August 2020: This chapter was updated when a link was added to the Restraint Reduction Network, as above.
There may be times when, for the safety of the adult and others around them, it would be neglectful not to restrain the adult.
In such circumstances restraint should only ever:
- be used as a last resort when no other option is available;
- employ the least restrictive option; and
- use the minimum amount of force for the shortest time possible.
Legally, restraint can only be used in two sets of circumstances:
- where there is an immediate risk of harm to the person or to others. For example, if a pan of hot liquid fell from a hob in a kitchen, it would be lawful to use physical force to pull an adult out of the way. It would not be lawful to use force to remove them from the kitchen just in case a pan was to fall.
- where an adult lacks mental capacity and where staff believe that restraint is necessary to prevent the adult from being harmed or harming others (see 3.2, Adults who lack mental capacity).
Not following these principles may constitute a criminal offence for which the staff member can be prosecuted.
The legislation gives staff powers to prevent harm occurring to adults who lack mental capacity and staff would be failing in their duty of care if they did not intervene when necessary. But should adults be put at risk because staff do not to use appropriate and lawful restraint, staff could be subject to a criminal charge of neglect under the Mental Capacity Act 2005.
If a criminal act is believed to have been committed, the local Safeguarding Adults Board procedures must be followed.
Restraint techniques should not cause injury or pain and the degree of distress or psychological trauma to the adult should be minimised. It should not humiliate or degrade them or undermine their dignity or human rights.
Restraint must never be used as a form of punishment, a form of threat, intimidation or emotional blackmail.
Restraint must only ever be used in order to keep people safe.
Other less restrictive options than restraint, such as persuasion or de-escalation techniques to manage challenging behaviour, should always be considered first.
Restraint is the restriction of movement or action of an adult whether they are resisting the action or not, and if necessary by the use of force. It includes:
- environmental measures such as locked doors, straps on wheelchairs, bed rails;
- less impactive interventions such as leading someone back into a service environment, keeping adults from coming into conflict with others by diversion / distraction techniques;
- high intensity interventions such as responding to violent and aggressive behaviour.
Reasonable force is the use of the minimum degree of force required to prevent harm occurring.
3. Mental Capacity
See Mental Capacity.
There is a difference in law between actions which can be taken in relation to adults who have mental capacity and those who do not. It is important staff have an understanding of the law in relation to restraint.
3.1 Adults with mental capacity
Movements or actions of adults who have mental capacity cannot usually be restricted without their consent.
There are times, however, when they can be restrained. For instance it may be necessary to to restrain an adult with mental capacity if the person is:
- threatening harm to another person;
- injuring another person;
- causing damage to property;
In such situations action can be taken under common law, therefore an adult with mental capacity does not have to consent to staff intervening.
Where staff believe a criminal offence is or about to occur, the police should be contacted.
When person who usually has mental capacity then lacks capacity, when they are under the influence of drugs or alcohol for example, and there is an imminent risk of harm to themselves or others a best interest decision must be made at that time. This is in relation to any actions staff have to take, as the adult may not be able to keep themselves or others safe at that time.
3.2 Adults who lack mental capacity
In relation to restraining those who lack mental capacity, most incidents where restraint is needed will not be emergencies but will be known in advance (for example to physically hold someone whilst they receive personal care)
In these circumstances there must always be:
- an assessment of their mental capacity;
- a best interest decision which includes a detailed description in the care and support plan of the type, duration and description of the restriction / restraint to be used;
- a care and support plan drawn up by all concerned with the adult, including the adult where possible, their family and involved professionals.
If it is thought that restraint may have to be used in the future, whether it has been used previously or not, an assessment of capacity must take place.
If this shows that the person does not have capacity, a formal best interest decision must be made which specifies what can be done by whom and in which circumstances. This can be done at a best interest meeting or at the person’s care and support plan review, provided the review incorporates the views of all relevant stakeholders including the adult and family members wherever possible.
4. Practice Issues
4.1 Care and support
Following the use of restraint, care and support must be given to the adult to address any harm or distress they may have suffered as a result. This may be given by the member of staff involved in the restraint but it may be more appropriate for it to be given by another staff member.
4.2 Risk assessment
A positive risk assessment should be undertaken, or an existing one reviewed, which considers:
- the circumstances in which restraint may be needed;
- the potential impact of that restraint on the adult;
- and anyone else who may be affected;
- the use of less restrictive options before considering restraint;
- the potential of restraint needing to be used again in the future and under what likely circumstances.
Agreed actions must be clearly documented in the adult’s care and support plan.
Planned restraint must only be considered if:
- it is necessary to prevent the adult from being harmed or from harming others and no other option to restraint is available;
- the person lacks mental capacity to consent to treatment or other interventions such as personal care, and it is decided restraint is necessary to in order to administer these .
4.3 Best interests
If a best interests meeting or review agrees that restraint may be necessary, it must document:
- the specific type of restraint to be used, providing as much detail as possible;
- the circumstances in which the restraint can be used and what interventions must be tried before restraint is used;
- the date to review the decision;
- all of the above must be documented in the adult’s care and support plan.
4.4 Deprivation of Liberty Safeguards
4.4.1 Freedom to leave
If restraint restricts or curtails the adult’s freedom to leave the service / home, a Deprivation of Liberty Safeguards (DoLS) authorisation should be sought if necessary.
If medication is being considered to help manage someone’s behaviour, this is a form of restraint and may amount to a Deprivation of Liberty. If so a DoLS authorisation must also be sought. Medication must be prescribed by the adult’s GP or hospital doctor, must be regularly reviewed and identified in the care and support plan as a necessary form of restraint including the reasons why. Consideration should always be given to the use of other interventions as an alternative to medication and the effectiveness of these considered during the medication review to see if the medication used to manage behaviour can be reduced or withdrawn.
4.4.3 Mechanical restraints
If mechanical restraints such as bed rails, lap belts or chair trays are being considered, the advice of a qualified occupational therapists should be sought to ensure the least restrictive option is being used. An assessment should be made to decide whether mechanical restraint amounts to a Deprivation of Liberty; if so a DoLS authorisation must be sought.
4.4.4 Environmental measures
If environmental measures such as locked doors, coded keypads or complicated handles are being considered, the potential impact on other adults must be assessed to ensure they are not being restrained as well. If locking doors or the use of bed rails is likely to be a long term measure, detailed care and support planning and regular reviews will be required. An assessment should be made to decide whether environmental restraint amounts to a Deprivation of Liberty; if so a DoLS authorisation must be sought.
4.4.5 Physical intervention
If restraint involves physical intervention, for example holding an adult:
- this must be agreed in advance by the staff team in consultation with the adult where possible, and their carers or advocates and recorded in the care and support plan;
- it must be made with due regard to the person’s age, gender, culture, physical strength or frailty;
- staff who may be expected to administer restraint must receive training in relation to restraint and the specific circumstances in which it may be used.
Incidents should be recorded and monitored by managers to identify any sequences of events, patterns and potential triggers for the adult concerned. Management oversight should be clearly recorded on the file. This will help inform risk assessment and care and support plan reviews, review of the environment, planned interventions or Deprivation of Liberty Safeguards (DoLS) are necessary. This is with the aim of a reduction in the number of incidents where restraint is required.
The use of restraint must be constantly monitored and must be formally reviewed at least every six months, or more urgently if any of the following circumstances apply:
- restraint is used more frequently than had been envisaged;
- it is being used with increasing frequency;
- any injuries are sustained by anyone during incidents of restraint;
- the method of restraint that has been agreed is not effective in keeping the adult or others safe;
- there is any indication that procedures, boundaries and limitations on restraint are not being adhered to.
Restrictive physical intervention, restraint and deprivation of liberty require high standards of record keeping, monitoring. This helps identify patterns warranting involvement of appropriate informal carers, professionals, a court or DoLS supervisory body and to identify whether an intervention can be changed or end.
All incidences of restraint must be recorded immediately by both the member of staff who practiced the restraint and any staff witnesses. The information recorded must include the views of the restrained adult wherever possible. Recorded information should be supervised by the senior staff member on duty and include:
- the reason why restraint was used;
- the reason why it was the only remaining option, including alternatives previously tried;
- a full description of the event from beginning to end;
- any consequences of the restraint.
Unexpected events and incidents must also be fully documented after the event.
The organisation should have clear mechanisms to share learning with staff and across the organisation as needed.
Injuries to adults which result from the use of restraint must be reported immediately to the manager who should report to the Care Quality Commission (see Notification of Significant Events) and the local Safeguarding Adults Board procedures instigated.
4.7 Other issues
Consideration should be given to how many staff are involved in any restraint to help ensure safety and accountability but at the same time not make the situation worse.
Adults who use services, or their family or friends, may not be permitted to restrain or to assist in the restraint of other adults in the service.
4.8 Staff support and supervision
Staff de-briefing following situation is vital, not solely in relation to staff support but also in relation to management support and oversight, including what may have been done differently and useful in managing future events. It should be clearly documented how any learning is shared with other workers and across the organisation. Such information is key to risk assessment and care and support plans reviews and ongoing one-to-one keywork with adults, as appropriate.
Staff supervision also plays a vital role in effective management. This gives the member of staff opportunity and time to express how they feel about particular situations, and managers should offer support as appropriate, including additional training were required.
Staff must receive regular supervision and have support and guidance offered to them following the use of restraint.