Government tells care services to end use of face-down restraint

New guidelines say services must have programmes to cut the use of restrictive interventions

The Department of Health has issued guidelines to stop the intentional use of face-down restraint.

The guidelines, “Positive and proactive care: reducing the need for restrictive interventions”, make recommendations on how to cut the use of restraint and seclusion in health and social care facilities.

Restrictive interventions include one person restraining another using their body, equipment, medication or seclusion as a temporary way of dealing with a dangerous situation.

The guidelines say restrictive interventions should only be used “as a last resort” and for the shortest time possible after the investigation into the scandal at Winterbourne View found restraint was used to abuse patients.Face-down restraint is particularly dangerous because it can lead to suffocation.

In June 2013 a study by mental health charity Mind found that there had been 13 restraint-related deaths since David “Rocky” Bennett died in a mental health unit in 1998 after prolonged, forceful face down restraint. The charity found 39,883 incidents of physical restraint and almost 3,439 of face-down restraint in 2011-12 and said restrictive interventions were being used for too long, not as a last resort and to punish, humiliate or hurt people.

The new guidelines, which were developed by the Royal College of Nursing following a consultation, state: “Staff must not deliberately restrain people in a way that impacts on their airway, breathing or circulation, such as face down restraint on any surface, not just on the floor.”

The guidelines also say:

  • Post-incident reviews and debriefs must be planned so that lessons are learned when incidents occur where restrictive interventions have had to be used
  • Service commissioners must be informed by providers about the use of restrictive interventions and should monitor and act if concerned
  • People who use services, families and carers must be involved in planning, reviewing and evaluating all aspects of care and support.
  • Services must train their staff on reducing restrictive interventions and increased behavioural support planning. .
  • Service providers must have transparent polices on the use of restrictive interventions and ensure these are produced with and accessible to users of services and carers.
  • Providers must review the quality, design and application of behaviour support plans, or their equivalents in their internal audits and act in response to the findings
  • Services must publish accurate data on progress in reducing restrictive interventions and training and development and submit data to mandatory reporting systems like the National Reporting and Learning Service

The guidelines add that staff must not deliberately inflict pain during restrictive intervention and must not use seclusion except for people detained under the Mental Health Act 1983. Services must also have programmes to reduce the use of restrictive interventions and publish data on their progress.

The rating CQC gives care providers will be influenced by the guidance, according to the paper. The CQC’s deputy chief inspector of hospitals Dr Paul Lelliott, said it and the NHS Confederation would develop supplementary guidance on how it would apply the guidelines.

A person at board level in each service providers should be responsible for the issue of restrictive interventions, the guidelines said.

The guidelines recommend that people who are likely to be restrained or secluded must have a support plan, including a behaviour support plan, and the CQC will scrutinise those plans that involve restrictive interventions.

Service users, their families and carers must be involved in planning, reviewing and evaluating their care, and these groups must also be involved in the design of policies on restrictive interventions, the guidelines said.

The government also said it would invest £1.2m in training to help staff avoid using restrictive interventions. Skills for Care and Skills for Health will also publish another document, “A positive and proactive workforce”, to help services commission training for their staff.

Care and Support Minister, Norman Lamb, said: “No-one should ever come to harm in the health or care system. Although it is sometimes necessary to use restraint to stop someone hurting themselves or others, the safety of patients must always come first.
“This new guidance will stop inappropriate use of all types of restraint, reduce this outdated practice and help staff to keep patients safe.”

Paul Farmer, chief executive of Mind, said: “We are delighted to support the launch of this important guidance, which marks a significant step towards changing attitudes to restraint and ending face-down restraint.

“We know that healthcare staff do a challenging job and sometimes need to make difficult decisions very quickly. This is comprehensive guidance that looks to address the system as a whole, transforming cultures and attitudes so that difficult situations are less likely to arise and so that staff are supported to use alternatives to restraint when faced with challenging behaviour.

“When someone is in a mental health crisis they need help, not harm. Physical restraint can be humiliating, dangerous and even life-threatening and our own research indicates that some trusts are currently using it too quickly. We look forward to seeing this guidance implemented in health and social care services across England for the benefit of all people with mental health problems and the frontline staff who support them through crisis.”

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