others consider that a person receiving care who lacks mental capacity is being, or risks being, deprived of their freedoms because of restrictions being imposed by third parties, which could include those with a Power of Attorney or Deputy appointed by the Court of Protection, it will make a safeguarding referral and work with the safeguarding team and those involved to ease or minimise any restrictions being imposed on the individual.

{{org_field_name}} understands that any decisions about restricting a person’s freedom must be based on a judgment of what is in the best interests of the person, in which all interested parties will be involved. Any action taken should be proportionate to the assessed level of risk and must respect the rights of the person receiving care. Where the assessment indicates that an advocate is required, this should be provided.

Outcomes of all decisions taken will be recorded on the care plan and regularly reviewed.. The aim will always be to reduce the need for restrictive interventions with risk assessments being regularly updated.

Following any decision that a restriction on a person’s freedom is necessary to keep the person safe from harm, a plan will be agreed, and {{org_field_name}} in partnership with the local authority team involved in the decision-making, will then:

make regular checks to see if the restrictions continue to be necessary
adjust or remove them where they are no longer necessary
provide the person and their lawful representatives with information about the plans and their rights and entitlements
ensure the person’s cultural or faith-based and other protected needs continue to be met.

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 the environments of people receiving care 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 the freedom of movement of person receiving care and access by locking their bedrooms and other doors. Nor should anyone be locked in their accommodation to control and restrict their freedom of movement.

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.

The service deplores 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 behaviour.

The service does not support the use any form of enforced or covert surveillance methods such as CCTV and other technological aids, which intrude into a person’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 the service’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 Who Use a Domiciliary Care Service from Abuse or Harm Policy.)

When Minimal Restraint is Acceptable and Reasonable

The service 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 liberty, thereby requiring authorisation under the Court of Protection.

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.

The service undertakes to provide its staff with appropriate guidance, supervision and training in those interventions that are seen to be acceptable and reasonable for the people receiving care.

Importance of 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 must be 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, the service 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 on the policy on dealing with aggression and violence as well as this policy on physical restraint as part of their induction process in line with the safeguarding learning requirements of the All Wales Induction Framework for Health and Social Care.

Training should be refreshed on annual review as required by any changes in the service’s policies or best practice guidance.

All staff are expected to receive refresher training after annual review to update them in any aspects of the home’s restraints policies and procedures that need to change. The home provides existing staff with further training to address challenging behaviour and aggression and violence.

The service provides existing staff with further training to address challenging behaviour and aggression and violence as appropriate to their roles and responsibilities.

The service provides ongoing training so that staff can develop skills to manage and reduce unacceptable behaviour based on detailed problem analyses and the selection of individualised interventions appropriate to each case.

Staff are trained in a range of intervention strategies in line with the training standards produced by the Restraint Reduction Network (2020) as they apply to Wales, all national guidance, and the resources made available by Social Care Wales.

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}}

DW197. Safeguarding People from Abuse and Harm: Minimising Restraints, Including Physical Controls, and Restrictive Practices in Domiciliary Support