At what point does careful consideration for the safety of someone in your care cross the line and become abuse? For people working in residential care with older people this can be an everyday issue. A report published by the Commission for Social Care Inspection in December documented several instances where care homes had overstepped the mark. The overuse of chemical sedation the use of physical restraints to strap people into their wheelchairs, tie them into chairs or confine them to bed vulnerable people being dragged by their hair, left in soiled pads for hours and threatened or intimidated. Nobody would seek to justify such behaviour.
However, the report also lists scenarios where the issue is not so clear cut. It points out that a locked front door might seem sensible security to some, while for others it can turn their home into a prison. Likewise the use of CCTV, electronic alarms or tagging devices treads a delicate line between protection and Big Brother-style intrusion.
There is much debate about what constitutes restraint and what does not (see The range of restraint) and while most in the care sector are against the use of restraint in principle, few are able to offer a practical alternative that fits every scenario. In the CSCI report, which sought the views of care professionals, service users and their families, 59% of respondents said restraint was an infringement of human rights and 63% favoured a restraint-free policy. Yet 80% said they thought that restraint could be justified in exceptional circumstances.
“It is not an easy discussion,” says Stephen Burke (pictured right), chief executive of elderly care charity Counsel and Care. “A delicate balance has to be made between an older person’s rights to take risks and make autonomous decisions and their families’ and involved professionals’ responsibility to protect and keep them safe where possible.”
A difficult discussion indeed, but one that needs to takes place. One of the CSCI’s most disturbing findings was that care homes are often tacitly reluctant to acknowledge that any form of restraint occurs at all.
“It is important that the issues around the use of restraint do not remain hidden and are brought out into the open for debate,” says Burke.
One of the key areas in that debate is bound to be the thorny issue of resources. At its worst extreme, the use of restraint can result in a care home being run on a skeleton staff using chemical coshes and incarceration to subdue the residents and save money. But even well-run care homes may struggle with the resource implications of reducing the situations where restraint is likely to occur. Most published guidelines stress the importance of anticipating situations where restraint might become necessary and avoiding or gently diffusing them. But this approach can be highly labour intensive and requires considerable investment in staff training.
According to Neil Hunt, chief executive of the Alzheimer’s Society, the inappropriate use of restraint in care homes is often the result of “an overstretched and under resourced system”.
“It’s all too easy to think that restraint is about belts and shackles. In fact restraint goes far wider – from the thousands of people with dementia being sedated by the inappropriate use of antipsychotic drugs to people being denied access to outdoor space because of a lack of staff in care homes.”
Hunt points out that two-thirds of care home residents have some form of dementia, yet many staff receive little or no training in dementia care. This can allow difficult situations to escalate to the point where some form of restraint becomes inevitable.
“Many of the horrendous stories of abuse in the [CSCI] report occurred because of care staff’s lack of understanding and training in dementia care. We can no longer leave people in the front line of care to cope alone without adequate resources and specialist dementia training. Mandatory dementia training for staff in all care settings would begin to tackle the huge variation in dementia care.” But who should pay for this extra staff and training? This is a question that is nagging Frank Ursell, chief executive of the Registered Nursing Home Association.
“While CSCI appears grudgingly to acknowledge the link between quality of care and the money available to pay for it, it doesn’t suggest how many more staff are needed in care homes and how much more that would cost,” he says.
Slur against nursing homes
Ursell is furious at the slur cast on his industry by the CSCI report which he describes as an “unjustified character assassination” that sends out confused messages. And, while he emphasises that he is not seeking to justify the use of restraint against older people, he points out that care home staff often have to deal with difficult and unpredictable situations involving residents who may “display erratic and challenging behaviour”.
“On the one hand the regulator says that care home residents must be allowed to take risks. On the other hand, when risks are taken and something goes wrong, such as a very frail older person falling over and breaking a hip, or someone becoming very aggressive and assaulting other residents, the poor care home workers get the blame.
“They have to use their professionalism and common sense to decide what is best for the individual concerned and the other patients around them. There is often no time to make detailed risk assessments or to consider a dozen or more different options.”
Clearly there is a need for some firm guidelines for care homes and their staff who may be feeling the debate on restraint leaves them damned if they do and damned if they don’t. The CSCI has followed up its report by producing guidance for its own inspectors on How to move towards restraint free care. This emphasises the importance of such things as staff numbers, training and the use of preventive measures to limit the use of restraint.
However, there are some who feel more urgent action is needed. “While we applaud CSCI in updating their guidance for inspectors on restraint, we feel that this matter requires a far more robust approach,” says Gary FitzGerald (pictured right), chief executive of Action on Elder Abuse. “Last year, CSCI produced a similar report on medication abuse, but there is no evidence that it resulted in a reduction in such abuse within the care home sector. This is just not acceptable.”
According to CSCI chair Dame Denise Platt the aim of its report was to explore “this sensitive issue and to raise questions and prompt debate about the balance that needs to be found”. But for the campaigners, it’s time for the debate to end and the action to begin.
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THE RANGE OF RESTRAINT
● Physical restraint – using equipment or furniture to impair freedom of movement; the physical intervention of staff to block movement.
This article appeared in the 14 February issue under the headline “Restraints on fair care”