Use of Restraint and Physical Intervention

Restraint means using force or restricting liberty of movement.

‘Using force’ includes physical restraint techniques that involve using force, i.e the positive application of force with the intention of overpowering a child. Practically, this means any measure or technique designed to completely restrict a child's mobility or prevent a child from leaving, for example:

• Any technique which involves a child being held on the floor;
• Any technique involving the child being held by two or more people;
• Any technique involving a child being held by one person if the balance of power is so great that the child is effectively overpowered; e.g. where a child under the age of ten is held firmly by an adult.

‘Restricting a child’s liberty of movement’ includes, for example, changes to the physical environment of the home (such as using high door handles) and removal of physical aids (such as turning off a child’s electric wheelchair). Some children, perhaps due to impairment or disability, may not offer any resistance, but such measures should still constitute a restraint.

Restrictions such as these, and all other restrictions of liberty of movement, should be recorded as Restraint. See Section 11, Recording and Management Review.

Whereas Restraint is designed to completely restrict a child's mobility, Physical Intervention provide the child with varying degrees of freedom and mobility, for example:

1. Holding includes any measure or technique which involves the child being held firmly by one person, so long as the child retains a degree of mobility and can leave if determined enough;
2. Touching includes minimum contact in order to lead, guide, usher or block a child; applied in a manner which permits the child quite a lot of freedom and mobility;
3. Presence is a form of control using no contact, such as standing in front of a child or obstructing a doorway to negotiate with a child; but allowing the child the freedom to leave if they wish.

These are less forceful and restrictive than Restraint, and may be used to protect children or others from less serious injury or damage to property, but must never be used to force compliance where there is not a risk of injury or damage to property nor as a form as punishment.

The assessment and planning process for all children in residential care must consider whether the child is likely to behave in ways which may place them or others at risk of Injury or may cause damage to property. The impact of the child's arrival on the group of children/young people living in the home should also be considered.

Staff caring for disabled children or children who communicate without speech, have a responsibility to understand individual children’s communication style. They can then help children to develop their skills in communication, so that the children can better express their feelings and views on the use of restraint and restrictive practice.

If any risks exist, strategies should be agreed to prevent or reduce the risk. These strategies may include Physical Intervention and/or Restraint. Staff should continually review any risk assessments. See also Risk Assessment and Planning Procedure.

Where Physical Intervention or Restraint is likely to be necessary, for example, if it has been used in the recent past or there is an indication from a risk assessment that it may be necessary, the circumstances that give rise to such risks and the strategies for managing it should be clearly outlined in the child's Placement Plan, including what interventions are agreed.

The Child’s Placement Plan and Risk Assessments are reviewed monthly, sooner if required, particularly when methods of supporting children and young people change.

In developing the Placement Plan, consideration must be given to whether there are any medical conditions which mean particular techniques or methods of physical intervention should be avoided. If so, any health care professional currently involved with the child should be consulted regarding appropriate strategies and this must be drawn to the attention of those working with or looking after the child and it must be stated in the Placement Plan. If in doubt, medical advice must be sought.

Individual Risk Assessments

A crucial aspect of appropriately managing behaviour is knowledge and awareness of actual or possible risks. Proper attention to risk can reduce both the incidence of aggression and its development into violent acts.

• The first step in this process should occur when Initial Assessment is made. The Social Worker’s views should be sought as to any likely risk presented by the young person;
• Risk Assessments must be completed for each child or young person, the Risk Assessments should be completed at the earliest opportunity;
• Risk Assessments must be shared by all staff. Whilst respecting confidentiality, it is important that everyone knows about the risks a young person may present;
• Risk Assessments are reviewed monthly. Should an incident occur that changes the level of risk or come to light, then an immediate review of Risk Assessment should take place;
• When completing Risk Assessments, it is important to seek a broad range of views. Staff should beware of subjective opinions, which may lead to inappropriate or inaccurate labelling. Where possible this should involve all those involved in the care planning and assessment process;
• All staff who work in the team must be involved at an appropriate level in the management of risk. To enable this, it is important that whenever they are working within the team, they are made aware of any identified risks and measures to reduce them;
• All staff must read, sign and acknowledge the Risk Assessment, after each update is made to confirm they understand it and can follow it.

Behaviour Support Plans

A crucial aspect of appropriately managing behaviour is through knowledge and awareness of actual behaviour young people display. Proper attention to this can reduce the incidents of challenging behaviour.

• This process starts when a young person is referred. Management will collect all available information and write an initial Behaviour Support Plan;
• Once a young person has moved in it is important that the staff team identify what strategies work, and which do not;
• The Behaviour Support Plan is under constant review for the first three months and will be changed as the staff observe the young person and their displayed behaviour;
• Once settled the Behaviour Support Plan will be reviewed monthly and changed when necessary;
• All staff who work at SMBC must read, acknowledge and sign to confirm that they have understood the Behaviour Support Plan.

Every young person should have an Individual Behaviour Support Plan and Risk Assessment.

Prevention

The most effective way to manage behaviour problems is to prevent or reduce, to a minimum, their occurrence.

Preventing incidents is always better than dealing with the consequences. The staff team must work together in a nurturing, positive environment that promotes the child's welfare and aims to deal effectively with challenging behaviour and reduce the frequency of incidents.

It is important to know about and use the skills of the other team members. Staff should maintain a consistent approach and agree on strategies for dealing with difficult behaviour. Staff should share good practices and what works and seek advice on alternative strategies from within the staff group.

The staff team should agree on strategies for dealing with difficult behaviour in general and with respect to individual young people in conjunction with a Risk Assessment.

All staff will be trained in methods of behaviour management, including the use of Physical Intervention and Restraint that are agreed by the service.

This training will be refreshed on an annual basis, or sooner if required.

This training must ensure that staff are able to:

• Manage their own feelings and responses to the emotions and behaviours presented by children;
• Manage their responses and feelings arising from working with children, particularly where children display challenging behaviour or have difficult emotional issues;
• Understand how children's previous experiences can manifest in challenging behaviour;
• Use methods to de-escalate confrontations or potentially violent behaviour to avoid the use of physical intervention and restraint.

The registered person is responsible for ensuring that all their staff have been adequately trained in the principles of Restraint and any Restraint techniques appropriate to the needs of the children the Home is set up to care for as defined in the Home’s Statement of Purpose. This is recorded within the homes training tracker and held centrally by the training team.

Those commissioning training in Restraint for staff should be satisfied that the training fits with their approach to Restraint or existing Restraint system, and is appropriate to the needs of the children the Home is set up to care for. They should see evidence that any Restraint techniques the training advocates for have been medically assessed to demonstrate their safety for use in a context of caring for children who are still developing, physically and emotionally.

PRICE

The preferred provider for positive behaviour is PRICE.

PRICE Overview-Behaviour support training-3 Day course for staff

When supporting people who are distressed in either education, health or social care settings, there are times when restrictive interventions are required to protect staff, the individual themselves and others within the community. Despite this need, PRICE Training is committed to restraint reduction and believes the use of coercive and restrictive practice can be minimised, and that the misuse of restraint can be prevented.

PRICE Training places a significant emphasis on the importance of primary, secondary and non-restrictive tertiary strategies. From a person-centred approach, that aims to understand and meet the needs of individuals before difficulties arise, to recognising an individual’s early behavioural signs (physical, emotional, communicative); our courses offer creative experienced-based skills that are effective in preventing situations from escalating. A significant emphasis is also placed on the use of non-restrictive tertiary strategies, such as de-escalation, diversion, distraction or strategic capitulation as well as the use of breakaway techniques to safely respond to unwanted physical contact.

PRICE Training equips delegates to make sense of behaviour and respond positively to reduce the use of restraint.

Where support workers need to physically intervene, PRICE have over 100 breakaways and holding techniques; from low arousal responses to 1, 2, 3 and 4 person holds that can quickly and safely restore stability.

Physical intervention or restraint must only ever be used as a last resort when all other measures have been fully exhausted to take control of a dangerous situation where there is a risk of injury to either the child, someone else or significant damage to property may occur.

Staff are required to be PRICE Trained to perform physical intervention techniques unless an emergency arises, and there is no alternative but for a non-trained person to intervene. Should this occur, a detailed account of why this was necessary, and the measure used must be included in the incident's written report. In these circumstances, it is essential the Registered Manager and Responsible Individual are made aware.

A physical intervention should always be treated seriously and follow an assessment of risk at that moment in time. Where possible, physical interventions used should follow the guidance within the child’s positive behaviour support plan, and all strategies from the plan to support de-escalation should have been attempted.

Regulation 20 sets out the sole purpose for which restraint can be used.

1. Preventing injury to any person (including the child who is being restrained);
2. Preventing severe damage to the property of any person (including the child who is being restrained); or
3. Preventing a child who is accommodated in a secure children's home from absconding from the home.

Restraint is permitted only in the case of 1 and 2 above, as we are NOT a secure accommodation provider. Restraint must be necessary and proportionate.

Physical intervention should never be used:

• To gain compliance;
• For convenience due to other external pressures for example time;
• As a punishment;
• As a reaction to verbal abuse or defiance;
• As a means of control when there is no apparent risk;
• When child is ill or injured unless to prevent further significant injury;
• When a member of staff in angry, frustrated or injured.

Wherever possible and unless there is an emergency, two staff should be present for a physical intervention. Every effort must be made to ensure the child is not hurt and should the child express they are at any point, this must be checked and rectified without delay.

Incidents of physical intervention must be reported to the on-call manager at the earliest possible opportunity to ensure that all required steps are taken to ensure the child’s welfare. All records of physical intervention must be recorded prior to the end of the involved staff members shift to ensure all follow up measures can be enacted within the following 24 hours.

Any physical intervention will be employed using the minimum reasonable force.

The physical intervention will only be sanctioned for the shortest possible period consistent with his/ her best interests and wherever possible under the direction of other professionals.

Children who receive the physical intervention will offer access to a medical professional once the Intervention has ended and the young person is calm and a full debrief.

Before the use of a restrictive physical intervention, appropriate steps must be taken to minimise the risks to staff.

Among the risks to staff are:

• A physical intervention could result in them suffering the injury, experiencing distress or trauma;
• The legal justification for the use of the physical intervention is challenged in court.

Staff must make a dynamic risk assessment before deciding whether to intervene.

 The main risks of not intervening are:

• Breach of duty of care;
• A child, young person or other people may be injured.

The decision to intervene will always be a balance between the risks and professional judgement at the time. Staff who do not intervene physically will be supported but will need to justify why they made that decision.

Staff must inform the registered manager of the home of any reason that may prevent or inhibit them from employing a restrictive physical intervention.

Full training and support will be given.

‘Injury’ could include physical injury or harm or psychological injury or harm.

Restraint in relation to a child must be necessary and proportionate.

This does not prevent a child from being deprived of liberty where that deprivation is authorised in accordance with a court order. See Section 8, Deprivation of Liberty.

When Restraint involves the use of force, the force used must not be more than is necessary and should be applied in a way that is proportionate i.e. the minimum amount of force necessary to avert injury or serious damage to property for the shortest possible time.

Restraint that deliberately inflicts pain cannot be proportionate and should never be used on children.

There may be circumstances where a child may be prevented from leaving the Home for example a child who is putting themselves at risk of injury by leaving the Home to meet someone who is sexually exploiting them or intends to do so. Any such measure of Restraint must be proportionate and should never be used as standard practice.

Where such incidents as defied above occur a professional meeting should be arranged as a priority to ensure the safety of the child is maintained and the placement is reviewed.

In a Restraint situation, staff should use their professional judgement, supported by their knowledge of each child’s risk assessment, an understanding of the needs of the child (as set out in their relevant plans) and an understanding of the risks the child faces.

Approaches to Restraint should recognise that children are continuing to develop, both physically and emotionally. Any use of Restraint should be suitable for the needs of the individual child. The context in which Restraint is used should also recognise that, as a result of past experiences, children will have a unique understanding of their circumstances which will affect their response to Restraint by adults responsible for their care.

Trained staff should only use techniques that are approved by the Home and that they are trained to do so. Approved techniques should comply with the following principles:

1. Not impede the process of breathing - the use of 'prone face down' techniques must never be used;
2. Not be used in a way which may be interpreted as sexual;
3. Not intentionally inflict pain or injury or threaten to do so;
4. Avoid vulnerable parts of the body, e.g. the neck, chest and sexual areas;
5. Avoid hyperextension, hyper flexion and pressure on or across the joints;
6. Not employ potentially dangerous positions.

Any use of Restraint carries risks. These include causing physical injury, psychological trauma or emotional disturbance. When considering whether Restraint is warranted, staff need to take into account:

• The age and understanding of the child;
• The size of the child;
• The relevance of any disability, health problem or medication to the behaviour in question and the action that might be taken as a result;
• The relative risks of not intervening;
• The child’s previously sought views on strategies that they considered might de-escalate or calm a situation, if appropriate;
• The method of Restraint which would be appropriate in the specific circumstances; and
• The impact of the Restraint on the carer’s future relationship with the child.

Staff need to demonstrate that they fully understand the risks associated with any Restraint technique used in the Home. Techniques used for Restraint that may interfere with breathing and holds by the neck that may result in injury to the spine are not permissible in any circumstances.

The locking of external doors, or doors to hazardous materials, may be acceptable as a security precaution if applied within the normal routine of the Home. Please refer to the homes risk assessment. 

A deprivation of liberty may occur where a child is both under continuous supervision and control and is not free to leave the Home. The Home cannot routinely deprive a child of their liberty without a court order, such as an order under section 25 Children Act 1989 to place a child in a licensed secure children’s home, or, in the case of young people aged over 16 who lack mental capacity, a deprivation of liberty may be authorised by the Court of Protection following an application under the Mental Capacity Act 2005.

Where physical Restraint has been used, the child, staff and others involved must be able to call on medical assistance and children must always be given the opportunity to see a Registered Nurse or Medical Practitioner, even if there are no apparent injuries.

If a Registered Nurse or Medical Practitioner is seen, they must be informed that any injuries may have been caused from an incident involving physical Restraint.

Whether or not the child or others decide to see a Registered Nurse or Medical Practitioner it must be recorded, together with the outcome.

The registered person should regularly review the effectiveness and check the medical assessment of the system remains up to date.

If Restraint is used upon a child, the Home Manager and child's social worker must be notified within one working day.

If a serious incident or the police/emergency services are called, the relevant senior manager must be notified and consideration given to whether a Notifiable Event has occurred, if so, see Notification of Serious Events Procedure.

The social worker should make a decision about whether to inform the child's parent(s) and, if so, who should do so.

The registered manager must ensure that records are maintained within the home regarding all forms of behaviour management. The registered manager must ensure that the records are kept up to date.

Records of Restraint must be kept and should enable the registered person and staff to review the use of control, discipline and Restraint to identify effective practice and respond promptly where any issues or trends of concern emerge. The review should provide the opportunity for amending practice to ensure it meets the needs of each child.

Legislation, Statutory Guidance and Government Non-Statutory Guidance

Guidance: Positive Environments Where Children Can Flourish (Ofsted)

Restraint and restrictive practices: positive environments for children – Ofsted: social care