{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Safe Space Policy

1. Purpose

This policy sets out how {{org_field_name}} provides and manages a “Safe Space” to help people we support regulate emotions, reduce distress and anxiety, and maintain their wellbeing. The Safe Space is a voluntary, dignity-preserving alternative to restrictive practices and is designed to support de-escalation, recovery and positive behaviour support (PBS).

2. Scope

This policy applies wherever {{org_field_name}} provides support (including people’s own homes and communal areas) and to any designated Safe Space or calm/sensory area operated by {{org_field_name}}.

3. Definitions

• Safe Space: A low-stimulus, calm area that a person may choose to use to feel safe, decompress or self-regulate.
• Restrictive practice: Any act that limits a person’s rights or freedom of movement (including restraint, seclusion, segregation or chemical restraint).
• Time-out: A planned strategy within a person’s PBS plan that involves moving to a low-demand setting by choice.

We do not use seclusion or long-term segregation. The Safe Space must never be locked or used to confine a person alone and prevent them from leaving.

4. Legal and regulatory framework

This policy will be implemented in accordance with all applicable legislation, regulations and statutory guidance, including:

• Health and Social Care Act 2008.
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including:
  • Regulation 9 – Person-centred care.
  • Regulation 10 – Dignity and respect.
  • Regulation 11 – Need for consent.
  • Regulation 12 – Safe care and treatment.
  • Regulation 13 – Safeguarding service users from abuse and improper treatment.
  • Regulation 17 – Good governance.
  • Regulation 18 – Staffing.
  • Regulation 20 – Duty of candour.
• Care Quality Commission (Registration) Regulations 2009, including requirements relating to statutory notifications.
• Health and Care Act 2022, including the statutory requirement for learning disability and autism training appropriate to each worker’s role.
• Mental Capacity Act 2005 and the Mental Capacity Act Code of Practice.
• Human Rights Act 1998, including the rights protected by Articles 3, 5, 8 and 14 of the European Convention on Human Rights where applicable.
• Care Act 2014, including safeguarding duties.
• Equality Act 2010, including the duty to make reasonable adjustments.
• Mental Health Act 1983 and applicable Code of Practice requirements where relevant to an individual’s legal status.
• Health and Safety at Work etc. Act 1974 and associated regulations.
• Data Protection Act 2018 and UK GDPR.

Any restriction associated with the Safe Space must be considered in accordance with the Mental Capacity Act 2005, human rights law and current case law relating to deprivation of liberty.

Following the UK Supreme Court judgment of 2 June 2026 concerning the meaning of deprivation of liberty, staff must not rely solely on whether a person is under continuous supervision and control and not free to leave. Where there is concern that a person’s overall care arrangements may amount to a deprivation of liberty, the circumstances must be considered as a whole, including the type, duration, effects and manner of implementation of the restrictions, the person’s wishes and feelings, any indication of objection and whether the person is able validly to indicate acceptance of the arrangements.

For people living in supported living arrangements or their own homes, where arrangements may amount to a deprivation of liberty and lawful authority is required, the matter must be escalated promptly to the Registered Manager and the relevant commissioning or local authority professionals so that legal advice and, where necessary, authorisation from the Court of Protection can be sought. The Safe Space itself must never be used as an unauthorised means of depriving a person of their liberty.

5. Principles

1. Voluntary use: People choose to use the Safe Space; they can leave at any time.
2. Human rights first: Dignity, privacy, liberty and choice are respected.
3. Least-restrictive and preventative: The Safe Space supports PBS and de-escalation to avoid restrictive practices.
4. Co-production: People and those important to them help design, review and personalise how the Safe Space is used.
5. Accessibility and inclusion: Reasonable adjustments are made to meet sensory, cultural, communication and disability needs.
6. Safety by design: Environment and equipment are risk-assessed and maintained to keep people safe without unnecessary restrictions.
7. Learning culture: We record, review and learn from each use to improve outcomes.

6. Roles and responsibilities

• Registered Manager (RM): {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}} – Ensures policy implementation, safe environment, incident review and learning; approves individual plans.

Nominated Individual: {{org_field_nominated_individual_first_name}} {{org_field_nominated_individual_last_name}} – Provides governance oversight and resourcing.

• Safeguarding Lead: {{org_field_safeguarding_lead_name}} ({{org_field_safeguarding_lead_role}}) – ensures concerns are escalated to {{org_field_local_authority_authority_name}} and, where required, to CQC without delay.
• Infection Prevention & Control Lead: {{org_field_infection_control_lead_name}} ({{org_field_infection_control_lead_role}}) – ensures cleaning schedules and IPC risk assessments.
• Fire Safety Lead/Warden: {{org_field_the_fire_safety_lead_name}} / {{org_field_the_fire_warden_name}} – ensures Safe Space is included in fire risk assessments/PEEPs and that exits are never blocked or locked.
• All staff: Follow this policy and individual PBS/MCA plans; complete required training; record and report use and outcomes.

7. Access and eligibility

• The Safe Space is available to any person we support who wishes to use it, including as part of a personalised PBS plan.
• Visitors may be invited where this helps the person feel safe, subject to consent, confidentiality and risk assessment.
• Staff may offer (not direct or coerce) the Safe Space during early signs of distress (“Show, offer, support, never force”).

8. Using the Safe Space – procedure

Before use

• Check that the Safe Space is safe, clean, appropriately maintained and ready for use in accordance with Section 10.
• Review the person’s current care and support plan, Positive Behaviour Support plan, risk assessments, communication passport and any relevant Mental Capacity Act assessments or best-interests decisions.
• Explain or offer the Safe Space in a way that the person can understand, using their preferred communication method and any required reasonable adjustments.
• Seek the person’s consent before supporting them to use the Safe Space.
• A person must not be directed, threatened, coerced, physically forced or otherwise compelled to enter or remain in the Safe Space merely because they are distressed, displaying behaviour that challenges, refusing care or because staff consider use of the room desirable.
• Where there is reason to doubt the person’s capacity to make the relevant decision, staff must follow Section 9 of this policy.
• A best-interests decision does not, by itself, authorise staff to deprive a person of their liberty. Any restraint must additionally satisfy the Mental Capacity Act 2005 and Regulation 13 requirements set out in Section 11.

During use

• Support the person to use the Safe Space in accordance with their wishes, preferences, communication needs and agreed support plan.
• Adjust the environment, where safe to do so, according to the person’s preferences, for example lighting, music, sensory equipment or other agreed items.
• Staff must maintain the person’s privacy and dignity while providing the level of observation or support that is necessary to manage identified risks.
• Any observations or check-ins must be the least intrusive necessary and should reflect the person’s assessed needs and agreed preferences.
• The door must remain unlocked and the person’s exit route must remain unobstructed.
• The person must be free to communicate that they wish to leave, verbally or through behaviour, gesture, communication aids or any other recognised method.
• If the person indicates that they wish to leave, staff must support them to leave immediately unless an exceptional intervention is lawfully required to prevent harm and meets all requirements in Section 11.
• Staff must continually consider whether the person’s use of the Safe Space remains voluntary. Compliance, passivity or an absence of verbal objection must not automatically be treated as consent.
• Any attempt to leave, physical rejection of support, distress, verbal objection or other behaviour indicating that the person does not wish to remain must be taken seriously and acted upon.

After use

• Offer the person an opportunity to discuss their experience using their preferred communication method.
• Record what helped, what did not help, the person’s expressed wishes and feelings and any changes that may improve future support.
• Complete the Safe Space Use Record and any separate incident, safeguarding, restraint or restrictive practice record required by organisational procedures.
• Where any restriction or restraint occurred, record the reason, duration, nature of the intervention, alternatives attempted, the person’s response, any injury or harm and the action taken afterwards.
• Review and update the person’s care and support plan, Positive Behaviour Support plan and risk assessments where learning from the event indicates that a change is required.
• Escalate any concern that use of the Safe Space may have become restrictive, coercive, abusive or a potential deprivation of liberty to the Registered Manager without delay.

9. Consent, Mental Capacity, best interests and deprivation of liberty

• The person’s informed consent must be sought whenever the Safe Space is offered or used.
• Information must be provided in a form the person can understand, using their preferred communication methods and any necessary reasonable adjustments.
• Staff must presume that an adult has capacity unless it is established otherwise in accordance with the Mental Capacity Act 2005.
• A person must not be treated as unable to make a decision merely because they make a decision that staff, relatives or professionals consider unwise.
• Before concluding that a person lacks capacity, all practicable steps must be taken to support them to make the decision themselves.

Assessment of capacity

Where there is reason to doubt capacity, the assessment must be:

• specific to the particular decision;
• specific to the time at which the decision needs to be made;
• based on whether an impairment of, or disturbance in the functioning of, the mind or brain means the person is unable to make the particular decision; and
• properly recorded.

The relevant decision may include whether the person is able to decide whether to enter, remain in or leave the Safe Space and whether they can consent to any associated care or support arrangements.

Where the person lacks capacity

Where a person lacks capacity to make the relevant decision:

• any action taken or decision made on their behalf must be in their best interests in accordance with the Mental Capacity Act 2005;
• the decision-maker must consider the person’s past and present wishes and feelings, beliefs and values and other factors the person would be likely to consider;
• appropriate consultation must take place with people who should be consulted under the Mental Capacity Act, including an attorney, deputy or advocate where applicable;
• staff must consider whether the intended outcome can be achieved in a less restrictive way; and
• the assessment and resulting best-interests decision must be recorded.

A best-interests decision does not give staff unrestricted authority to restrain a person or deprive them of their liberty.

Restraint

Where the person lacks capacity and restraint is proposed or becomes necessary in connection with care or treatment, the requirements of sections 5 and 6 of the Mental Capacity Act 2005 must be satisfied. Staff must reasonably believe that restraint is necessary to prevent harm to the person and that the restraint is proportionate to the likelihood and seriousness of that harm.

The additional requirements of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 must also be met.

Deprivation of liberty

Staff must consider the person’s overall circumstances and must not rely on a single test when deciding whether care or support arrangements may amount to a deprivation of liberty.

Following the UK Supreme Court judgment of 2 June 2026, consideration must include, as relevant:

• the type of restrictions being imposed;
• their duration;
• their effects on the person;
• the manner in which the restrictions are implemented;
• the person’s wishes and feelings;
• whether the person is objecting verbally or through their behaviour;
• attempts by the person to leave;
• physical restraint or close supervision used to prevent the person doing something they wish to do;
• whether medication is being used in a way that affects the person’s ability to express or act upon their wishes;
• whether the person understands and is able validly to indicate acceptance of the arrangements; and
• the person’s circumstances considered as a whole.

Compliance, passivity or the absence of an obvious verbal objection must not automatically be treated as valid consent.

Any objection or attempted departure from the Safe Space must be treated as significant and must trigger an immediate review of whether continued intervention is lawful.

Where there is any doubt about whether the person’s overall care arrangements amount to a deprivation of liberty, the matter must be escalated without delay to the Registered Manager. Appropriate professional and legal advice must be sought.

For supported living and other community settings outside hospitals and care homes, where a deprivation of liberty requires authorisation, the appropriate court process must be followed and, where necessary, authorisation sought from the Court of Protection.

The Safe Space must never be used to impose an unauthorised deprivation of liberty.

Mental Health Act

Where the Mental Health Act 1983 applies to a person, staff must act within the legal authority provided by that Act and must follow the person’s relevant care arrangements and professional advice. A person’s Mental Health Act status must not be treated as providing general authority for staff in supported living to lock, confine or seclude that person in the Safe Space.

10. Environment and safety standards (design checklist)

• Layout: Calm, low-stimulus décor; adequate space for wheelchair users; clear, unlocked exit route.
• Fixtures: Anti-ligature where indicated by risk assessment; no trailing cables; robust, safe furnishings with rounded edges.
• Equipment: Sensory tools available according to individual plans; secure storage for removable items.
• Privacy: Sound-dampening where possible; visual privacy without obstructing safe observation.
• Alarms: Accessible call bell/emergency call point; staff carry communication devices.
• Fire safety: Clear signage; not used for storage; included in fire drills and PEEPs; never locked.
• Cleaning/IPC: Schedule maintained by {{org_field_infection_control_lead_name}}; products used under COSHH; clean between uses if required.

11. Restrictive practices – clear limits

• The Safe Space is intended to be a voluntary therapeutic, sensory or calming environment. It must never be used as punishment, as a means of enforcing compliance or as a substitute for appropriate staffing, care planning or Positive Behaviour Support.
• The Safe Space must not be used for seclusion.
• The Safe Space must not be used to isolate a person against their will.
• The door must not be locked, held shut, blocked or otherwise controlled in a way that prevents the person from leaving.
• Staff must not position themselves or furniture in a way that deliberately prevents the person from leaving.
• The person must not be threatened, intimidated, coerced or physically forced to enter or remain in the Safe Space.
• A person’s refusal to use the Safe Space must be respected.

Any restraint used in connection with the provision of a regulated activity must be lawful.

Restraint may only be used where:

• it is necessary to prevent harm;
• it is proportionate to the likelihood of that harm occurring;
• it is proportionate to the seriousness of the harm that could occur;
• no less restrictive reasonably practicable intervention would adequately manage the immediate risk; and
• the person using the intervention is appropriately trained and competent.

Where the person lacks capacity in relation to the relevant care or treatment, restraint must additionally comply with sections 5 and 6 of the Mental Capacity Act 2005. Staff must reasonably believe that restraint is necessary to prevent harm to the person and that it is proportionate to the likelihood and seriousness of that harm.

Any unplanned or emergency restraint must cease as soon as the immediate necessity for it has ended.

Any restraint must be:

• recorded accurately and contemporaneously;
• reported in accordance with the organisation’s incident and restrictive practice procedures;
• reviewed by the Registered Manager or appropriate senior person;
• considered for safeguarding referral where there is any concern that the intervention was unlawful, excessive, disproportionate or abusive; and
• notified to CQC where the circumstances meet a statutory notification requirement.

Chemical restraint must not be used unless the medication is lawfully prescribed and its use is clinically authorised and consistent with the person’s care plan, Mental Capacity Act requirements and medicines management arrangements.

Mechanical restraint must not be introduced or used unless there is a lawful, person-specific basis for doing so, it has been properly assessed and planned, and staff are trained and competent in its use.

“Time-out” may only describe a voluntary, person-led strategy in which the person can leave at any time. If a person is required or compelled to remain apart from others, prevented from leaving or subjected to staff control that removes their freedom to leave, staff must not record or describe this merely as “time-out”. The intervention must be recognised, recorded, reviewed and escalated according to what actually occurred.

12. Recording, reporting, safeguarding and statutory notifications

A Safe Space Use Record must be completed after each use where the Safe Space forms part of planned care or support, or where staff have actively supported or monitored its use.

Records must be accurate, complete and contemporaneous and must include, where applicable:

• the date, start time and end time;
• the reason the Safe Space was offered or used;
• whether the person requested the Safe Space or it was offered by staff;
• how consent was obtained;
• any communication support or reasonable adjustment used;
• any relevant capacity assessment or best-interests decision;
• the person’s wishes, feelings and response;
• any signs of objection, distress or attempts to leave;
• support or interventions provided;
• any restrictive intervention or restraint;
• the reason for any restraint;
• the duration and type of restraint;
• any injury, harm or adverse effect;
• action taken following the event;
• whether safeguarding procedures were initiated;
• whether an incident report was completed;
• whether external reporting or statutory notification was required; and
• learning and amendments required to the person’s care plan, Positive Behaviour Support plan or risk assessment.

Where use of the Safe Space gives rise to a safeguarding concern, including suspected unlawful restraint, coercion, neglect, degrading treatment, inappropriate isolation, abuse or an unauthorised deprivation of liberty, staff must report the concern immediately in accordance with the organisation’s safeguarding procedure.

Safeguarding concerns must be referred to {{org_field_local_authority_authority_name}} where the criteria for a safeguarding referral are met, in accordance with the Care Act 2014 and local safeguarding arrangements.

The Registered Manager or other authorised person must separately consider whether a statutory notification to CQC is required.

CQC must be notified in accordance with the Care Quality Commission (Registration) Regulations 2009 whenever a notifiable event has occurred. Relevant examples associated with use of the Safe Space may include:

• abuse or an allegation of abuse concerning a person who uses the service;
• a serious injury that occurred while the regulated activity was being provided or which may have resulted from the regulated activity or how it was provided;
• an incident reported to or investigated by the police where the statutory notification requirements are met; and
• any other event or incident that is notifiable under the Registration Regulations.

An allegation of abuse must not be withheld from CQC merely because:

• an internal investigation has not concluded;
• the allegation has not been substantiated;
• the local authority has not yet completed its safeguarding enquiries; or
• the member of staff concerned disputes the allegation.

Where an incident has been reported to the police, the Registered Manager must determine which CQC notification category applies. Where the incident is itself a death, serious injury or abuse allegation, the relevant specific notification must be used rather than recording it only as police involvement.

Notifications must be made within the statutory timescale applicable to the event and using the current CQC notification process and form.

Submission of a CQC notification does not replace the requirement to:

• make a safeguarding referral where required;
• contact the police where a criminal offence may have occurred;
• obtain emergency medical assistance where required;
• report internally;
• comply with the statutory Duty of Candour where Regulation 20 applies; or
• undertake appropriate investigation, review and learning.

Where the statutory Duty of Candour applies following a notifiable safety incident, {{org_field_name}} will act openly and transparently with the person or their relevant representative and follow the requirements of Regulation 20.

13. Information governance and confidentiality

• Records are accurate, contemporaneous and stored securely in line with UK GDPR and the Data Protection Act 2018.
• Only share information on a need-to-know basis or where required by law or to protect vital interests.
• Retain records in line with our Records Retention Schedule.

14. Training and competence

{{org_field_name}} will ensure that staff have the qualifications, competence, skills, knowledge, training and experience required to perform their roles safely.

Staff must not undertake an intervention for which they have not been appropriately trained and assessed as competent.

All relevant staff must receive training appropriate to their responsibilities in:

• Positive Behaviour Support and preventative approaches;
• de-escalation;
• reduction of restrictive practices;
• Mental Capacity Act 2005, consent and best-interests decision-making;
• recognising circumstances that may amount to a deprivation of liberty;
• safeguarding adults;
• dignity and human rights;
• equality, diversity and reasonable adjustments;
• communication appropriate to the people they support;
• incident reporting and escalation; and
• any person-specific techniques or equipment they are expected to use.

Statutory learning disability and autism training

In accordance with the Health and Social Care Act 2008, as amended by the Health and Care Act 2022, {{org_field_name}} must ensure that every person working for the purpose of the regulated activities receives training on learning disability and autism that is appropriate to their role.

Training arrangements must meet the standards contained in the current Oliver McGowan Code of Practice on statutory learning disability and autism training.

This requirement applies to all staff working for the purpose of the regulated activities and is not limited to staff who routinely support a person with a diagnosed learning disability or autism.

The level and content of training must reflect the staff member’s role, responsibilities, autonomy and level of contact with people receiving care and support.

Staff providing direct care or support, registered managers, team leaders and others whose roles require the relevant higher-level capabilities must receive the level of learning disability and autism training required for those responsibilities under the current Code of Practice.

Training must include the required live and interactive element and must involve people with a learning disability and autistic people in accordance with the standards set by the Code of Practice.

{{org_field_name}} must maintain evidence that:

• staff have completed the required training;
• training is appropriate to each person’s role;
• training meets the applicable standards in the current Code of Practice;
• refresher or additional training is provided where required;
• staff competence is monitored; and
• learning is applied in practice.

Restrictive intervention training

Where a role may lawfully involve physical restraint or another restrictive intervention, the staff member must receive appropriate role-specific training and competency assessment before undertaking that intervention.

Training must emphasise prevention, de-escalation, least restrictive practice, human rights, the Mental Capacity Act 2005 and the requirements of Regulation 13.

Completion of restraint training does not itself authorise restraint. Every use of restraint must independently satisfy the legal requirements set out in Section 11.

15. Equality, diversity and inclusion

• The Safe Space design and use reflect cultural, spiritual and sensory preferences.
• We make reasonable adjustments (e.g., BSL interpreter, visual supports, preferred music, prayer mat, gender-sensitive support) in line with the Equality Act 2010.

16. Co-production, feedback and involvement

• People we support help shape the Safe Space and its rules of use.
• We seek feedback after use and via regular forums/surveys; we share “you said, we did” outcomes.

17. Monitoring, audit and assurance

The Registered Manager will maintain effective systems to assess, monitor and improve the safety and quality of practice relating to the Safe Space.

Safe Space records will be reviewed regularly and at least monthly where the Safe Space has been used during that period.

The review must consider, where applicable:

• frequency and duration of use;
• whether use was initiated by the person or offered by staff;
• evidence of consent;
• capacity assessments and best-interests decisions;
• evidence that the person’s wishes and feelings were identified and respected;
• instances of objection, attempts to leave or distress associated with use;
• restrictive interventions or restraint;
• any occasions when staff prevented or attempted to prevent a person leaving;
• injuries or adverse outcomes;
• safeguarding concerns;
• incidents and complaints;
• CQC or other statutory notifications;
• whether Duty of Candour requirements arose;
• patterns involving individual staff members or people receiving support;
• equality or human rights impacts;
• whether less restrictive alternatives could have been used;
• whether care plans, Positive Behaviour Support plans and risk assessments remain current; and
• actions required to prevent recurrence of inappropriate or unnecessarily restrictive practice.

Any indication that the Safe Space has been used as punishment, involuntary isolation, seclusion, coercion or unauthorised restriction must be escalated immediately and must not wait for the routine monthly audit.

The Registered Manager must ensure that identified actions are recorded, allocated, completed and reviewed for effectiveness.

Significant themes, restrictive practice, safeguarding matters, incidents and learning must be considered through the organisation’s governance arrangements and used to improve the quality and safety of the regulated service.

Records of audits, actions and subsequent improvements must be retained as evidence of compliance with Regulation 17.

18. Related policies and documents

Individual PBS Plans, Communication Passports, Risk Assessments, PEEPs

Positive Behaviour Support Policy

Safeguarding Adults Policy (and Children/Visitors Procedure)

Restrictive Practices/Restraint Reduction Policy

Mental Capacity Act and Consent Policy

Incident Reporting and Duty of Candour Policy

Infection Prevention & Control Policy

Health & Safety and Fire Safety Policies

Data Protection/Records Management Policy

---

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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.