Proven Practice: Minimising the use of restraint in care homes for elderly people

The Social Care Institute for Excellence explains how a thorough knowledge of residents’ needs, multi-agency partnerships, and good record-keeping can reduce the need for restraint of residents in care homes

For many people, the word “restraint” conjures an image of residents in care homes tied to chairs or being forcibly held down, but there are many other types. Restraint can include:

● Chemical restraint – the inappropriate use of sedatives or antipsychotic medication.

● Environmental restraint, such as poor lay-out and design of care homes.

● Technological restraint, such as keypad locks on doors and electronic tagging.

● Passive restraint, such as failing to support residents to be as independent as possible.

The main law governing the use of restraint is the Mental Capacity Act 2005, although several other laws are also relevant. The act defines restraint as:

● The use, or threat, of force to make someone do something that they are resisting; or

● The restriction of a person’s freedom of movement, whether they are resisting or not (s6.40).

By law, if a person has decision-making capacity, restraint can only be used if they consent to it, or in an emergency to prevent harm to themselves or others or to prevent a crime.

If the person lacks decision-making capacity, the decision to use restraint must be based on the person’s best interests. Restraint can only be used to protect the person from harm, and must be proportionate to the likelihood of harm, and applied for the shortest time possible.

Common law permits staff to restrain or remove someone who is exhibiting challenging behaviour or is thought likely to cause harm to others.

The Mental Capacity Act also includes the deprivation of liberty safeguards to protect people from being unlawfully deprived of their freedom in a hospital or care home, including through ongoing, inappropriate restraint.

Acceptable restraint

Restraint is acceptable in some circumstances, and residents may ask for a form of restraint because it makes them feel safer.

For example, a resident may ask for bed rails if they are afraid of falling out of bed, or the resident, relatives and staff may agree they should take a tagging device with them when walking in the neighbourhood for their safety.

Care staff may sometimes have to decide quickly to restrain a person physically if a situation suddenly arises where there is a serious risk of harm. Not to do so on such occasions could be considered neglect.

Unacceptable restraint

In some situations restraint is clearly unacceptable. Holding people down or physically stopping them from doing something they want to do, for example, would be considered unacceptable in almost all cases.

Where there has been no formal assessment of risk and no thorough examination of alternative strategies involving the resident and relatives, the use of manual restraint could be considered a form of abuse.

Sometimes the circumstances in which the restraint is used can make it unacceptable. Electronic tagging can lead to inappropriate restraint if, say, a person is prevented from going on a regular outing because of a lack of staff available to monitor their movements.

Unintentional restraint

Sometimes care staff may not even realise that they, the staff team or the care environment as a whole are restraining a resident. For example:

● Older people can find deep-seated chairs difficult to get into and out of without help. This can be a form of restraint, particularly if staff are not available when needed.

● Lack of interaction between staff and residents is another form of unintentional restraint. If staff don’t communicate with residents, they won’t know what they need.

● Staff shortages and lack of appropriate professional support can make inappropriate and unintentional restraint more likely. If staff do not have time to properly record or reflect on their practice, care plans and individualised care suffer.

Decisions about use of restraint

The decision to use a form of restraint is usually related to concerns that the resident may come to some harm otherwise.

The resident’s needs should guide decisions about use of restraint, not those of the staff, the care home, or relatives, although relatives must be fully involved and consulted. Finding out about a resident’s past and interests, if possible with the help of family, could be the key to knowing what to do.

Generally, approaches that do not involve the use of restraint should always be tried first. Often, with reflection and teamwork, staff can work together to develop an action plan to respond differently to challenging behaviour.

It is important to consult all relevant parties, including other involved professionals, such as a GP and, in some particularly difficult cases, the inspection services.

Good record-keeping is essential for good decision-making. It is also where you explain your reasons for taking any restraining action – an important legal record.

Sometimes restraint will be the only option, but the aim should be to minimise its use as far as possible. Some of the most important steps to achieving this are knowing the individual, valuing the views of relatives and working as a team.

Further information

Scie, At a glance guide: Managing risk, minimising restraint: Challenges, dilemmas and positive approaches for working with older people in care homes. 

Mental Capacity Act court decisions

Case study: ending medication

Des came to the Oak Leaf residential care home on a high dose of antipsychotics because of challenging behaviour. The care staff found him very unsettled and angry. He kept piling up all the furniture in the middle of the dining room. He would also strip the sheets off his bed and cover up the televisions. They weren’t at all sure they could keep him there.

They had a meeting and talked to his family about his life history and made a really important discovery. Des used to be a painter and decorator. It became clear that he was in fact piling up the furniture in preparation for decorating the room. Just understanding what he was doing helped the staff.

Their solution was to provide him with paint brushes and a roller and some water in a tin. He was so pleased to be able to have some sort of meaningful occupation and calmed down so much that it was possible to take him off the antipsychotic medication.

Practioners’ messages

● Know the legal position. The Mental Capacity Act 2005 provides clear guidance, including when the use of restraint is appropriate.

● Find out about the person. If we know the person well, we are more likely to be alert to their needs and understand what they are saying to us when a difficult situation develops.

● Good care planning and good record-keeping can help the team find the best way to respond when the need to restrain someone arises.

● Consulting and involving family and friends and other concerned professionals will produce better solutions.

● Ensuring staff are well supported and supervised and have access to ongoing learning and development opportunities will help promote good decision-making.

● Adapting the physical environment and ensuring adequate staffing levels can help minimise the need for restraint.

Research Abstracts

Author: Goldman, Beryl

Title: Commentary: barriers to a sustained restraint-free environment.

Reference: Journal of Aging and Social Policy (US), 20(3), 2008, pp.286-294.

Abstract This article examines measures introduced in US care homes to reduce the use of physical restraint. It also explains why poor supervision and high staff turnover contribute to the incorrect use of restraint. It highlights the importance of staff and management training and valuing of care assistants. (Copies of this article are available from: Haworth Document Delivery Centre, Haworth Press Inc, 10 Alice Street, Binghamton, NY 13904-1580).

Author: Hughes, Rhidian

Title: Older people falling out of bed: restraint, risk and safety.

Reference: British Journal of Occupational Therapy, 71(9), September 2008, pp.389-392.

Abstract This article examines the significance of bedside rails and good practice in their use in the context of mental capacity legislation. It highlights the importance of putting the best interests of older people at the centre of all decisions about their care.

Editor: Hughes, Rhidian

Title: Reducing restraints in health and social care: practice and policy perspectives

Publisher: London: Quay Books, 2009. 141p.

Abstract This book also explores restraint from the perspective of people who use health and social care services, including the history of its use and current trends towards restraint-free care.

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