Following a study into the use of restraint in care homes the Social Care Institute for Excellence (Scie) launched its Managing Risk, Minimising Restraint guidelines outlining approaches to minimise its use
Many of the challenges around restraint were highlighted by the experiences of Rosemary Hurtley’s mother, who spent the last years of her life in a care home.
“I came in one day and I found that my mother, who is a very good walker, was in a wheelchair. I said to the staff, ‘what’s going on here?’ They said they were taking her to the dining room. I told them she can walk, to which they replied, ‘Oh, well it’s just a little bit quicker if we put her in a chair.’
“What they didn’t realise, is that if you don’t walk you lose the power of your legs. But also my mother enjoyed walking. So putting her in a wheelchair was restraint because it took away her independence, and something she liked doing.”
Hurtley believes that by treating her mother this way, some staff in the care home were preventing her mother from living her life the way she would choose to live – they were restraining her.
Rosemary Hurtley and her mother’s experience is just one example of restraint in a care home. Restraining someone could range from unintentionally leaving their walking frame out of reach, to physically holding them. Because the term covers such a wide range of actions it can make it difficult for staff, residents and relatives to understand what restraint means, whether it is acceptable and in what circumstances, and what is good practice.
The Scie guide Managing Risk, Minimising Restraint goes some way towards answering these questions, and provides support for care staff so they can feel confident when making decisions about the use of restraint. The guide was put together following research into the use of restraint in care homes for older people, and is based on the learning from literature and discussions with residents, relatives and staff. It covers:
● What types of actions constitute restraint
● Understanding the link between risk and restraint
● Developing knowledge and skills
● Creating a positive environment
● Making informed decisions
This step-by-step guide raises awareness of the routine issues faced by staff, like those in Hurtley’s mother’s care home
Tom Owen, joint author of the Scie report Minimising the use of Restraint in Care Homes: challenges, dilemmas and positive approaches, explains: “You have residents who might not be able to make decisions and they’re adamant that they want to walk around but they might be at risk of falling. Then you have the relatives who are frightened of seeing their family taking risks that are unnecessary. The staff are quite often in the middle – they feel a sense of duty to care and to protect these vulnerable people, but they also have to honour the choice of the resident. It’s a really difficult one.”
Although some emergency situations demand an immediate decision about whether to use restraint, most develop over a longer period of time. In these situations decisions must be carefully thought out and based on individual circumstances. The Scie guide includes a five-step framework to help care staff to make an informed decision. Each step prompts the staff member to think about or consider different elements of the situation in relation to the individual. The five steps are:
● What is the resident saying and how do they look?
● What are they doing?
● What are the staff saying?
● When is it happening?
● Who is it a problem for?
● Is anyone else involved or present?
2 Do some detective work. Try to find out:
● What the behaviour might mean?
● What risks are associated with the behaviour?
● Who it is risky for?
● Who else should be consulted?
● What the legal position is?
3 Consider options and make a decision. Think about:
● What works to help this person?
● When are they happiest?
● Which is the least restrictive option if restraint is needed?
4 Implement the plan. Agree:
● How long the approach should be tried before it is reviewed
● What records should be kept
5 Monitor and review the plan. Consider:
● Has the intervention helped?
● Who has it helped?
● What does everyone think?
● Are any changes needed or do you need to try something different?
Owen says: “Care homes need to start with the assumption that their residents should be able to exercise choice, should be able to do whatever they like, and should not need to be restrained in any way. The next stage is to assess whether they are capable of making these decisions.”
Presuming capacity is the first principle of the Mental Capacity Act 2005, which outlines what needs to happen if there are concerns about someone’s ability to make their own decisions, for example if they have dementia. If it is found that they lack capacity, decisions must be made in the person’s best interests.
Dr David Oliver, senior lecturer in elderly care medicine at the University of Reading, says: “When it comes to restraint the Mental Capacity Act says ‘in certain limited circumstances restraints are acceptable if they’re the only way that you can protect someone from harm, if you’ve explored all the other ways of protecting them from harm, and if you review it regularly and do it to the least possible degree’.”
Owen agrees: “If someone is not capable of making decisions it is the responsibility of the carer to learn more about the person by talking to them and those around them to find out what risks they would normally take. This way we are constantly looking at the positive side – what does this person want to achieve and how can we help them achieve it?”
Hurtley says it was this shift towards a person-centred approach to care that did so much for her mother in the last years of her life. “For my mother, being able to continue walking meant she was able to come out with the family and still enjoy doing the things she liked, such as visiting the garden centre. If she had been kept in a wheelchair her choices would have been restricted and her world would have been made smaller, and that is what restraint is about.”
The key messages from Managing Risk, Minimising Restraint include:
● Understanding what restraint is, and the occasions on which it is acceptable, is the first step towards minimising its use. The Mental Capacity Act 2005 code of practice provides guidance for making these decisions.
● Using a five-step framework will help with making informed decisions in situations where the use of restraint is being considered.
● Supporting residents to take positive risks helps increase their wellbeing as well as reducing reliance on restraint to maintain their safety.
● Talking openly about restraint with residents, relatives and staff will help promote good practice.
● Using the physical environment to promote a sense of wellbeing can help avoid some of the situations that result in the use of restraint.
● Care staff need opportunities to develop their skills and knowledge, and to share learning about how to respond to the challenges they face.