SCOPE OF THIS CHAPTER

This procedure applies when any kind of restraint is being considered for anyone. Restraint is defined as any act or omission which restricts a person’s freedom of movement whether they resist or not. There are several different kinds of restraint including:

  • Physical restraint such as holding someone, preventing or limiting movement, stopping someone from leaving an area, placing someone in a position which limits their ability to move such as a low chair from which the person cannot rise without difficulty, or removing walking aids;
  • Mechanical restraint such as lap straps, bed rails or chair trays;
  • Forced care, such as washing or dressing someone against their will;
  • Chemical restraint such as the use of tranquillisers or sedatives;
  • Environmental restraint such as locking doors or using coded key pads or complicated door handles;
  • Use of threats, intimidation or emotional blackmail.

RELATED CHAPTERS

Mental Capacity Act 2005: Policy and Practice Guidelines (Including Mental Capacity Assessments)

Deprivation of Liberty Safeguards

Mental Capacity Act 2005: Guidance for Best Interests Meetings

1. Principles

Restraint of any kind should only ever be used as a last resort when no other option is available and should employ the least restrictive option using the minimum amount of force for the shortest time possible. Failure to do so may constitute a criminal offence for which the staff member can be prosecuted.

Restraint can only be used legally in two sets of circumstances. The first is where there is an immediate and present risk of harm to the person or others. For example, if a pan of boiling water fell, it would be quite legal to use physical force to pull someone out of the way. It would not be legal to use force to remove them from the kitchen in case a pan was to fall.

The second set of circumstances where restraint is legal is when someone lacks capacity and where it is felt that restraint is necessary to prevent the person from being harmed or harming others. A description of the restraint to be used and the circumstances in which it can be used must be documented in the person’s support plan and must be the result of a Best Interest Decision, using a positive risk assessment. See also Best Interest Decision Making Procedure.

Restraint should not cause injury or pain and should minimise the degree of distress or psychological trauma. It should not undermine dignity, humiliate or degrade the person.

When restraint has been used, it should always be clearly documented.

Restraint is defined as the restriction of movement or action by service users whether they are resisting or not, if necessary by the use of force. It will take a variety of forms:

  • Environmental such as locked doors, straps on wheelchairs bed rails etc.;
  • Low intensity interventions such as assisting with personal care, leading someone back into a care home, keeping users from coming into conflict with others by diversion/distraction etc.;
  • High intensity interventions such as dealing with violent and aggressive behaviour.

Reasonable force is the use of the minimum degree of force required to prevent harm taking place. Restraint would be unlawful if it were used as a punishment; it must always be about safeguarding people from harm.

The law differentiates between actions which can be taken in regard to capacitated and incapacitated adults and it is important that staff have an understanding of what the law states is respect of the use of restraint.

For each service user a consistent person-centred approach should be used supported by clear person-centred documentation such as One Page Profiles, Life History, Communication Passports, Learning Logs etc., and this should form part of staff induction and supervision.

1.1 Capacitated Adults

The movements or actions of capacitated adults cannot generally be restricted without their full consent. There are times though when they can be restrained and this is when it appears someone may be going to harm another person or seriously damage property. They are likely to be potentially committing a criminal offence.

Social and health care staff may need at times to restrain a capacitated adult and they may do this using reasonable force under the following circumstances:

  • Threatening harm to another person;
  • Injuring another person;
  • Causing damage to property;
  • Self harming.

In these situations, action can be taken under common law, therefore a capacitated person does not have to consent for staff to intervene.

Where staff believe a criminal offence is or about to occur the police service must be involved.

When a normally capacitated person loses capacity, for example if they are intoxicated and there is an imminent risk of harm to themselves or others a Best Interest Decision must be made at that point for any interventions they cannot at that time consent to.

There will be times when workers believe a capacitated person made be not acting in the best interests of a vulnerable adult in these cases consider involving the safeguarding team.

1.2 Incapacitated Adults

Incapacitated means not being able to consent to actions that others may wish to take. The vast majority of incidences where restraint is needed will not be emergencies but known in advance (for example to physically hold someone whilst they receive personal care) and in these circumstances there must always be:

  • An assessment of capacity;
  • A best interest decision which includes a detailed description in the care plan of the type, duration and description of the restriction or restraint to be used;
  • A management plan drawn up by all concerned with the service users care to include family and all professionals involved.

Restraint must only be used when less restrictive interventions have been tried but have failed to reduce the seriousness of harm. For example this might be where the use of gloves to prevent scratching has failed.

Restraint must never be used as a form of punishment but only in the service user’s best interests.

If service users are put at risk because staff decide not to use appropriate and lawful restraint then the workers involved could be subject to a criminal offence of neglect under S44 of the Mental Capacity Act 2005. The law has given staff powers that are designed to prevent harm occurring to incapacitated adults. Staff would be failing in their duty of care if they did not intervene when necessary.

If a criminal act is believed to have been committed, the Hull Safeguarding Adults Partnership Board Procedures must be followed.

Restraint must only be used for the minimum time necessary and must cease when the service user is judged to be safe and no longer at risk of self harming or harming others. However some restraints for example locking doors or the use of bed rails may be long term measure and will need detailed care planning and regular reviews.

Consideration should be given to how many staff are involved in any restraint to help ensure safety and accountability but at the same time not make the situation worse.

Service users may not be permitted to restrain or to assist in the restraint of other service users.

Any injuries to service users resulting from the use of restraint must be reported immediately to the Manager who should report to the Care Quality Commission and the Safeguarding Adults Partnership Board Procedures instigated.

Unexpected events and incidents must also be fully documented after the event.

There must be regular reviews to discuss any form of restraint which has been necessary.

Staff must receive regular supervision and have support and guidance offered to them following the use of restraint.

Managers are responsible for ensuring that a service is able to meet an individual’s needs including personality mix of service users.

Incidents should be monitored by the Manager to prevent and identify sequences of events, possible patterns and triggers to know when a risk assessment, review of the environment or individual, planned intervention or Deprivation of Liberty Safeguards (DoLS) are necessary, see Deprivation of Liberty Safeguards.

When restraint is used it must always be recorded. Restrictive physical intervention, restraint and deprivation of liberty require high standards of record keeping, monitoring and regular review to identify patterns warranting involvement of appropriate informal carers, professionals, a court or DoLS supervisory body and to identify whether the intervention can end. Consideration should also be given to the involvement of an Advocate.

2. Procedural Steps

Step Action By Whom
1. If restraint has been used to prevent immediate harm, attention must be paid to the person who has been restrained to address any harm or distress they may have suffered as a result of being restrained. This can be given by the person who has practiced restraint but might need to be given by someone else. Care staff
2. The event must be recorded immediately by both the person who has practiced restraint and any witnesses and must include the views of the person who has been restrained wherever possible. It should be overseen by the senior staff member on duty and should cover:
  • The reason why restraint was used;
  • The reason why it was the only remaining option;
  • A full description of the event from beginning to end;
  • Any consequences of restraint.
Person practicing restraint/ senior staff on duty
3. A positive risk assessment should either be carried out or an existing one reviewed to assess the likelihood of restraint needing to be used again in the future. Planned restraint must only be considered if:
  • It is necessary to prevent the person from being harmed or from harming others and no other option to restraint is available;
  • The person lacks capacity to consent to treatment or other interventions such as personal care and it is believed to be necessary to restrain them to administer this. It is important to note that unnecessary or excessive restraint is a criminal offence and will be treated as such.

Restraint should never be used just so that staff may do something more easily and less restrictive options than restraint such as persuasion, or de-escalation techniques to manage aggression should always be considered first.

Senior staff member/ keyworker overseen by senior staff member
4. If it can be reasonably foreseen that restraint may have to be used in the future, whether it has been used previously or not, an assessment of capacity must take place. If this shows that the person does not have capacity then a formal Best Interest decision must be made which specifies what can be done by whom and in which circumstances. This can be done at a Best Interest Meeting or at the person’s review, provided the review incorporates the views of all relevant stakeholders. Any restraint planned must be the least restrictive option, used for the minimum amount of time and it must be proportionate to the level of harm foreseeable. A positive risk assessment should be done which considers not only the circumstances which might give rise to the possibility that restraint may be needed but also the effects of that restraint on the person. The risk assessment must consider the use of less restrictive options before considering restraint. Any agreed actions must be clearly documented on the person’s Care Plan. Senior staff member/ Best Interest meeting/ review meeting members
5. If the restraint restricts or curtails the customer freedom to leave the building, it should be checked against the Deprivation of Liberty Safeguards (DoLS) guidance and a DOLS authorisation sought if necessary. See also Deprivation of Liberty Safeguards. Senior staff member/ safeguarding team in consultation with Best Interest decision meeting/ review meeting members
6. If mechanical restraint is being considered, such as bed rails, lap belts or chair trays are being considered, the advice of a qualified Occupational Therapists should be sought to make sure the least restrictive option is being used. Senior staff member/ Occupational Therapist in consultation with Best Interest decision meeting/ review meeting members
7. If medication is being considered to help manage someone’s behaviour, this is a form of restraint and may amount to a Deprivation of Liberty. If it does, then a DoLS authorisation must be sought. Medication must be prescribed by the customer’s GP or hospital consultant, must be regularly reviewed and identified in the support plan as a necessary form of restraint. Consideration should always be given to the use of social therapeutic interventions as an alternative to medication and the effectiveness of these considered during the medication review to see if medication can be reduced or withdrawn. Senior staff member/ GP/ hospital consultant in consultation with Best Interest decision meeting/ review meeting members
8. If environmental restraint such as locked doors, coded keypads or complicated handles is being considered, then the effect on others must be assessed to make sure they are not being restrained as well. An assessment should also be made to determine whether the environmental restraint amounts to a Deprivation of Liberty. If it does, a DoLS authorisation must be sought. Senior staff member/ safeguarding team in consultation with Best Interest decision meeting/ review meeting members
9. If the restraint involves physical intervention, for example holding someone, then:
  • This must be agreed in advance by the care team in consultation with the service user and his/her carers or advocates and recorded in the care plan;
  • It must be made with due regard to the person’s age, gender, culture, physical strength or frailty;
  • Staff who may reasonably be expected to administer restraint must receive training in the form of restraint and the specific circumstances in which it may be used.
Senior staff member in consultation with Best Interest decision meeting/ review meeting members
10. Restraint in the form of threats, intimidation or emotional blackmail should never be used in any circumstances. Everyone
11. If the Best Interest Meeting or review agrees that restraint may be necessary, it must:
  • Specify the type of restraint to be used in as much detail as possible;
  • Describe the circumstances in which restraint can be used and what must be attempted before restraint is used;
  • Set a date to review the decision (see point 13 below);
  • Make sure the person’s support plan is amended to contain all of the above.
Best Interest decision meeting/ review meeting members
12. If restraint has been used on an individual, the event must be recorded immediately by both the person who has practiced restraint and any witnesses and must include the views of the person who has been restrained wherever possible. The record should cover:
  • The reason why restraint was used;
  • The reason why it was the only remaining option;
  • A full description of the event from beginning to end;
  • Any consequences of restraint.
Person practicing restraint/ senior staff on duty
13. The use of restraint must be constantly monitored and must be formally reviewed at least every six months or more urgently if any of the following circumstances apply:
  • Restraint is used more frequently than had been envisaged;
  • Restraint is used with increasing frequency;
  • Any injuries are sustained by anyone during restraint;
  • The method of restraint agreed is not effective in keeping the person or others safe;
  • There is any indication that the agreed procedures, boundaries and limitations on restraint are not being adhered to.
Senior staff member/ Best Interest decision meeting/ review meeting members