A Positive and Proactive Workforce

A positive and proactive workforce
A guide to workforce development for commissioners and

employers seeking to minimise the use of restrictive practices
in social care and health
Ministerial foreword
Investigations into abuses at Winterbourne View Hospital and Mind’s Mental
Health Crisis in Care: physical restraint in crisis (2013) showed that restrictive
interventions have not always been used only as a last resort in health and
care. They have even been used to inflict pain, humiliate or punish. Restrictive
interventions are often a major contribution to delaying recovery, and have been
linked with causing serious trauma, both physical and psychological, to people
who use services and staff. These interventions have been used too much, for
too long and we must change this.
There is overwhelming support for the need to act. Over 95% of respondents were supportive in
consultation. The Royal College of Nursing Congress voted by 99% in favour of new guidelines.
Whilst I appreciate there may be times when restrictive interventions may be required to protect
staff or other people who use services, or the individuals themselves, there is a clear and
overwhelming case for change.
This is about ensuring service user and staff safety, dignity and respect. This is absolutely not
about blaming staff. Whilst at Winterbourne there was clearly abuse and this must not be allowed
to happen, we know that many staff have just been doing what they have been trained to do and
have been struggling in difficult situations and often with very little support.
We need to equip these individuals with the skills to do things differently. The guidance makes clear
that restrictive interventions may be required in life threatening situations to protect both people
who use services and staff or as part of an agreed care plan.
Together Positive and Proactive Care and A Positive and Proactive workforce provide a framework
to radically transform culture, leadership and professional practice to deliver care and support
which keeps people safe, and promotes recovery. I want to thank the Royal College of Nursing
for leading the multi-professional consortium who led on developing the Department’s guidance
and Skills for Care and Skills for Health in developing the complementary guidance to support the
commissioning of learning and development. This was a great example of organisations working
together to deliver high quality products that affect all of us.
This guidance is only one part of the story. From April 2014, DH will launch a new, wider two-year
initiative Positive and Safe to deliver this transformation across all health and adult social care.
We will identify levers to bring these changes about including improving reporting, training and
governance. DH will also develop accompanying guidance in relation to children, young people
and those in transition in healthcare settings.
I look forward to working with you to co-produce this programme. Through Positive and Safe
we have the potential to make whole scale system-wide changes, ensuring we have a modern,
compassionate and therapeutic health and care service fit for the 21st century.
Norman Lamb
Minister for Care and Support
Contents
1. Executive summary 1
1.1. Key points 2
1.2. Acknowledgements 3
2. Introduction 5
2.1. The purpose of this guide 5
2.2. Why you should read this guide 6
People in need of care and support, and patients 6
Workers 6
Employers and managers 6
Commissioners, regulators and inspectors 9
Safeguarding leads 9
2.3. Shared key principles 9
2.4. What do we mean by ‘restrictive practices’ 10
Diagram illustrating how restrictive practices and restrictive interventions
can be seen within a human rights based model of positive and proactive
support 12
2.5. The legal and ethical justification for restrictive practices 13
Pain 13
2.6. How to identify when a practice is a restrictive practice or intervention 13
Flowchart to show considerations about whether restrictions are legally
and ethically justified 15
Edie’s story 17
3. Effective workforce development to minimise the use of restrictive practices 18

3.1. Organisational values into practice 19
How to design, recruit and retain the workforce you need 19
Data collection and use 20
Being a person-centred organisation 20
Person-centred thinking 22
3.2. Designing support and care that works 24
Commissioning social care and health 24
The right staff 25
Designing staff structures to minimise restrictive practices 25
Recruiting and retaining the right workers 26
Supporting workers 26
Supervision 27
Other support 28
De-briefing 28
3.3. Developing your workforce’s skills and knowledge 28
Identifying workforce skills and knowledge 28
Skills and knowledge development 29
Choosing the right learning provider 31
Planning and purchasing learning and development 32
The learning provider’s role 33
4. Implementation: information for specific situations 35
4.1. ‘Positive behaviour support’ (PBS) 35
4.2. People with mental health needs 39
4.3. People with dementia 43
4.4. People who have a learning disability 44
4.5. Acute health services 49
4.6. Working in partnership with people in need of care and support, patients
and carers 50
4.7. Individual employers 52
4.8. People with autism 52
5. Appendices 53
Appendix A – More details on workforce 53
Appendix B - List of recommended units and qualifications to support the
minimisation of restrictive practices 57
Appendix C – List of qualifications suitable for those delivering learning
and assessment activities in the use of physical restraint 59
Appendix D – Legislation and codes of practice 61
Legislation 61
Codes of practice 61
Guidance and standards 62
Appendix E – Content of learning; a starting point 63
Appendix F – Accreditation systems and models of learning 65
Voluntary accreditation systems 65
List of learning models which participants in this project have used and
recommended: 65
Appendix G – Questions to consider when choosing a learning provider
for minimising restrictive practices 66
6. References 67
A positive and proactive workforce. A guide to workforce development for commissioners and employers seeking to minimise
the use of restrictive practices in social care and health.
Published by:
Skills for Care, West Gate, 6 Grace Street, Leeds LS1 2RP www.skillsforcare.org.uk
Skills for Health, 1st Floor, Goldsmiths House, Broad Plain, Bristol BS2 0JP www.skillsforhealth.org.uk
© Skills for Care & Skills for Health 2014
Copies of this work may be made for non-commercial distribution to aid social care workforce development. Any other copying
requires the permission of the publishers. Skills for Care is the employer-led strategic body for workforce development in social
care for adults in England. It is part of the sector skills council, Skills for Care and Development. Skills for Health is the sector
skills council for all health employers; NHS, independent and third sector.
Bibliographic reference data for Harvard-style author/date referencing system:

Short reference: Skills for Care & Skills for Health [or SfC&SfH] 2014
Long reference: Skills for Care & Skills for Health, A positive and proactive workforce. A guide to workforce development for
commissioners and employers seeking to minimise the use of restrictive practices in social care and health,
(Leeds, 2014) www.skillsforcare.org.uk www.skillsforhealth.org.uk
1. Executive summary
Within the last few years, a number of reports have focused attention on the use, or abuse
of restrictive interventions in health and care services. In 2012 the Department of Health
published Transforming Care: A national response to Winterbourne View Hospital which outlined
the actions to be taken to avoid any repeat of the abuse and illegal practices witnessed at
Winterbourne View Hospital.
In June 2013 Mind published its report Mental Health Crisis Care: physical restraint in crisis
which provided evidence of significant variations in the use of restraint across the country and
raised concerns about the use of face down or ‘prone’ restraint and the numbers of restraint
related injuries that were sustained.
“A positive and proactive workforce; A guide to workforce development for commissioners and
employers seeking to minimise the use of restrictive practices in social care and health” has
been co produced by Skills for Care and Skills for Health. It is one of a suite of guidance that
has been written to support the introduction of ‘Positive and Safe’.
Skills for Care and Skills for Health have worked extensively with focus groups and test sites
representing experts in Positive Behaviour Support, people with learning disabilities, mental
health problems, autism, older people, family carers, commissioners, social care employers and
learning providers to inform and agree the content of the guide.
The guide will help commissioners and employers to develop a workforce that is skilled,
knowledgeable, competent and well supported to work in a positive and proactive way to.
It will inform decision making when planning, purchasing or providing learning and development
activites to support workers and individuals to work in a positive and proactive way.
In addition it outlines some key points for organisations to ensure that any restrictive practice or
intervention is legally and ethically justifiable and underpinned by following key principles which
are shared with the DH guidance:
Compliance with the relevant rights in the European Convention on Human Rights at all
times.
Understanding people’s behaviour allows their unique needs, aspirations, experiences
and strengths to be recognised and their quality of life to be enhanced.
Involvement and participation of people with care and support needs and their families,
carers and advocates is essential, wherever practicable and subject to the person’s wishes
and confidentiality obligations;
People must be treated with compassion, dignity and kindness.
Social care and health services must support people to balance safety from harm with
freedom of choice.
Positive relationships between the people who deliver services and the people they
support must be protected and preserved.
1.
1.1. Key points
This guide is concerned with developing workers so that they can work in a positive
and pro-active way to minimise the use of all forms of restrictive practices. In everyday
language we consider this to be: “Making someone do something they don’t want to
do or stopping someone doing something they want to do”.
Anyone who may carry out a restrictive practice or provide learning in this area should
have completed training in the Mental Capacity Act which covers the learning outcomes
of the QCF unit MCA01, ‘Awareness of the Mental Capacity Act 2005’ (level 3) and other
legislation relevant to their situation (see Appendix D).
Learning about human rights based, positive and pro-active, non-aversive approaches
must precede any training on or use of restrictive interventions.
Significantly more time should be spent learning about positive and pro-active approaches
and non-restrictive alternatives. Any learning about how to carry out restrictive interventions
should always focus on good practice where positive pro-active strategies are the norm
and are part of an ongoing learning pathway.
Bank / agency / casual / self-employed workers should receive training and support in line
with all other workers in the team.
Learning must be offered to individuals for whom restrictive practices are planned. Their
family carers or support network should be included in learning proportionate to their level
of their involvement in supporting the individual.
Information must be offered to anyone experiencing planned or unplanned restrictive
practices, and to their carers1.
Anyone delivering learning or assessing competence in restrictive practices should be
occupationally competent and hold or be working towards achieving a recognised teaching
/training qualification.
All learning should be co-produced; including the voices of the people being supported and
their carers in appropriate formats in design, production, delivery and evaluation.
Workers in all social care and health services must have an appropriate level of awareness
of the specific needs of people with whom they may come into contact. This may include
people with dementia, psychosis, autism, borderline personality disorder, head injury,
trauma, anxiety, learning disability, etc., and the ways in which these conditions may lead to
behaviour that challenges or a resistance to essential care.
Workers should have an understanding of how to access specialist advice and support for
people, which includes advice on the impact of culture and the environment.
Executive board members (and their equivalents in non-regulated services) who authorise
1
‘Carer’ is used throughout to indicate family or friends who provide social care or health support, as distinct from
social care or health workers. 2.

D.ESCAL8

3.

4.
2. Introduction
2.1. The purpose of this guide care or health needs. This could include the
individual and their family and friends along
This guide is aimed at commissioners and with paid workers, people who shape the
employers responsible for developing a services by providing regulation or training,
adult social care and health workforce who those commissioning the service and senior
are skilled, knowledgeable and competent. level managers and board members.
Organisations will have plans to reduce This guide supports and complements the
restrictive practices both for individuals and for Department of Health’s Positive and Proactive
their service as a whole and this guide should Care: reducing the need for restrictive
help them to implement these. This guide interventions (DH 2014), developed by the
shows how workers can be developed and Royal College of Nursing, which provides
supported to minimise (reduce the necessity, guidance on the use of organisational
frequency, intensity and duration of) restrictive models of restrictive intervention reduction
practices and ensure they are only ever used and positive behavioural support in order to
appropriately and not misused or abused. provide better outcomes for people.
This guide has also been written at the
This guide applies to services for people with same time as “Ensuring Quality Services
any kind of adult social care or health need, - Core principles for the commissioning of
including people with longer term needs such services for children, young people, adults
as some people with a learning disability, and older adults with learning disabilities
autism, acquired brain injury or dementia, and / or autism who display or are at risk of
those with intermittent or frequently changing displaying behaviour that challenges” which
needs such as people with mental health or has been developed by NHS England and
substance misuse problems, and people in the Association of Directors of Adult Social
an acute health crisis such as following an Services (NHSE LGA 2014 3). This guide aims
accident, severe infection, recovering from an to support and complement this in relevant
anaesthetic or under the influence of alcohol or services.
drugs. Those with intermittent or acute needs
could, of course, include people who have Current legislation, policy and accepted good
also a learning disability, dementia or other practice are consistent that any restrictive
long term condition. practice should only be carried out where it
is legally and ethically justified. This means it
Although the guide does not specifically apply must be essential to prevent serious harm to
to services for children and young people, somebody and it must be the least restrictive
those working within theses services may find option.
it helpful. It has particular relevance to services
supporting young people in transition. In these circumstances you will be working
within the Human Rights Act 1998 and the
Throughout this guide we refer to ‘workforce’. European Convention on Human Rights, the
In this context we mean everyone involved in Mental Health Act 1983 as amended by the
supporting a person or persons with social Mental Health Act 2007, the Mental Capacity
5.
Act 2005 (MCA), including the Deprivation of Workers
Liberties Safeguards (DOLS), the Health and You should feel knowledgeable, skilled,
Safety at Work Act 1974 and the Management competent, and supported to do your job
of Health and Safety at Work Regulations to the best of your abilities.
1999 and, in some circumstances, the You will know what is expected of you.
Children Act 2004 and Common Law.
Employers and managers
2.2. Why you should read this Provides clear expectations of the
guide standards expected from workers.
Provides clear guidance on how to
Good proactive workforce planning and purchase or plan learning for workers and
development will produce better outcomes teams.
for people using the services in a way that is Feel confident and assured that you are
cost effective in the long term. The reasons developing your workforce to deliver a
why you should use this guide will be different quality service.
dependent upon your role. These include:
Aids good staff recruitment and retention.
People in need of care and support, and Provides a baseline for negotiating
patients contracts with commissioners of services
The guide offers clear expectations of and with learning providers.
how people working and contributing Provides evidence for relevant Care
to the service you use, should be Quality Commission Standards and
developed. Regulations (2010, currently under
You should receive a higher quality review), specifically:
service and one you can trust.
These standards should help when
purchasing your own care and support,
contributing to commissioning for others
or monitoring services.
6.
Involvement and information Suitability of staffing
Outcome 1: Respecting and involving Outcome 12: Requirements relating to
people who use services workers
Outcome 2: Consent to care and Outcome 14: Supporting workers
treatment
Quality and management
Personalised care, treatment and support Outcome 16: Assessing and monitoring
Outcome 4: Care and welfare of people the quality of service provision
who use services Outcome 21: Records
Outcome 6: Cooperating with other
providers Suitability of management
Outcome 24: Requirements relating to
Safeguarding and safety registered managers
Outcome 7: Safeguarding people who
use services from abuse
Commissioners, regulators and inspectors Safeguarding leads

Outlines the standards required. Assists in considering situations where
Outlines good practice in workforce restrictions or interventions are used which
development to enable transparency in may or may not be ethically or legally
discussions with service providers. justified.
7.
New and current resources
Positive and Proactive Care: MCA 2005 National Partnership Agreement:

reducing the need for restrictive guides and The National Offender
interventions. DH (2014) resources Management Service, NHS
England and Public Health England
Care Quality for the Co-Commissioning and
Health and Safety at Work Act 1974 Commission Delivery of Healthcare Services in
Prisons in England 2013
Everyone
People in secure Children and Children’s
settings young people Act 2004
A positive Care Quality Commission
and Standards and
proactive Regulations (2010) People who
People with Ensuring quality
have a learning
workforce. dementia
disability / autism services. NHS
Skills for Nothing ventured England & LGA
Care / Skills nothing gained: risk (2014)
for Health guidance for people
(2014) with dementia. DH People in acute People with mental Mental Health
(2010) health crisis health problems Act 1983 /
2008 Code of
Practice (under
review) DH
Supporting Meeting needs and Violence: the
workers reducing distress: short-term Safewards; making
working guidance on the management of psychiatric wards more
with people prevention and disturbed / violent peaceful places
who management of behaviour in in-
challenge clinically related patient psychiatric
challenging and emergency The Mental Health
- guidance
behaviour in NHS departments. NICE Crisis Care Concordat:
for
settings - NHS Clinical Guideline improving outcomes
employers.
Protect: (2014) 25 (2005). for people experiencing
SFC (2013)
mental health crisis. HM
Government (2014)
Closing the Gap: priorities for

Guidance on prevention and management of physical essential change in mental
assaults in mental health settings - NHS protect health. DH (2014)
8.
This guide fits with other guidance that is Shared key principles
currently available and with work which is on- Compliance with the relevant rights in
going. the European Convention on Human
Rights at all times.
Current on-going work; allied Understanding people’s behaviour
projects and future products allows their unique needs, aspirations,
experiences and strengths to be
A number of additional projects are on recognised and their quality of life to be
going which include; enhanced.
The positive and safe programme. Involvement and participation of
New DH guidance for children and young people with care and support needs
people on restrictive interventions. and their families, carers and advocates
is essential, wherever practicable and
New NICE guidelines on violence and
subject to the person’s wishes and
aggression and also on challenging
confidentiality obligations;
behaviour and learning disability. both
due 14 / 15 People must be treated with
compassion, dignity and kindness.
A place I call home; the winterbourne
view joint improvement programme Social care and health services must
support people to balance safety from
harm with freedom of choice.
2.3. Shared key principles
Positive relationships between the
This guide and Positive and Proactive Care: people who deliver services and the
reducing the need for restrictive interventions people they support must be protected
(DH 2014) are based upon a number of and preserved.
shared key principles which apply to adult
social care and health services. These key 2.4. What do we mean by
principles underpin the need to deliver
positive and proactive care, which requires
‘restrictive practices’
rigorous governance in order to reduce
This guide is concerned with developing
excessive reliance on restrictive practices and
workers so that they can work in a positive
interventions and to ensure that, when they
and pro-active way to minimise the use of all
have to be used, it is only ever as a last resort
forms of restrictive practices. In everyday
and is undertaken in a proportionate, least
language we consider this to be:
restrictive way.
Making someone do something they don’t

want to do or stopping someone doing
something they want to do.
9.
Positive and Proactive Care: reducing the as sleeping tablets, can have restrictive
need for restrictive interventions (DH 2014) side effects.
includes detailed definitions of forms of Restrictions may also be used with
restrictive interventions which are used people who are displaying or are at risk
as an immediate and deliberate response of displaying behaviour that challenges,
to behaviours that challenge; the MCA including self-injurious behaviour. In
has a broader definition of restraint and of this case, the principle of an approach
deprivations of liberty. This guide considers called ‘positive behaviour support’ (PBS)
restrictive interventions, restraint and should be used. More detail about this is
deprivations of liberty as well as broader in section 4.1 below. Other techniques
forms of restrictive practices that might be are also useful with people with specific
used as a routine feature of someone’s care needs, this might also include those
and support rather than solely in response to outlined within the ‘Safewards Project’
some form of crisis in mental health in-patient services or
Restrictive practices can be very obvious or ‘dementia care mapping’ with people
very subtle; they may be planned in advance who have dementia. The NHS Protect
or used as a response to an emergency. guidance, Meeting needs and reducing
We have identified four main ways in which distress: Guidance for the prevention
restrictive practices can happen, as follows. and management of clinically related
Restrictions that arise because of habit challenging behaviour in NHS settings
or blanket rules, like everyone having (2014) will be particularly useful in
to be up by a certain time, rules on situations where you do not know the
whether people can have their phones or person in advance or do not have enough
doors being routinely locked. These are time to fully use PBS.
sometimes called “de facto” restrictions.
Safety: these could be restrictions such In all situations where restrictive practices
as locking a room to keep household may be used many of the principles and
cleaning products or medicine out of techniques of PBS will help to create a caring
someone’s reach or allowing someone culture and a positive and proactive workforce.
a planned portion of jam each day. This There should be evidence that restrictions
could also mean responding to violence are questioned and considered and only ever
or aggression towards the individual carried out when all other approaches have
themselves, or to workers or others. been considered and tried or are impractical.
Treatment or care: restrictive practices
Restrictive practices are a wide range
may be used in a planned or unplanned
of activities, some deliberate and some
way in order to provide essential care,
less so, which restrict people. Restrictive
support or medical treatment. This could
interventions lie within this and are a range of
be in an emergency. Some prescribed
specific interventions.
medication not designed to restrict, such
10.
For the purposes of this guide we are using
the definitions of restrictive interventions as
contained in Positive and Proactive Care:
reducing the need for restrictive interventions
(DH 2014).
“‘Restrictive interventions’ are defined as:
‘Interventions that restrict an individual’s

movement, liberty and/or freedom to act
independently in order to:
take immediate control of a dangerous
situation: and
end or reduce significantly the danger to
the person or others; and
contain or limit the patient’s freedom for
no longer than is necessary’.”
If carried out for any other purpose concerns

about the misuse of restrictive interventions
should always be escalated through local
safeguarding procedures and protocols.
Within the context of this definition, restrictive

interventions can take a number of forms,
each defined more fully in Positive and
Proactive Care: reducing the need for
restrictive interventions (DH 2014):
physical restraint (using physical contact
mechanical restraint (using devices)
chemical restraint (using medication)
seclusion (confining or isolating people).
11.
Diagram illustrating how restrictive practices and restrictive interventions can be seen
within a human rights-based model of positive and proactive support
Positive and proactive care
This diagram illustrates how restrictive interventions and/or restrictive practices may sit within
a human rights-based positive and proactive system of care, treatment or support. It is not
intended to be exhaustive, but shows that restrictive interventions and restrictive practices
will always be a small part of an overall response to supporting people. Learning activities for
workers should have a similar focus on positive ways of working in difficult situations.
12.
2.5. The legal and ethical their instructions. Positive and Proactive Care:
reducing the need for restrictive interventions
justification for restrictive (DH 2014) explains that pain should only ever
practices be used in the most extreme situations where
there is an immediate risk to life.
Workers should always strive to support and
care for people in ways that are enabling and A successful physical restrictive practice
empowering. When people are distressed, should never cause pain and if it does it needs
ill, angry, confused or lack understanding of to be reviewed. “The deliberate application
their situation they may need some degree of of pain has no therapeutic value and could
restriction to keep them or other people safe. only be justified for the immediate rescue of
All restrictive practices should be expressly workers, service users and/or others. NICE
acknowledged and must be legally and Clinical Guideline CG 25, Violence: The
ethically justifiable. Decisions to use restrictive short-term management of disturbed/violent
practices must be transparent and establish behaviour in in-patient psychiatric settings and
clear lines of accountability. Many of these emergency departments”
decisions will involve assessing whether the
person involved has the mental capacity to
make a specific decision, for example to
2.6. How to identify when a
understand that a product or foodstuff may be practice is a restrictive practice
unsafe, or to refuse or accept treatment. or intervention
Anyone carrying out or observing any
restrictive practice must be sure that it is The following examples and flowchart may be
absolutely necessary to prevent harm, that it a useful tool for identifying whether restrictive
is the least restrictive option available, that it is practices are appropriate and the legal and
not done routinely for convenience, and that it ethical justification for their use.
is done for the shortest possible time.
The examples illustrate the range of different
It is preferable that restrictive practices should restrictive practices and interventions and are
be considered and planned in advance and based upon real life situations.
involve the individual (and their family where
appropriate) and relevant multi-disciplinary Some of these examples could be abusive,
professionals. They must ensure that or alternately an appropriate way to support
monitoring, planning and reviewing takes place someone, some might be justifiable as a
to find a more positive alternative on a longer last resort, when absolutely necessary, in an
term basis. extreme situation. The justification for using
them is dependent upon proper care planning
Pain which includes assessment of the person’s
mental capacity, the likelihood and potential
Workers must not cause deliberate pain to a severity of harm, the cultural perspective of
person in an attempt to force compliance with
13.
the individual involved, the potential for using A woman is told she can’t go home ‘on
alternatives, and the legal situation. leave’ from a mental health ward unless
she shows that she is willing to take her
A lady who lives in a care home is medication.
regularly encouraged to return to ‘spend A member of the intensive care nursing
time in your room alone’ because her team holds a woman’s hands to stop
singing upsets other residents. her from removing a tracheotomy tube
A man with dementia on a ‘respite’ stay following surgery.
brings a bottle of whisky with him. The A young woman who is detained under
workers keep it in the office and bring him section 3 of the Mental Health Act is held
up to two glasses per evening when he down on her bed while nurses give her
asks for it. If he asks for a third then they an injection of medication because she is
remind him he has already had two. refusing it.
A man is prescribed a sleeping tablet The personal assistants to a young man
because his family are worried he may with severe epilepsy, learning disabilities
get up and wander or fall during the and some mobility difficulties are told by
night. his Mum to use his wheelchair when out
An ambulance crew attend to someone even though he can walk short distances,
who is intoxicated with alcohol and has as he is less likely to injure himself badly
a head injury from a fall. They strap the if he has a seizure while seated and
person to a trolley to stop him climbing strapped in and will be generally ‘safer’.
off. A person with Prader-Willi Syndrome
In a day centre, a guest is left for several needs to have food in his home provided
hours with her dinner tray or wheelchair to him in small portions at mealtimes.
seatbelt on to prevent her ‘wandering’. All other food needs to be locked away
On a hospital ward a man’s walking frame to prevent him overeating or eating raw
is moved out of his reach while workers food.
are cleaning and they forget to put it During an admission under section to
back. a mental health unit a person is denied
A daughter wheels her dad in his access to blades although it is written in
wheelchair away from a crowded section their care plan that they can use blades
in a supermarket because he is making for safe & responsible self harm.
sexually explicit comments about other
customers. She tells him she won’t bring
him here again.
14.
Restrictive practices - what you should consider
Am I stopping someone doing

No Ensure you are
something they want to do or making Are you considering promoting choice and
them do something they don’t want to restricting someone? independance
do? (or considering this)
Yes
This diagram is intended to Have you tried all
illustrate the key questions No reasonable non- This may be as part of a ‘positive
which need to be considered restrictive alternatives? behaviour support’ plan, a ‘DOLS’
restriction, an advance care plan or
in order to ensure that any a ‘clinical or therapeutic hold
Yes
restriction is minimised and is
ethically and legally justified. It Is this a planned Care homes and hospitals and
restriction as part of a other settings might need to
cannot cover all eventualities Yes
apply for a DOLS authorisation
but shows the main differences care plan?
in different situations. Many of No
these decisions may need to be
Is there a real risk of
taken quickly and reviewed more
serious harm to the
carefully later. individual?
No Yes
Is there a real risk
of serious harm to Is the person detained
No under the Mental Health
someone other than the Carry out the
individual? Act? restiction as
Yes Yes No planned, record
and report as
Does the person have planned
Is the restriction the mental capacity
No Yes
necessary for their to make this decision
treatment themselves?
Yes No
Has every effort been

No
made to help them
decide?
Yes
Is a restriction in their best interests?
No Is a restriction in their
best interests?
Yes
Is this the least

restrictive option?
No
Does the restriction need to be carried out now?
Yes
No Does the restriction

need to be carried out
now?
The restriction is unlikely to be justified. Yes

Unjustified restrictions are not acceptable and The restriction may be justified,
The restriction may be justified, but should
must be changed. This could be by amending a but should be for the shortest
be for the shortest period possible, recorded,
support plan, raising with a line manager, using period possible, recorded,
monitored & reviewed
safeguarding processes or whistleblowing monitored & reviewed
‘Least restrictive’ will depend on the likelihood of harm occuring, the severity of the harm and how proportionate the restriction is to the level of likely harm. How often is this restriction carried out? How long does it last? How intense / forceful is it? What other options are there? ‘Least restrictive’ will depend on the likelihood of harm occuring, the severity of the harm and how proportionate the restriction is to the level of likely harm. How often is this restriction carried out? How long does it last? How intense / forceful is it? What other options are there? ‘Least restrictive’ will depend on the likelihood of harm occuring, the severity of the harm and how proportionate the restriction is to the level of likely harm. How often is this restriction carried out? How long does it last? How intense / forceful is it? What other options are there?
Information on assessing Seclusion is never ‘Least restrictive’ will depend on the likelihood of harm
‘mental capacity’ and ‘best justified except occuring, the severity of the harm and how proportionate
interests’; https://www. when the person is the restriction is to the level of likely harm. How often is this
justice.gov.uk/protecting-the- detained under the restriction carried out? How long does it last? How intense /
vulnerable/mental-capacity-act mental health act. forceful is it? What other options are there?
Click here for Printable version of
Restrictive practices - what you should consider.
Edie’s story
Throughout this guide we consider briefly how a team in a residential care home learned to
positively support a woman whose distress and behaviour presented the team with challenges
in how they could best offer care to her.
On the Skills for Care and Skills for Health website Edie’s story is available as a supporting
resource for the guide as a full ‘case study’ along with other case studies and vignettes from
other people. These are in written and video format. For more information see
www.skillsforcare.org.uk/cbcasestudies
All of the case studies and vignettes are anonymous and full permission for their use has been
granted.
We would encourage people to submit further examples in order to share good practice.
Edie is 82, she is widowed, has dementia, and lives in a residential care
home. She was placed there reluctantly by her family as she had been
assessed as not having the capacity to make the decision to move by
herself.
During her first year there she became increasingly distressed and
anxious. This seemed to happen most in her bedroom when she
needed personal care such as help with washing and dressing. She was
incontinent of both urine and faeces and workers believed that it was in
her best interests to wash her and change her clothing.
She would resist any help by screaming, biting and pushing workers,
and so workers became scared of going into her room to support her.
17.
3. Effective workforce development to minimise the use of
restrictive practices
Much of this section draws on more detailed guidance in other Skills for Care or Skills for Health
guides:
Practical approaches to workforce planning; A guide to support workforce planning
processes and plans for adult social care support services.
http://www.skillsforcare.org.uk/Document-library/NMDS-SC,-workforce-intelligence-
and-innovation/Workforce-planning/Workforce-planning-guide.pdf
Principles of workforce redesign.
http://www.skillsforcare.org.uk/NMDS-SC-intelligence-research-and-innovation/
Workforce-redesign/Principles-of-Workforce-Redesign-downloads-and-practical-
resources.aspx
National occupational standards (health).
http://www.skillsforhealth.org.uk/about-us/competences%10national-occupational-
standards
The NHS Knowledge and Skills Framework.
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/
publicationsandstatistics/publications/publicationspolicyandguidance/dh_4090843
Supporting workers working with people who challenge – guidance for employers.
http://www.skillsforcare.org.uk/Skills/People-whose-behaviour-challenges/People-
whose-behaviour-challenges.aspx
Commissioners and employers may find it When can I assess and improve the
useful to plan and deliver good workforce levels of skills needed and the level that
development on minimising restrictive workers have?
practices by considering the following How will I develop the skills that workers
questions: have?
Who are my workforce?
What do we expect them to do? See Appendix A for more detail
Where do we expect them to do it?
The answers to these questions will in many
What skills, knowledge, attitudes, values, cases come from collecting and analysing
confidence and competences do they (a) reliable data well.
need and (b) already have?
18.
3.1. Organisational values into operate in a culture of openness, respect
and transparency
practice
have organisational leadership which
How to design, recruit and retain the is fully committed to identifying and
workforce you need minimising the use of restrictive practices
and promoting person-centred working.
“In order to design a workforce with very well Management teams need to be in touch
developed knowledge and skills to support with what actually happens, and have
people who challenge, an employer needs systems in place to reduce or eliminate
to ensure that their organisational processes restrictive practices
and systems enable workers to use their skills
develop a culture of learning from
effectively. Training workers to a high degree
incidents and mistakes, avoiding
of skill will not, on its own, lead to high quality
attaching blame to genuine mistakes
support. The organisation needs to have the
structures and culture in place to support the promote a culture of learning from
application of those skills.” Institute for Public practice; sharing and promoting good
Care, 2012 practice with a pro-active response to
poor practice
The values of any organisation are vital to
the way that services are commissioned and ensure everyone understands the
delivered. To ensure that workers are able to legislation, polices and requirements of
practise in a way which minimises the use of their particular situation, including CQC’s
restrictive practices, organisations need to: Essential Standards and regulations. See
Appendix D.
recognise that the person is central to the
service it delivers
Edie’s story: a culture of fear
Workers were scared of going to support Edie and were doing so in

two’s and wearing coats to protect their arms. Edie was becoming
defensive; protecting her bedroom and becoming more isolated by
remaining alone in her room, on her bed.
19.
Data collection and use be triangulated (checking one source of
data against another)
It is essential to collect and use data effectively
be monitored over time to identify trends
in order to monitor how well people are
being supported and to make improvements. and/or be compared with comparative
Services should routinely collect and regularly services or with targets set
analyse data from: identify ‘exceptions’ to usual
feedback from people being supported expectations; for example, particular
by the service, their families, friends, times of day or particular activities which
visitors and advocates, ideally this coincide with higher or lower than usual
should be systematically sought through levels of restrictive practices
satisfaction surveys, complaints or highlight sudden changes
regular activities as well as being
identify individuals who are particularly at
encouraged ad hoc
risk of experiencing restrictive practices.
incidents of behaviour that challenges
and any other incidents which give rise
The outcome of the analysis should:
to any restrictive interventions and any
planned or significant restrictive practices inform individual support plans
the use of any restrictive interventions shape learning and development activities
and any planned or significant restrictive be used to review worker performance
practices, including form, intensity and
duration, and any injuries sustained inform organisational policies and actions
during them such as restrictive practice reduction
plans.
post-incident debrief and analysis
safeguarding alerts, complaints, use of Being a person-centred organisation
internal whistleblowing policies, relevant
workers’ grievances This involves adopting person-centred
approaches to all areas of organisational
worker vacancies, turnover and sickness
activity in a way that recognises the person
rates
and takes a positive, solution-focused attitude.
relevant data about the needs and This includes the following.
wellbeing of the people being supported
Knowing that the rights of the individual
by the service (such as participation in
are paramount, and respecting them.
meaningful activities, medication, waiting
times or other health indicators). Valuing the individual’s history, skills,
aspirations and knowledge.
Analysis will vary from service to service but Involving and nurturing the individual and
should enable the information to: their support network, e.g. friends, family,
community, professionals.
20.
Understanding that people’s behaviour Developing holistic, strengths-based
serves an important function for them, plans of care that encourage positive
and is a form of communication. risk-taking and enable people to live less
Recognising that behaviour may be restricted lives, while maintaining a ‘duty
influenced by a chronic, intermittent or of care’.
acute physical condition such as very Where it is not possible for the individual
high temperature / effects of anaesthesia, to make a decision at the time it needs to
epilepsy, pain or the influence of drugs or be made or by indicating their decision in
alcohol. advance, then a best interests decision
Recognising that behaviour may be should be made – again involving all
influenced by their environment and the relevant people.
behaviour of others. Understanding that restrictive practices
Promoting choice and control for are only to be used once all other
individuals in all the decisions made planned proactive and reactive
about their lives, and involving their interventions have been tried or are not
friends and families where this is relevant. practical.
Providing a space for the individuals’ Wherever possible, working with the
voices and preferences to be heard; individual and supporting them (and their
giving access to independent accessible family should they choose to involve
information, advice and advocacy to them) to understand the restrictive
ensure that choices are well informed and practices that are affecting them,
current. preferably prior to use.
Considering people’s culture and belief Adopting and promoting the principles
systems at all times. and practices of positive behaviour
support in a way that suits your service
Valuing workers and recognising their and the individuals supported by it.
individual and team strengths.
21.
Person-centred thinking
Person centred planning Good practice
Support plans; meeting

individual needs Communication Safeguarding
Creative ways of
Learning process
recording this
Checking in -
Funding
is this working
Language/ terminology Best Interests
Circle of support Health Skills
Life History How I Communicate
Choice Knowledge Gender
Sexuality Environment Ethnicity
22.
Edie’s story continued:
Edie became more isolated, staying in her room and with workers
tending to avoid her.
With the help of the local challenging behaviour service a holistic

assessment was carried out including work to capture Edie’s life story
and, views from her daughter who visited her often. This revealed
particular triggers for Edie, such as feeling her personal room was
being “invaded” and the cultural practice in the home of getting
people dressed by a certain time.
A detailed individual support plan was put in place which allowed

Edie to rise and dress in her own time and allowing her to eat
breakfast in her dressing gown if she chose. It also specified
proactive strategies for workers to offer personal care; only entering
the room individually, using and avoiding specific language (both
verbal and non-verbal), and leaving if Edie indicated that she was not
ready, coming back 10 minutes later.
Changes to her environment were also made; the wall behind her
toilet was painted a dark colour so that she could see the toilet better
and the workers played quiet background music when they offered
her personal care.
23.
3.2. Designing support and care establish seamless pathways for
transitions and changes (for example
that works into adulthood or as conditions
progress)
Commissioning social care and health
avoid the need for ‘out of area
You may be commissioning a service for a placements’.
large population in a geographic area or for a
Describe the appropriate staffing levels
known individual or small group of people.
required to deliver the service including
the need for specialist advisors (for
Anyone commissioning and purchasing
example, specialist learning disabilities
social care or health services should always:
liaison nurses in general hospitals).
Understand the needs of the people for Use local and national service specifications
whom they are commissioning services. that lead to good workforce development,
such as Ensuring Quality Services (EQS)
Understand the importance and role of
when commissioning services for people
positive behaviour support plans for the
who have learning disabilities and/or autism
individuals concerned and commission
and who display or are at risk of displaying
services built around their needs.
behaviour that challenges.
Engage with people being supported
Establish contracts which include the
by services, and with their families and
right resources for good workforce
communities – particularly if there is a risk
development.
of someone having to move away from
their home area, such as in “out of area Visit the services they commission or see
placements”. them in action.
Understand the settings and situations Consider data on their local population,
and the incidents where workers may be including that about children and young
required to use restrictive practices—and people who have special educational
how to provide positive and pro-active needs or disabilities.
alternatives.
Commissioners should ensure that
Understand the implications and role of
employers and services have clear systems
restrictive practices in the services they
for:
are commissioning.
Setting outcomes and work plans that
Consider all of the local services that can: support person-centred care (including
work in a positive way in partnership positive behaviour support) and aim
with providers in order to provide a to improve quality of life, physical and
good range of support and services mental health and reduce ‘placement
breakdown’.
24.
Measuring and monitoring service and good performance, retaining them and
worker performance. developing a career pathway.
Addressing poor practice.
Throughout these processes you should:
Recording and reporting when restrictive
involve people who are supported by the
practices have been used or avoided,
service (‘experts by experience’)
both internally and externally.
demonstrate a commitment to equality
Defining accountability at all levels of the and diversity.
organisation.
Making sure whistleblowing policies are in Designing staff structures to minimise
place, reviewed and are working. restrictive practices
Organisational, team and individual
Employers and services must have clear
learning from what works well.
systems to meet the commissioners’
Ensuring staff capacity to respond to requirements as outlined above and must
fluctuating or emergency situations. design a staff structure capable of meeting
Proactive transferable knowledge the needs of the service at all times. This will
between services; for example, the use of involve considering the following.
‘hospital passports’ between care homes How to balance the need for consistency
and A&E, between departments in acute of care with realistic expectations of
hospitals and when people are moving individual workers, including the support
into adulthood. that workers need.
Promote effective sharing of knowledge Using a matching process to ensure
between statutory, independent and the team can meet people’s needs and
voluntary services. interests.
Monitoring the impact of learning and The consistency and continuity that
development activities. contracted workers can offer and only
using ‘bank’, casual or agency workers
The right staff when there is a compelling reason to do
so.
The baseline of any good service is having
Ensuring that workers do not have to
the right workers to meet the needs of the
work excessively long shifts and have
individuals being supported by it. This will
breaks, holidays and rest periods.
involve everything that happens throughout
their employment, such as designing the staff Responsive rotas based on person-
team, finding people, recruiting and selecting centred plans and or periods of expected
them, inducting them to their role, training and high demand (times of the week, winter
supporting them, monitoring how they work, pressures, etc).
dealing with poor performance, celebrating
25.
The effect of workers’ holidays, training experience and is registered with the
and sickness. relevant professional body where
registration is required.
Ensuring workers’ capacity to respond to
fluctuating and emergency situations. How to recruit people with the right
attitude and values, which may include:
Up-to-date assessment of risk, and
behavioural audits. a caring* supportive attitude
Staffing requirements from the service respect
specification and as recommended commitment* to offer dignified care
by relevant national and local policies, and choice and to team working
procedures and legislation.
demonstrating unconditional positive
Any organisation or practitioner that regard
develops and implements behaviour
support plans or restrictive practices showing compassion*
must be able to provide evidence of their having the courage* to learn and to
competence to do so. appropriately challenge,
having an understanding of the
Recruiting and retaining the right workers importance of good communication*
flexibility
In recruiting workers you should consider:
willingness to learn and develop
Where and how to recruit workers competence*
including ways of recruiting from diverse relevant interests (in very personalised
groups of people with the right attitudes, services, shared characteristics with
physical abilities and availability. the individual)
Using competence-based job profiles. a commitment* to equality and
At what stage to share information about diversity.
what the job is in order to; build rapport, * indicates the “Six ‘C’s”:
be clear about the organisational values The 6Cs strategy sets out the shared purpose
and aims and allow people to self-select of nurses, midwives and health visitors in
themselves out. response to the Francis report into the Mid
Using appropriate selection techniques Staffordshire NHS Foundation Trust Public
involving people being supported by Inquiry ( 2013) into the care of patients in
the service, and their carers, such as hospital.
scenario-based interviews and/or task-
orientated assessments. http://www.midstaffspublicinquiry.com/
How to ensure the candidate has the http://www.6cs.england.nhs.uk/

necessary skills, qualifications and
26.
Supporting workers
It is important to support workers to find alternatives to restrictive practices. When restrictive

practices are used it is essential to offer support and de-briefing to the person concerned,
their families and carers, the staff team, and other people being supported, if relevant, or any
witnesses.
Support and supervision should allow time for essential reflection on practice and the feelings
that are brought up.
Edie’s story continued: supporting workers to minimise restrictive practices
Workers who supported Edie had become very scared of working with her and
their behaviour reflected this, such as showing fear or bravado or wearing outdoor
clothing to protect themselves.
In response to this culture of fear the care team worked alongside the challenging
behaviour specialists and Edie’s daughter to develop Edie’s care plan.
Workers and Edie’s daughter needed support individually and as a team to

implement the plan. The manager also prepared a one page profile to help
workers see Edie as an individual with a history and a range of experiences and to
put her behaviour into context. For example, explaining that she likes to sing along
to music, but may stop if others join in.
Supervision regular—planned in advance but also

available ad hoc when needed
Management and clinical supervision for of a high quality—provided by someone
individuals and groups is an essential tool who has been trained to undertake
in minimising restrictive practices. It should supervision, including specialists when
be written into policies and procedures required
as the way of regularly monitoring an
individual’s performance, setting their targets underpinned by and support the values of
and responsibilities and highlighting their the organisation
development needs. structured around a shared agreed
agenda
Supervision should be:
prioritised—all involved identify protected
time for it to happen
27.
a way of celebrating success and All of the above forms of support should feed
achievement and addressing areas for back into individual and team learning and
improvement. development plans and into organisational
development plans. These include restrictive
Other support practice reductions plans, stress management
and reduction plans and reviews of policies
This can include support from: and procedures.
experts by experience
peers 3.3. Developing your workforce’s
coaching skills and knowledge
shadowing In order to provide good support and services
mentoring to people, employers need to know that
workers have the right skills and knowledge
use of “champions” within the service to
and are competent to undertake their work.
offer specialised support.
This involves understanding what is required
within the service, setting or role, identifying
De-briefing
the skills and knowledge held within the team
and by the individual, putting in place learning
De-briefing is essential and can be a way
and development plans to meet any gaps
of offering support and developing learning.
in knowledge and skills and to ensure that
It might identify a learning need for an
workers continue to develop.
individual worker or team, an amendment to
a care plan or inform organisational actions
Identifying workforce skills and knowledge
through incident review, data collection and
analysis. There is further advice in Positive
Employers can work out what knowledge and
and Proactive Care: reducing the need for
skills workers need to have, and when, from
restrictive interventions (DH 2014).
the following.
De-briefing following an incident or a ‘near
The shared key principles and core
miss’ should:
values, vision and purpose of the
be led by the needs of the worker organisation.
be undertaken by a skilled practitioner The needs, preferences and aspirations
with a ‘no blame’ attitude, emphasising of the people being supported by the
any learning and considering the service.
psychological impact on the people
involved Understanding the impact of trauma and
life experience on people’s behaviour
identify any further or on-going support
and decision making. Relevant people
and learning that is needed.
28.
may include individuals supported by the Job descriptions and person
service, carers, staff, board members and specifications associated with the role.
the public.
Supervision, appraisal and personal
Understanding the setting, situations development planning.
and incidents in which staff are required
to use the range of restrictive practices,
and why they may be needed. This could Skills and knowledge development
include:
There are a wide range of learning options
preventing someone from hurting available and as commissioners and
themselves employers you need to be certain that the
learning solutions that you are using are right
holding a person or part of their body
for your teams and the people that they are
so that an essential health or care task
supporting. All workers should learn to meet
or intervention can be carried out, in a
the requirements of the service they provide
planned or emergency situation
and their role. Learning and development will
carrying out planned reactive physical vary according to role but all workers should
interventions in line with a positive learn to deliver a service which is person-
behaviour support plan centred and seeks to minimise the use of
restrictive practices. When an individual’s
self defence family are providing support to them they
escaping (breakaway) from violence should be offered opportunities for learning
and aggression alongside workers and the individual or
other learning opportunities suitable for their
protecting vulnerable people from situation.
violence and aggression.
The legal and policy frameworks that Currently there are no nationally recognised
apply to the service. or approved training standards for the
minimisation of restrictive practices.
Undertaking a regular skills reviews of the
team.
Completing a comprehensive training
and learning needs analysis based
upon appraisals, supervision, policies,
standards, learning from incidents
and de-briefs, feedback from learning
providers, changes to the needs of
people supported by the service,
inspections and contract reviews, etc.
29.
Edie’s story continued: lessons learned
The best way to develop Edie’s care and support plan was by holding
a staff development day with the challenging behaviour team and
developing the plan during the day.
Many of the aspects of the plan appeared to not only help Edie be
calm but also made it much easier and more pleasant for workers,
allowing them to ‘let go’ of the negative emotions when an incident had
occurred.
“It’s been like everyone has breathed a sigh of relief,” said the manager.
All training and learning activities about Delivered by someone who is qualified to
restrictive practices should be: deliver and is occupationally and clinically
competent. This means people who have
Part of a coherent learning pathway, relevant experience and knowledge.
based on evidence of good practice in Inclusive in design and delivery of the
that situation and emphasising positive perspectives of people being supported
communication, support for fulfilling lives by the service.
and dignified care, and understanding of
the functions of behaviour.
“I feel that the service user input / forum was

excellent, thought provoking and powerful /
beneficial.”
Participant on ‘RESPECT’ training
30.
Realistically costed and have resources the teaching of only those physical
(funding, physical space and time) intervention skills which have been
allocated in the context of the costs assessed as physically and bio-
of failing to proactively develop the mechanically suitable for the individuals
workforce. concerned, as well as legally and ethically
Regularly and systematically monitored justified.
and updated to meet changes to policy,
practice and legislation. (At least once a There are social care and health units, and
year but more often as necessary.) BTEC qualifications, relevant to positive
Based on a commitment to minimising behaviour support and to restrictive practices.
the use of restrictive practices throughout Units can be taken as part of a qualification
the organisation for people working at and/or as part of continuing professional
all levels, and applied to each job and development. The learning outcomes from the
service as appropriate. units can help you structure bespoke training
programmes. A list of relevant units and other
A priority for strategic and senior qualifications can be found at Appendix B.
management teams (for example by
CEOs and boards of trustees) who are Although this guide is unable to provide a
responsible for authorising and approving set of standards for commissioners and
the content. employers, some suggestions for content can
Fully understood by executive board be found at Appendix E.
members in regulated services, and their
equivalents in non-regulated services, Choosing the right learning provider
to ensure they are fully aware of the
techniques workers are learning and that You may choose to develop internal learning
all learning reflects the therapeutic nature providers to deliver ‘in-house’ learning or
and purpose of social care and health to commission external learning provision.
settings. In some areas partnerships exist to enable
smaller providers to commission with
Be tailored to meet the needs of particular
others. Larger providers who develop in-
service users (e.g. for individuals with a
house learning may also be able to offer this
learning disability, autism or dementia).
externally to other providers. This choice might
Essential for ‘bank’, casual and agency well depend on the size of your organisation,
workers as well as regular employees. the capacity and capabilities of your workers
and the results of your training needs analysis.
It should also include: The following apply to both in-house and
external learning provision.
the assessment of the impact of learning
and training (McGill et al, 2006 & 2013).
31.
Planning and purchasing learning and discussing / debriefing
development
feedback from people being
supported, and carers
The person commissioning or planning
learning should: considering how the content of
bespoke learning provision can
Understand the process of
map to units, awards, certificates or
commissioning including specifying
diplomas (see Appendices B and E).
learning outcomes and the required
impact on practice. Be clear about what physical restraint
techniques should be taught and in
Specify outcomes which are measurable
which circumstances they may be
and show how the learning will support
used.
workers to improve life outcomes for
people supported by the service. Ensure that significantly more time is
spent learning about positive and pro-
Have direct experience of the service.
active approaches, and non-restrictive
Ensure that learning is co-produced, alternatives, than on restrictions.
including the voices of people being Any learning about how to carry out
supported, and carers, in appropriate restrictive interventions should always
formats in the design, production, focus on good practice where positive
delivery and evaluation. pro-active strategies are the norm,
Have an understanding of approaches to and are part of an ongoing learning
minimising restrictive practices with the pathway.
ability to focus strategically. Take a long-term view of the learning and
Ensure adequate funds and resources development which the workers will need,
are available. including:
Ensure the content meets the needs of refresher and update learning when
the service, this will include: needed, and at least once a year,
which takes account of the current
consideration of organisational needs of people being supported and
policies and procedures of feedback and reflection on practice
training needs analysis and workforce development over the
previous year
consideration of specific roles and
situations, including chief executive, induction training for new workers
management and trustee levels and changes to learning and development
possibly in-house learning providers’ as needs change
development
career development
learning from incidents, including:
offering learning opportunities to
recording / reporting / analysis
32.
people being supported, their carers Have systems in place for learning
and support networks. providers to feed back when learners are
Ensure that anyone delivering learning seen as not competent to practise.
or assessing competence in restrictive Plan and carry out evaluation and quality
practices should be occupationally assurance to ensure that learning is
competent and hold or be working embedded into practice and fed back
towards achieving a recognised teaching into restraint reduction plans.
or training qualification (see Appendix C
for more detail).
If you decide to commission external learning providers you may find the Skills for Care guide to
choosing a learning provider, Choosing workplace learning, useful. This tool is also available as
an app with an interactive checklist for both iOS and Android.
http://www.skillsforcare.org.uk/Qualifications-and-Apprenticeships/Finding-learning-
providers/Finding-learning-providers.aspx
Other resources which are relevant to the issue of restrictive practices include Skills for Care’s
Workforce development outcome measurement tool
http://www.skillsforcare.org.uk/NMDS-SC-intelligence-research-and-innovation/Workforce-
commissioning/Workforce-outcome-measurement-model.aspx and Skills for Health’s:
national occupational standards
http://www.skillsforhealth.org.uk/about-us/competences%10national-occupational-
standards/
Quality mark; a new benchmark for outstanding healthcare training.
http://www.skillsforhealth.org.uk/getting-the-right-qualifications/quality-mark/
At present there is no current mandatory Additionally the learning provider should:

accreditation system for learning providers. Ensure all individual learning providers
Further information on voluntary accreditation and assessors are occupationally
systems can be found in Appendix F. competent and have or are working
towards a recognised teaching or training
The learning provider’s role qualification.
The learning provider must work in Ensure that individual learning providers
partnership with the person commissioning and assessors are experts by practice
the learning and with people being supported and have knowledge relevant to the types
to ensure that the learning delivered meets the of service to which they provide learning,
requirements listed above. including understanding:
33.
the needs of the people being development plan.
supported, including awareness of the Ensure that individual learners have the
needs of that group (e.g. dementia, opportunity to put what has been learnt
autism, etc.), and the specific needs into practice.
of individuals being supported
Develop the skills and experience of
relevant legal frameworks individual learning providers and the
the remit and aims of the services to learning provision available to meet
which they are delivering. the very specific needs of services
Carry out or contribute to a training (for example a service for people with
needs analysis. early onset dementia) and network with
other learning providers to ensure that
Ensure that assessment of learning appropriate provision is available to
is robust and carried out by suitably the full range of social care and health
occupationally competent people. services.
Feed back to employers on learners who Be willing, skilled and able to challenge
are not competent to practise, so that existing practices when required.
this is reflected in the individual’s personal
Edie’s story continued: Getting the culture right
“It’s about giving people choice and control, making sure we take
the time to understand people. Previously it had been our fault as we
had not taken the time to understand what Edie was going through
or fully understand her needs. Now that we do, Edie is a lovely
person and much happier.”
Care worker
“I want these changes to continue; the atmosphere is much better

now, and I see parts of Mam returning. I don’t think she’ll ever come
back, which is hard, but she is improving and happier. I still find it
hard, but it’s been a big change, not just for Mam but for everyone.”
Edie’s daughter
34.
4. Implementation: information for specific situations
This guide aims to show how workers can Below are short summaries and illustrative
be developed and supported to minimise vignettes about people who have displayed
(reduce the necessity, frequency, intensity behaviour that is challenging with lists of
and duration) restrictive practices and ensure helpful contacts that may be useful in specific
they are only ever used appropriately and not situations. All of the vignettes have been
misused or abused. anonymised and full consent to their use
agreed.
It outlines key recommendations for good
practice in workforce development for Other vignettes in written and video format
commissioners and employers whose role it are available on the Skills for Care and Skills
is to ensure that restrictive practices including for Health websites to accompany this guide -
physical intervention are only ever used as a see www.skillsforcare.org.uk/cbcasestudies
last resort.
4.1. ‘Positive behaviour support’
Central to this is ensuring that the
recommendations of this guide and of Positive (PBS)
and Proactive Care: reducing the need
for restrictive interventions (DH 2014) are “PBS is a framework for developing
implemented, monitored and reviewed within understanding of an individual’s challenging
organisations and services. behaviour and for using this understanding to
develop effective support” (NHSE LGA 2013).
Workers in every service will need to have This is described in detail in The International
information about the very specific conditions, Journal of Positive Behavioural Support
disorders and diagnoses of any of the people (IJPBS), Volume 3, Number 2, Autumn 2013.
they are supporting.
There is a strong evidence base for the use
National organisations such as Mind, Age of PBS for people with intellectual impairment
UK and the National Autistic Society provide or learning disabilities and we would also
robust information through their websites. advocate the use of this model for people
It is also important to find local sources of with other needs, such as people who have
information and support. dementia and people with mental health
needs.
35.
IJPBS proposes that PBS is a multi-component framework which, while flexible and adaptable
for individuals, must contain the following components.
Values 1. Prevention and reduction of challenging behaviour occurs within the context
of increased quality of life, inclusion, participation and the defence and support
of valued social roles.
2. Constructional approaches to intervention design build stakeholder skills and
opportunities and eschew aversive and restrictive practices.
3. stakeholder participation informs, implements and validates assessment and
intervention practices.
Theory and 4. An understanding that challenging behaviour develops to serve important
evidence functions for people.
base 5. The primary use of applied behaviour analysis to assess and support
behaviour change.
6. The secondary use of other complementary, evidence-based approaches to
support behaviour change at multiple levels of a system.
Process 7. A data-driven approach to decision making at every stage.
8. Functional assessment to inform function-based intervention.
9. Multicomponent interventions to change behaviour (proactively) and manage
behaviour (reactively).
10. Implementation support, monitoring and evaluation of interventions over the
long term.
Services offering positive behaviour support individuals have completed, or are undergoing,
should meet the specifications described externally-validated training in PBS which
in EQS, including these for a well trained includes both practice and theory-based
workforce, as follows. assignments with independent assessment
of performance at National Qualifications
1. All support workers receive training in Framework level 5 or above.
positive behaviour support, which is refreshed
at least annually. 4. All workers involved in the development
or implementation of PBS strategies receive
2. All support workers with a leadership role supervision from an individual with more
(e.g. shift leaders, direct employers, frontline extensive PBS training and experience.
managers) should have completed or are Workers in consultant roles are supervised
undergoing more extensive training in PBS by an individual (within or outside the
which includes practice-based assignments organisation) with a relevant postgraduate
and independent assessment of performance. qualification, e.g. applied behaviour analysis,
positive behaviour support, clinical psychology.
3. All workers with a role (which may be
peripatetic or consultant) in respect of In addition, a core competences framework
assessing or advising on the use of PBS with for PBS is currently being developed.
36.
Simon’s story
Using a PBS approach for both the person in need of care and
support and the team and others around him or her: Simon’s very
good day at the zoo
Simon (not his real name) is young person with identified behaviour
management issues around his need to feel in control of other people
including his support workers. Procedures had been put in place to
support workers in how to manage the demands placed on them
by Simon when necessary. Simon also has an identified need to be
supported to learn social rules so that he is more able to socialise
with other young people without him wanting to be in control of the
interaction.
Simon was having a lovely day out at the zoo. Around 40 minutes
before the time to leave Simon noticed a stream in the play area. The
water was around an inch deep in some places. Simon removed his
shoes and paddled in the stream, then asked if his supporting workers
would like to join in. They told Simon that the water was too cold for
them and that they would prefer to watch instead. Simon persisted
attempting to make the workers get in the water. Simon then threatened
to run away if they did not join in. The workers knew Simon very well
and realised that he was showing signs of irritation but felt that he
wasn’t showing signs of anxiety or becoming distressed.
The workers made the decision to not respond to the threats and used
distractions to which they thought Simon might respond well, such as
37.
mentioning the gorillas in the pen nearby. Simon began to move away
from the stream towards a quiet lane. The zoo was reasonably empty
and there were no other people nearby. The workers realised that Simon
would move further away if approached. Therefore the workers decided
to follow slowly behind him, understanding that if they moved too fast
this might make him run. Simon led himself away from the stream
and into a grass clearing where he could no longer see the stream or
any water. The workers realised that this meant the trigger had been
removed. They then decided to sit on a bench where they could see
Simon safely. After five minutes Simon approached them and continued
to be unsettled. Simon re-engaged with the Workers, when they offered
him a choice between two options.
As there was only fifteen minutes left at the zoo before they had to leave
and return home. They explained that he could either leave and play
on his ipad in the van and show them what he had been making that
morning or he could choose an animal he wanted to see before they
left. Simon decided to leave but wanted to pass the maze on the way
back. There were no more challenging incidents.
Not engaging Simon when he made demands, but presenting

alternative options that his workers knew Simon enjoyed, was easier
once the main trigger had been removed, i.e. the water from the stream.
Simon found it harder once the trigger had been removed to carry on
with the incident with the same conviction, although it is thought that his
main need was to be able to feel in control.
38.
4.2. People with mental health needs
Grace’s story
We have included Grace’s story here to illustrate the use of physical
restraint within a mental health setting and how workers can positively
undertake restrictive practices and physical interventions. Grace is not
her real name. Grace is 18 and lives in North London. She has some
positive experiences of restraint in healthcare settings, which she is able
to compare with negative experiences of restraint by the police around
the same time.
Grace spent 14 months in a mental health hospital in London and was

discharged in July. The hospital has a very strict ‘no touch’ policy, where
staff don’t physically touch patients unless absolutely necessary and
patients can’t touch other patients under any circumstances. Restraint
is very much a last resort and even then is done in a way that is very
gentle and respectful.
From time to time Grace would have psychotic episodes that would
see her self-harm. It was in these situations that workers might feel it
necessary to restrain Grace to prevent her from harming herself. They
would speak to her calmly to explain what was about to happen and
then gently move her arm to prevent her from hurting herself.
At the time, she says, she may have felt angry and resentful that
someone was stopping her doing what she needed to do. Coming out
of a psychotic episode is scary and she would be confused about why
someone was touching her, especially since she traditionally struggles
with physical contact. But she can see that it was the right thing for the
workers to do. She adds that because it was done in such a positive
way, it actually helped to solidify the relationship between her and the
workers, helping to improve trust.
39.
Grace has witnessed others being restrained in a more forceful way—a
friend of hers was restrained and injected with medication, which
she says was frightening to witness. She feels strongly that restraint
shouldn’t be done in front of other people as it is humiliating for the
person being restrained and distressing for those watching.
Grace has also been restrained by police, when on one occasion she
ran away from the hospital. This was a different experience altogether
and Grace was given a direct order to ‘stand still’ before being “grabbed
and shoved in the back of the police car”. She felt she was treated like a
criminal.”
When considering the minimisation of The ‘Safewards’ Project from research,

restrictive practices within mental health model formulation, through trial to
settings you could make reference to the management action: Safewards project:
following metal health specific resources. Force Free Futures
‘Talk well’ guide for communicating with
Recovery-based care. Recovery-based people on in-patient wards, including
approaches are central to mental health people who have psychosis
care. Personal recovery means different http://starwards.org.uk/
things to different people and should publications/187-talkwell-2nd-edition-
be defined by the person experiencing is-ready-to-download
mental illness. It has become more
accepted that people can and do recover ImROC (Implementing Recovery
from severe mental illness. However, for through Organisational Change). This
many people it means a way of living a supports mental health service providers
satisfying and meaningful life within the to become more recovery oriented
limits of their mental health condition. and its themes are very relevant to
http://www.rethink.org/living-with- restrictive practices work, e.g. culture
mental-illness/recovery/what-is- change, changing the approach to risk
recovery assessment and management, increasing
personalisation and choice, transforming
The Mind campaign on restraint: the workforce and supporting workers.
http://www.mind.org.uk/news- A joint initiative of the Centre for Mental
campaigns/campaigns/crisis-care/ Health and the NHS Confederation’s
40.
Mental Health Network. Closing the Gap: Priorities for essential
http://www.imroc.org/ change in mental health:
National Survivor User Network (NSUN): https://www.gov.uk/government/
National Involvement Standards - 4PI uploads/system/uploads/attachment_
http://www.nsun.org.uk/assets/ data/file/281250/Closing_the_gap_V2_-
downloadableFiles/4pi.-ni-standards- _17_Feb_2014.pdf
for-web.pdf The Ten Essential Shared Capabilities A
Wellness Recovery Action Plans (WRAP) Framework for the Whole of the Mental
http://www.mentalhealth.org.uk/help- Health Workforce:
information/mental-health-a-z/R/ http://www.iapt.nhs.uk/silo/files/10-
recovery/ essential-shared-capabilities.pdf
Preventing suicide in England: One year Service User Involvement in Mental

on First annual report on the cross- Health Training, Education and Research
government outcomes strategy to save in West Yorkshire
lives. http://eprints.hud.ac.uk/12434/1/6210.
pdf
No health without mental health:
implementation framework: Peer support (from other people with
https://www.gov.uk/government/ experience of mental health problems):
publications/the-mental-health- http://www.imroc.org/peer-support-
strategy-for-england workers-in-mental-health-recovery-
benefits-and-costs/) and ‘advance
The Mental Health Crisis Care Concordat statements’ to encourage more
https://www.gov.uk/government/ empowering ways of working and
publications/mental-health-crisis-care- anticipate issues that could arise.
agreement
41.
People who self-harm, or who are at risk of doing so, may need extra reassurance about
a service being non-judgemental and confidential, so that their own uncertainty or feelings of
shame do not become, in effect, restrictive practices. RAISE mental health have produced
a video by two women who self harm explaining that for them it is a way of staying alive.
The video can be viewed on the skills for care website. Below is part of a series of posters
offering guidance to accident and emergency staff to help them support people who come for
treatments following self harming behaviour.
Self harmed?
Want to speak to someone in private?
Let reception know its personal and it will
be arranged. We have a separate room
where you can sit and be helped.
We are here to help.

We will treat you with respect.
You are not alone.
You have NO reason to feel
ashamed.
Source: Sam O’Brien, Service User Consultant

for Mental Health, Respect Training Solutions
42.
4.3. People with dementia
We have included Ron’s story here to illustrate the importance of understanding a person’s life
history and the function that a behaviour is serving for an individual when providing care and
support. Ron is not his real name.
Ron’s story
Ron had fronto-temporal dementia diagnosed at the age of 60. He was
physically fit, energetic and had always had a ‘feisty’ personality! As his
illness progressed, he was placed in a nursing home close to his family.
On hearing shouting and banging from Ron’s room, the nurse entered
to find him throwing things around and trying his best to push clothing
out of the small gap in the open window, water had been left running in
the bathroom and was slowly seeping over the carpet. Ron immediately
began to shout at the nurse, his verbal skills were limited but there was
no question about his mood or intention as the nurse became the focus
for the flying missiles of socks and pants.
The nurse immediately called for assistance, the first to arrive in the
room was the ancillary worker who had been in the next room; she had
always got on well with Ron and found him helpful and polite. On seeing
the situation she grabbed a refuse sack from her trolley and calmly
walked up to Ron holding the bag open, saying “Here you go Ron, lets
collect them all up for you so we can sort them out”. The effect was
instant; Ron began to stuff the clothing into the sack, muttering as he
did so.
Ron was a very private person who had lived alone for many years with
a few close friends; he prided himself on being self sufficient. He had
dirty underwear that he couldn’t work out how to wash. Having tried to
do so in the sink he became more and more frustrated, which damaged
43.
his social skills and inhibitions, Ron’s temper flared so he did what he
could to get rid of the dirty clothes out of the window. The nurse coming
into the room in uniform made Ron feel humiliated at not being able to
do things for himself so he lashed out in temper.
The ancillary worker had got to know Ron and recognised his
frustration, guessing it was something to do with the clothing. Staying
calm and offering the refuse sack made Ron feel his actions were
understood. Seeing the immediate response, the nurse backed out of
the room but observed what was happening; once Ron was calmer
she was then able to re-enter and support Ron to collect the clothing.
A team meeting was called, including the ancillary worker, to update
Ron’s personal profile, and his family were consulted to build a better
understanding of Ron’s habits, values and principles. The care plan was
updated to reflect the new information with the amount of clothing left in
Ron’s room reduced to a minimum by doing twice daily checks for dirty
laundry.
Good practice in patient care must involve all workers sharing

information and knowledge of the individual needs. Identifying triggers
for the behaviour allows for practical strategies to avoid conflict. Most
importantly, manage the situation that is causing the behaviour, not just
the behaviour.
44.
Additional resources to support people Factsheet on dementia and aggressive
with dementia behaviour.
http://www.alzheimers.org.uk/
When considering the minimisation of site/scripts/documents_info.
restrictive practices when supporting a person php?documentID=96
with dementia you could make reference to
Royal College of Nursing S.P.A.C.E.
the following specific resources.
http://www.rcn.org.uk/development/
practice/dementia/commitment_to_
Common Core Principles for Supporting
the_care_of_people_with_dementia_
People with Dementia: guide to training
in_general_hospitals/make_space_for_
the social care and health workforce.
good_dementia_care
http://www.skillsforcare.org.uk/Skills/
Dementia/Dementia.aspx National Institute of Health and Clinical
Excellence (NICE) (2010) Dementia
Dementia care mapping: Approaches
Quality Standards.
based on the work of Professor Tom
http://publications.nice.org.uk/
Kitwood.
dementia-quality-standard-qs1
http://www.nursingtimes.net/dementia-
care-mapping/201154.article National Institute of Health and Clinical
Excellence Public Health Intervention
Department of Health (2009). Living Well
Guidance
with Dementia: A National Dementia
http://www.nice.org.uk/guidance/phg/
Strategy.
https://www.gov.uk/government/ Occupational therapy intervention and
publications/living-well-with-dementia- physical intervention to promote the
a-national-dementia-strategy mental health and well being of older
people in primary care and residential
Department of Health (2010). Quality
care
Outcomes for people with dementia:
http://www.nice.org.uk/Guidance/PH16
Building on the work of the National
Dementia Strategy. Life Story work
https://www.gov.uk/government/ http://www.dementiauk.org/information-
publications/quality-outcomes-for- support/life-story-work/
people-with-dementia-building-on-the- VIPS tools and resources University of
work-of-the-national-dementia-strategy Worcester
Department of Health (2010) Nothing http://www.carefitforvips.co.uk/
ventured nothing gained: risk guidance for
people with dementia.
https://www.gov.uk/government/
publications/nothing-ventured-nothing-
gained-risk-guidance-for-people-with-
dementia
45.
4.4. People who have a learning disability
Positive behaviour support is widely accepted as good evidence-based practice when
supporting people with learning disabilities and/or autism who display or are at risk of displaying
behaviour that is challenging. We have included Jane’s story here to illustrate the importance of
PBS when supporting a person with a learning disability. Jane is not her real name.
Jane’s story
Jane is a woman with learning disabilities. She lives in a residential care
home with three other people. Jane requires support with her personal
care and wears incontinence pads. Sometimes, Jane is reluctant to
go to the bathroom to have her pad changed, including when she
has been doubly incontinent. This places her at risk of infection and
also places her dignity at risk. The manager of Jane’s home raised
concerns about the level of intervention that her team were feeling was
necessary in order to support Jane with this aspect of her personal
hygiene, particularly as workers were lifting Jane and carrying her to
the bathroom where she could have her pad changed in privacy. Jane
appeared not to like this intervention and would often struggle when
being carried. This was distressing and potentially dangerous for all
involved. It was also a restrictive practice. Under the Mental Capacity
Act (2005) Jane was deemed not to have the mental capacity to decide
whether and where to have her incontinence pad changed.
The multi-disciplinary team worked with the home manager and

her team to try to understand the reasons why Jane was reluctant
to have her pad changed, in an approach consistent with positive
behaviour support. This included a health screening (from a community
nurse), a sensory assessment (from an occupational therapist) and a
46.
communication assessment (from a speech and language therapist).
The physiotherapist in the team also advised that Jane should only be
lifted in ‘emergency’ situations.
This information led to a new care plan, agreed by all involved to be in

Jane’s best interests (Mental Capacity Act, 2005), which took much
greater account of the reasons why Jane may have been reluctant to
have her pad changed. This led to prevention strategies that meant
that Jane was generally happy to accompany workers to the bathroom
to have her pad changed. These included improved communication
strategies so that Jane could understand what workers were asking
and what would be involved. There was also a change in the décor
of the bathroom, so that it was much more calming to Jane from a
sensory perspective. Through constructing the plan, the team agreed
much more clarity about the circumstances in which they would have to
step in and change Jane’s incontinence pad, even if she was refusing
to go to the bathroom (based on a clear risk assessment). In this (now
considerably less likely event), workers would find a way to screen
Jane from others’ view in whatever room she was in and change her
pad there. Jane’s Mum was much happier with the plan than with the
previous set of circumstances and agreed that it was in Jane’s best
interests.
The key to success in this situation was close multi-disciplinary work

including the care home workers alongside the other multi-disciplinary
workers. This was facilitated by having a clear process and system
through which restrictive practices could be reviewed, encouraging
open and honest dialogue. All involved were agreed that being changed
behind a screen is not an ideal situation, but it avoids the need for
potentially damaging physical interactions while better solutions are
developed.
47.
Additional resources to support people (making it real for everyone)
with a learning disability www.thinklocalactpersonal.org.uk/
Browse/mir/
When considering the minimisation of Five good communication standards:
restrictive practices when supporting a person Reasonable adjustments to
with a learning disability you could make communication that individuals with
reference to the following specific resources. learning disability and/or autism should
expect in specialist hospital and
“Ensuring Quality Services - Core residential settings
principles for the commissioning of http://www.rcslt.org/news/good_comm_
services for children, young people, standards
adults and older adults with learning
Greenhill B., Whitehead R., Grannell M.,
disabilities and/or autism who display or
Carney G., Williams J., Cookson A.,
are at risk of displaying behaviour that
Chapman F., Ward E. & Lee A. (2008)
challenges”
Human Rights Joint Risk Assessment
http://www.local.gov.uk/
& Management Plan. (HR-JRAMP),
documents/10180/12137/L14-
2nd edn. Equality & Human Rights
105+Ensuring+quality+services/
Commission. Available at:
085fff56-ef5c-4883-b1a1-d6810caa925f
http://www.equalityhumanrights.com/
Driving up quality code. uploaded_files/humanrights/HRO/
https://www.drivingupquality.org.uk/home mersey_care_hr-jramp.pdf
The Challenging Behaviour Foundation Lee A., Kaur K., Cookson A. & Greenhill
(CBF) is a charity specialising in severe B. (2008) The Keeping Me Safe and Well
learning disabilities and behaviour Screen (KMSAW), 2nd edn. Equality &
described as challenging. Established by Human Rights Commission. Available
a family carer, they work with families and at: http://www.equalityhumanrights.
professionals supporting children and com/uploaded_files/humanrights/HRO/
adults across the UK. The Challenging mersey_care_keeping_me_safe_and_
Behaviour Foundation offers a wide range well.pdf
of resources about challenging behaviour
Active support
and related topics.
http://www.kent.ac.uk/tizard/active/
http://www.challengingbehaviour.org.uk
Prader-Willi Syndrome Association UK
Functional communication training
guidance on legal and ethical issues
Health action planning around restricting food.
Use of communication tools such as http://www.pwsa.co.uk/index.php/what-
objects and easy to understand language is-pws/136-ethical-and-legal-issues
Total communication systems / PECS The Confidential Inquiry into the
(Picture exchange communication premature deaths of people with a
systems) learning disability http://www.bris.ac.uk/
Think Local Act Personal – Making it real cipold/
48.
4.4. Acute health services
We have included this vignette here to illustrate the importance of reviewing the use restraint
reduction plans in a timely manner and ensuring that individual, team and organisational
learning takes place and is implemented following the use of a restrictive practice or a physical
intervention. The person’s name is fictional.
Mr Palmer’s story
Mr Palmer was admitted to neuro-surgical ward following an operation
and was assessed as being at risk of falls. He has already fallen out of
bed once and banged his head and the team were concerned that he
may break a limb. The ward doctor had written in the medical notes that
he needed to be restrained and wrist restraints were put on him to help
prevent falls.
The night nurse thought this was not the way forward but did not
question it as the doctor had written it in the notes.
Mr Palmer was very distressed by the wrist restraints and kept pulling
against them as they dug into him and made him very agitated. He was
very strong man and was being nursed on a one-to-one ratio.
His key nurse on the next shift escalated her concerns to the bleep
holder and the use of wrist restraints was reviewed and they were
removed. Mr Palmer continued to receive one-to-one care but his
agitation decreased without the restraints.
The situation was fed back to the medical and nursing teams. The
safeguarding team became involved and they organised learning for the
junior doctors on safeguards, the use of restraint and falls prevention.
It was noted, too, that nurses need to feel empowered to question
medical practice that they feel might not be correct at the time.
49.
Additional resources to support people and workers using acute health care services
When considering the minimisation of restrictive practices when supporting a person using
acute health care services you could make reference to the following specific resources:
NHS Protect, Meeting needs and reducing distress: the prevention and management of
clinically related behaviour in NHS settings
www.nhsprotect.nhs.uk/reducingdistress
How to use the knowledge and skills of families and specialist professionals to provide a
holistic service.
4.6. Working in partnership with people in need of care and

support, patients and carers
We have included Bert’s (fictional name) story here to illustrate the importance of working in
partnership with people in need of care and support, patients and carers to understand the
individual’s life story and factors that might trigger behaviour which challenges, to help minimise
any need for restrictive interventions.
Bert’s story
Bert had fallen and broken his hip. Following surgery to repair it he
was recovering on an orthopaedic ward. He had a catheter and
an intravenous drip in place and an oxygen mask. Bert was semi-
conscious and he was trying to remove these.
The ward workers tried to explain to Bert that he needed this treatment;
in moments of lucidity Bert agreed that he needed and wanted the
treatment but as he became drowsier he began pulling at the oxygen
mask. When it was replaced Bert instantly removed it and was
becoming exhausted and more agitated in the process, trying to climb
out of bed.
There was a real risk that Bert would injure himself by falling out of bed
or by damaging his skin, bladder or urethra. There were risks to other
50.
patients as well as workers were distracted from their needs by taking
care of Bert.
Ward workers lowered Bert’s bed to the floor and placed foam
mattresses either side of the bed so that if he did ‘get out of bed’ the
chances of him being injured were greatly reduced.
Bert’s son Martin arrived to visit and the nurses asked him to try and
help Bert tolerate the equipment. This was very stressful for Martin as
he wasn’t sure how forceful to be; he wanted the best for his father and
did not like to see him distressed.
Martin remembered that his father had been used to wearing breathing
apparatus during his long career as a fire-fighter. He explained to Bert
that the oxygen mask was just like his ‘breathing apparatus’ using that
term and also saying “B.A.” which was the acronym Bert was familiar
with. This greatly alleviated Bert’s distress as the concept of wearing
a face mask was firmly lodged in his memory as an unpleasant but
necessary thing. He did still try to remove the mask but less often
and when reminded verbally he left it in place without needing it to be
physically replaced. As Bert’s distress lessened he was more tolerant of
the catheter and the drip, and actually needed the oxygen for a shorter
period of time.
In Bert’s case it was fortunate that he had that experience of wearing

BA in his working life; this will not be the case for everyone. However,
workers and carers can always work together quickly to think about
experiences and terminology that people might know (or conversely
which might be particularly worrying for them) from their earlier lives to
help them understand and accept treatment and interventions that they
need.
51.
Additional resources to support partnership your-own-care-and-support/
working with people who have care and Working-for-personalised-care---A-
support needs, patients and carers framework-for-supporting-personal-
assistants-working-in-adult-social-care.
When considering the way to work in pdf
partnership working with people who have
http://www.thinklocalactpersonal.org.
care and support needs, patients and carers
uk/Browse/mir/aboutMIR/
to minimise the use of restrictive practices, you
could make reference to the following specific
resources. 4.8. People with autism
National involvement partnership When considering the minimisation of
Involvement standards restrictive practices when supporting a person
http://www.nsun.org.uk/about-us/ with autism you could make reference to the
national-involvement-partnership/ following specific resources:
NHS England; Transforming Participation
Sensory differences
in Health and Care, Guidance for
http://www.autism.org.uk/sensory
Commissioners
http://www.england.nhs.uk/2013/09/25/ National Autistic society
trans-part/ http://www.autism.org.uk/living-with-
autism/understanding-behaviour.aspx
SCIE; The participation of adult service
users, including older people, in High functioning autism and aspergers
developing social care http://www.autism.org.uk/about-autism/
http://www.scie.org.uk/publications/ autism-and-asperger-syndrome-an-
guides/guide17/participation/ introduction/high-functioning-autism-
and-asperger-syndrome-whats-the-
Skills for Health & Skills for Care, Carers
difference.aspx
Matter – Everybody’s Business (2011)
http://www.skillsforcare.org.uk/Skills/ The Autism strategy, rewarding and
Carers/Carers.aspx fulfilling lives
http://www.autism.org.uk/
autismstrategy
4.7. Individual employers
Skills for Care and Skills for Health’s
People who have care and support needs ‘Autism skills and knowledge list’
may employ or commission their own support http://www.skillsforcare.org.uk/Skills/
workers using direct payments or their own Autism/Autism.aspx
savings or resources.
http://www.skillsforcare.org.uk/
Document-library/Employing-
52.
5. Appendices
Appendix A – More details on workforce

Who is my workforce?: Consider how many people are in these roles, including part
time, relief, casual, bank and agency workers
The individual Individuals, family carers, friends, partners, neighbours advocates,
and their family or peer advocates, nearest relatives, next of kin, ‘relevant person’s
representatives representative’ (DOLS), shared lives carers, foster carers.
Paid workers Support & care workers; registered workers including nurses,
allied health professionals and social workers; managers; medical
workers and doctors both community and inpatient; receptionists,
administrators, housekeeping, bank and agency workers.
Managers; paid and Chief executives, board members, senior managers, trustees and
unpaid shareholders.
Volunteers People working voluntarily within people’s homes, community and
hospital settings.
Trainers or All training / learning and development workers including assessors
Individual learning and specialist practitioners.
providers
Advisors / shapers Safeguarding leads, service commissioners, CQC, health and safety
advisers, solicitors and legal advisers including MCA & DOLS leads.
Students Any student on placement.
What we expect people to be able to do is dependent upon the person’s individual

situation and the service setting/provision. It may include:
Planned Upholding a person’s rights and dignity at all times
In partnership with individuals and their families/carers develop
person centred care plans which include positive behaviour
support plans and functional analysis
Developing and reviewing restrictive plans / reduction plans and
programmes
Undertake risk assessments to include choice and positive risk
taking in partnership with individuals and their families/carers
Carry out physical restraint as part of a person’s plan of care
and support
Provide hands on care and support tasks for example: bathing,
dressing, help with eating and drinking and giving medication.
53.
What we expect people to be able to do is dependent upon the person’s individual
situation and the service setting/provision. It may include:
Planned cont. Provide hands on medical and nursing care tasks for example:
changing dressings, undertaking physical health checks
Ensure that people’s physical health needs are identified and
met through regular and timely health checks
Undertake controlled restraint as part of a restraint team.
Deliver staff training and other learning and development
activities including assessment for qualifications.
Manage and supervise people delivering direct care
Embedding new learning into culture and practice
Work intensively in one to one situations supporting people and
teams
Write, scrutinise and interpret policy for practice
Commission services and /or learning
Record and report incidents of restraint as per organisational
policy and procedure
Approve strategic plans such as learning plans or policies and
procedures
Work alone
Unplanned Upholding a person’s rights and dignity at all times
Respond to unexpected situations which pose a risk of harm to
the individual and/or others
Provide emergency lifesaving interventions
Fill in for others when absent
Where
Where do we expect In relation to restrictive practices; good practice and the law may be
them to do it? applied differently dependent upon different situations, these might
include:
residential care homes
a person’s own home / family home
community / public places, e.g. accident and emergency units,
in the street, cinema, etc.
near environmental hazards, e.g. traffic, water, steep cliffs, etc.
stimulating or calming environments, e.g. noise, heat, crowds,
aromas, etc.
where children or vulnerable adults may be present
in a secure settings such as a secure mental health unit.
54.
What
What skills, and This might be assessed by considering:
knowledge, attitudes, The expectations above.
values, confidence The needs of people being supported which should be
and competences do expressed in care plans: positive behaviour support plans /
they (a) need, and (b) Wellness Recovery Action Plans (WRAP) / life story / advance
already have? care plans.
The appropriate level of awareness of the specific needs of
people with conditions such as dementia, borderline personality
disorder, autism. Either because the service is for people with
these conditions or because people with these conditions may
access the service as part of the general public.
The organisation’s values, purpose, policies and procedures.
Service specifications / contracts / feedback and instructions
from people being supportd or their carers.
Codes of conduct / (minimum) training standards induction
standards / sector skills council guidance / registration
requirements.
Supervisions, appraisal, personal development plans.
Job descriptions / person specifications.
When
When can I assess Opportunities might exist when carrying out:
and improve the levels Recruitment and selection.
of skills needed and Designing or redesigning a service or team; changes to
the level that workers individuals’ circumstances and roles.
have? Annual reviews (contract compliance / inspection / budget
planning).
Debrief / learn from incident / near misses / improvements.
Induction / probation / supervision / appraisal / personal
development planning.
Delivering learning/ assessing competence / refresher periods
Degree / ‘pre-registration’ training.
When data analysis suggests that skill levels need to be
considered.
55.
How
How will I develop By involving the voice of people being supported.
the skills that workers The following opportunities might exist:
have? Shadowing, mentoring, coaching, peer support.
In house or external learning; How will I ensure that learning
providers are up to date, teaching evidence-based approaches
that are in tune with my service?
Theory and competence; developing the relevant physical /
practical skills.
As part of induction / qualification / continuing professional
development.
Co-training with other partners / competitors / agencies.
How will I evaluate the learning and its impact on practice.
56.
Appendix B - List of recommended units and qualifications to support
the minimisation of restrictive practices
Units applicable to family carers and workers. To find detail of units visit the Ofqual site
http://register.ofqual.gov.uk/ and click on ‘search units’
Unit number Name Level

H/504/2891 Behaviour Change for health and wellbeing 2
H/601/9282 Approaches to enable rights and choices for individuals with dementia 2
whilst minimising risks
M/501/6004 Communication, relationships and promoting mental wellbeing with 2
older people
A/601/9546 Contribute to support of positive risk-taking for individuals 2
A/502/0590 Defusing Difficult Situations in the Workplace 2
K/501/5210 Effective communication in mental health work 2
A/601/8140 Implement person centred approaches in health and social care 2
Y/601/7352 Provide active support 2
HSC 2012 Support Individuals who are Distressed L/601/8143 2
F/601/4056 Support use of medication in health and social care settings 3
MCA01 Awareness of the Mental Capacity Act 2005 3

K/601/2415 Applied Psychological Perspectives for Health and Social Care 3
M/501/0591 Contribute to the prevention and management of abusive and 3
aggressive behaviour of individuals who misuse substances
L/601/9034 Enable individuals with behavioural difficulties to develop strategies to 3
change their behaviour
A/601/9191 Enable rights and choices of individuals with dementia whilst minimising 3
risks
H/601/8049 Facilitate person centred assessment, planning, implementation and 3
review
K/505/7778 Promote positive behaviour 3
Y/602/3099 Provide support for individuals with communication and interaction 3
difficulties
M/602/4825 Support individuals during emergency situations 3
R/503/9985 Enable individuals with mental health problems to develop alternative 4
coping strategies
HSC 3065 Implement the positive behavioural support model 4
57.
L/504/7079 Managing risk behaviour when supporting individuals with cognitive 4
related challenge
J/504/6240 Managing the risk of aggressive and challenging behaviour in the 4
workplace
R/504/6239 Managing the risks associated with crisis behaviour in the workplace 4
A/504/2217 Lead practice in assessing and planning for the needs of families and 5
carers
H/504/2213 Lead practice which supports individuals to take positive risks 5
K/602/2572 Lead positive behavioural support 7
Units applicable to social care and health workers
Y/505/8005 Delivering instruction in the implementation of physical interventions in 4
the management of high risk behaviours in the workplace.
D/505/8006 Delivering instruction in the use of physical interventions in the 4
management of acute behavioural disturbance and extreme risk
behaviour in the workplace.
Other qualifications include:

BTEC Professional Diploma in Positive Behaviour Management
BTEC PBS Advanced certificate.
BTEC PBS Advanced Diploma
58.
Appendix C – List of qualifications suitable for those delivering learning
and assessment activities in the use of restrictive practices
Currently there are no requirements for social care and health workers to hold teaching or
training qualifications.
However where an individual learning provider or trainer does not hold or is not working
towards a formal teaching or learning & development qualification (as outlined below) the
employer should satisfy themselves that the learning provider meets the same standards of
practice as set out in the Learning and Development National Occupational Standards and be
occupationally competent in the area in which they are providing learning.
Individual learning providers
Qualified Teacher Status

Certificate in Education in Post Compulsory Education (PCE)
Social Work Post Qualifying Award in Practice Teaching
Preparing to Teach in the Lifelong Learning Sector (PTLLS)
Certificate in Teaching in the Lifelong Learning Sector (CTLLS)
Diploma in Teaching in the Lifelong Learning sector (DTLLS)
Mentorship and Assessment in Health and Social Care Settings
Mentorship in Clinical/Health Care Practice
NOCN – Tutor/Assessor Award
QCF Level 4 Certificate in Education and Training
QCF Level 5 Diploma in Education and Training
Tutor/Trainer Qualification by recognised body/association in the prevention and
management of violence and aggression.
Clinical credibility (to be evidenced by previous work related experience and working
practice).
Assessors
Assessor must also be occupationally competent in the units they are assessing and hold a
relevant assessor qualification, for example;
Level 3 Award in Understanding the Principles and Practices of Assessment (QCF)
501/2212/5
59.
Level 3 Award in Assessing Competence in the Work Environment (QCF)
501/2387/7
Level 3 Award in Assessing Vocationally Related Achievement (QCF)
501/2385/3
Level 3 Certificate in Assessing Vocational Achievement (QCF)501/2388
Or pre-existing equivalent.
Please see Skills for Care and Development and Skills for Health assessment principles for
definitions.
http://cdn.cityandguilds.com/ProductDocuments/Health_and_Social_Care/Care/4222/
Centre_documents/Assessor%20requirements_v2.pdf
Note: the new Education and Training Foundation has a priority to refresh the professional
standards and launch them by summer 2014.
http://www.et-foundation.co.uk/our-priorities/professional-standards.html
60.
Appendix D – Legislation and codes of practice
Legislation
European Convention of Human Rights and The Human Rights Act 1998, in particular;
Article 2; right to life
Article 3; prohibition of torture, inhuman or degrading treatment
Article 5; right to liberty and security of person
Article 8; right to respect for private and family life
Article 10; freedom of expression
Article 14; prohibition of discrimination
The Mental Health Act 1983 as amended by the 2007 Mental Health Act
Mental Capacity Act 2005 (MCA)
Deprivation of Liberty Safeguards (under MCA 2005),
Health and Safety at Work Act 1974 (and other H&S legislation),
Common Law. (Offences against the person act 1861)
Statute Law
Care Bill (currently in draft form) 2013-2014
The Children Act 2004 where relevant
SEND reforms where relevant – these reform the system of supporting children and young
people with special educational needs or disabilities and cover the ages 0 – 25, bringing
health care and education plans together.
http://www.education.gov.uk/childrenandyoungpeople/send
Equality Act 2010 and the Disability Discrimination Act
http://odi.dwp.gov.uk/disabled-people-and-legislation/equality-act-2010-and-
dda-1995.php
Guidance on relevant legislation can be found here;

https://www.mind.org.uk/information-support/legal-rights/
http://www.mencap.org.uk/all-about-learning-disability/information-professionals/standards-care
Codes of practice
NHS Protect: Meeting needs and reducing distress

RCN Guidance
HCPC : Standards of conduct, performance and ethics
NMC: (Nursing and Midwifery Council) Code of practice
BILD code of practice / accreditation system
National Institute for Health and Care Excellence (NICE) Guideline no. 25 Violence: The
short-term management of disturbed/violent behaviour in in-patient psychiatric settings and
emergency departments
61.
Skills for Care and Skills for Health Code of Conduct for Healthcare Support Workers and
Adult Social Care Workers in England 2013
NMC Standards for Medicines Management 2007
Behaviour Analyst Certification Board; 1006 Guidelines For Responsible Conduct Revised,
January 29, 2014 - http://uk-sba.org/?attachment_id=425
Guidance and standards
The NHS Constitution

Practical approaches to workforce planning; A guide to support workforce planning
processes and plans for adult social care support services (SFC).
Principles of workforce redesign (Skills for Care).
National occupational standards.
The Knowledge and Skills Framework.
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/
publicationsandstatistics/publications/publicationspolicyandguidance/dh_4090843
Supporting Workers working with people who challenge services - Guidance for employers,
Skills for Care, February 2013
CQC Essential Standards and Quality and Safety
A unified approach to challenging behaviour – Royal College of Psychiatrists, British
Psychological Society and Royal College of Speech and Language Therapists, Approved
by Central Executive Committee: March 2007
Violence, The short-term management of disturbed/violent behaviour in in-patient
psychiatric settings and emergency departments.
http://www.nice.org.uk/nicemedia/live/10964/29715/29715.pdf
HSE:
RR440 - Violence and aggression management training for trainers and managers
http://www.hse.gov.uk/research/rrhtm/rr440.htm
RR495 - Violence management training: The development of effective trainers in the
delivery of violence management training in healthcare settings
http://www.hse.gov.uk/research/rrhtm/rr495.htm
The independent restraint advisory panel
Guidelines & policy around dealing with public & press opinion
The Social care commitment.
DH: Transforming care: A national response to Winterbourne View Hospital
“Choosing workplace learning”;
http://www.skillsforcare.org.uk/Qualifications-and-Apprenticeships/Finding-learning-
providers/Finding-learning-providers.aspx.
Whistleblower’s helpline run by Royal Mencap.
www.wbhelpline.org.uk [email protected]
Francis Report
62.
Appendix E – Content of learning; a starting point
Recommended content of learning
Learning content should:
Be developed and /or delivered by those who have lived experience of services and
conditions and their family members and carers.
Based upon policy and procedure, supported by culture and practice.
Be based on current evidence-based practice.
Be undertaken at an appropriate time so workers can work effectively from the outset.
Be delivered using a variety of different learning methods relevant to the situation
including skills practice.
Content could/should include To whom
Value based practice. All workers
Person-centred care and planning.
Safeguarding is all of our responsibilities.
Being person centred in your work/care: Core principles and Care and health
values. workers
Functional assessment of behaviour including triggers and the
impact of the environment and trauma.
Positive risk taking.
Understand the impact of gender, ethnicity culture, life history and
experiences on behaviour.
Ways of communicating: behaviour and non verbal
communication, communication breakdown and aided
communication.
Physiological aspects of behaviour: pain, illness, infection,
substance use, epilepsy, diabetes etc.
Positive behaviour support framework where person is known
with planned non aversive approaches / diffusion / distraction for
individual.
Positive person centred collaborative care planning to include:
active support, life story work, health actions plans, wellness
recovery action plans, advance decisions and end of life planning.
Legislation and application to practice: Human Rights Act, MHA,
MCA, DOLs and common law.
Role of debriefing and organisational practice.
63.
Being person-centred in your work/care. Core principles and Care and health
values. workers
Functional analysis of behaviour including triggers and the impact
of the environment and trauma.
Understand the impact of gender, ethnicity culture, life history and
experiences on behaviour.
Ways of communicating: behaviour and non verbal.
communication, communication breakdown and aided
communication.
Physiological aspects of behaviour : pain, illness, infection,
substance use, epilepsy, diabetes etc.
De escalation techniques; non aversive approaches / diffusion /
distraction for individual.
A gradient approach to restraint from:
De-escalation.
Seated.
The legislation and application to practice: Human rights act,
MHA, MCA, DOLs and common law.
Role of debriefing and organisational practice.
Functional Assessment. Supervisors
The role of evidence-based psychological treatments. Managers
Reflective and sustainable practice - Learning from events and
promoting ongoing learning with individuals and organisations.
Current research.
Understanding tolerances.
Resilience.
likely potential emergency situations where not known.
Include Prevention.
Recognising distress.
Common causes of needs.
Psychological wellbeing.
Risk assessment.
64.
Appendix F – Accreditation systems and models of learning
Voluntary accreditation systems
Although there is no current mandatory accreditation system for learning providers voluntary
systems do exist. Further information on these systems can be found at:
British Institute of Learning Disabilities (BILD) PIAS accreditation scheme
www.bild.org.uk/our-services/bilds-services/
Security Industry Authority
http://www.skillsforsecurity.org.uk/index.php/questions/1/39 or
http://www.sia.homeoffice.gov.uk/Pages/training.aspx
List of learning models which participants in this project have used and recommended:
Crisis Prevention Institute: www.crisisprevention.com

D.ESCAL8: http://de-escalate.com
The General Services Association (GSA): www.thegsa.co.uk
La-Vigna
Mapa: (Management of actual or potential aggression)
Maybo: www.maybo.co.uk
NHS Protect Sylabus www.nhsprotect.nhs.uk/reducingdistress
PROACT-SCIPr-uk ® http://www.proact-scipr-uk.com/
Respect training from NAVIGO NAV. [email protected]
St Anne’s Community Services Positive Behaviour Support model of training
TEACCH
65.
Appendix G – Questions to consider when choosing a learning provider
for reducing restrictive practices
Can they can evidence bespoke learning to meet the specific needs of the service,
e.g. different content will be required for a home supporting people with dementia
than one that is supporting people with autism?
What qualifications do the people delivering the learning have – for instance if the
course is a PBS introduction has the person attended a university accredited course
on positive behaviour support?
Can they provide examples of services which have previously applied the learning?
Can you provide an overview of the background requirements of the learning to be
purchased?
Does the programme conform to the 2/3 preventative proactive, 1/3 reactive physical
intervention, balance?
Does the learning provider have a system of feedback available to all, e.g. like ‘trip
adviser’ or ‘check a trade’?
Does the learning contain an element of competence testing – for instance role play
testing as well as verbal competence?
Have the individual learning providers a system in place to feed back about learners
who are unsafe in their practice?
Can the learning provider describe the biomechanical issues of any techniques that
are taught?
Do you know how to conduct a behaviour audit in order to meet the needs of the
service users receiving care and ensure the workers have the appropriate knowledge
and skills after the learning?
Do they include the functions of behaviour and positive behaviour support planning
within their learning provision?
Can the learning provider offer support to your organisation following the learning
provision?
Can they help with plans or suggestions about how training and learning should be
monitored to make sure it is working in practice?
Has the learning provider been accredited by undertaking a rigorous external
process (eg BILD)?
66.
6. References
Ensuring Quality Services (EQS: Core principles for the commissioning of services for children,
young people, adults and older adults with learning disabilities and / or autism who display or are
at risk of displaying behaviour that challenges” has been developed by NHS England and the Local
Government Association (NHSE LGA 2014).
http://www.local.gov.uk/documents/10180/12137/L14-105+Ensuring+quality+services/085fff56-
ef5c-4883-b1a1-d6810caa925f
Positive and Proactive Care: reducing the need for restrictive interventions (DH 2014).
Safewards Project.
Dementia care mapping’ with people who have dementia.
The NHS protect guidance ‘Meeting needs and reducing distress: Guidance for the prevention and
management of clinically related challenging behaviour in NHS settings’.
Institute for Public Care, 2012.:see NDTi Guide for reference.
‘RESPECT’ training- Navigo : Respect training from NAVIGO [email protected]
“The International Journal of Positive Behavioural Support (IJPBS)”, Volume 3, Number 2, Autumn
2013.
McGill P, Bradshaw J, & Hughes A (2006), Impact of Extended Education/Training in Positive
Behaviour Support on Staff Knowledge, Causal Attributions and Emotional Responses. Journal of
Applied Research in Intellectual Disabilities, Volume 20, Issue 1, 41–51, January 2007
http://onlinelibrary.wiley.com/doi/10.1111/j.1468-3148.2006.00338.x/full
McGill P & MacDonald A (2013), Outcomes of Staff Training in Positive Behaviour Support: A
Systematic Review. Journal of Developmental and Physical Disabilities 2013; 25(1): 17–33.
http://link.springer.com/article/10.1007/s10882-012-9327-8
67.
68.
Notes
69.
70.
Skills for Care Skills for Health
West Gate 2nd Floor
6 Grace Street Goldsmiths House
Leeds Broad Plain
LS1 2RP Bristol BS2 0JP
tel: 0113 245 1716 tel: 0117 922 1155

fax: 0113 243 6417 fax: 0117 925 1800
email: [email protected] email: [email protected]
web: www.skillsforcare.org.uk web: www.skillsforhealth.org.uk

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What is the purpose of this guide?

What is the purpose of this guide?

What groups should read this guide and why?

What groups should read this guide and why?

A positive and proactive workforce

A guide to workforce development for commissioners and

3. Effective workforce development to minimise the use of restrictive practices 18

© Skills for Care & Skills for Health 2014

Bibliographic reference data for Harvard-style author/date referencing system:

Commissioners, regulators and inspectors Safeguarding leads

Positive and Proactive Care: MCA 2005 National Partnership Agreement:

Closing the Gap: priorities for

Making someone do something they don’t

‘Interventions that restrict an individual’s

If carried out for any other purpose concerns

Within the context of this definition, restrictive

Positive and proactive care

Am I stopping someone doing

Has every effort been

Is this the least

No Does the restriction

The restriction is unlikely to be justified. Yes

Edie’s story: a culture of fear

Workers were scared of going to support Edie and were doing so in

Person centred planning Good practice

Support plans; meeting

Language/ terminology Best Interests

Circle of support Health Skills

Life History How I Communicate

Choice Knowledge Gender

Sexuality Environment Ethnicity

With the help of the local challenging behaviour service a holistic

A detailed individual support plan was put in place which allowed

 How to ensure the candidate has the http://www.6cs.england.nhs.uk/

It is important to support workers to find alternatives to restrictive practices. When restrictive

Edie’s story continued: supporting workers to minimise restrictive practices

Workers and Edie’s daughter needed support individually and as a team to

Supervision  regular—planned in advance but also

“I feel that the service user input / forum was

At present there is no current mandatory Additionally the learning provider should:

Edie’s story continued: Getting the culture right

“I want these changes to continue; the atmosphere is much better

Not engaging Simon when he made demands, but presenting

Grace spent 14 months in a mental health hospital in London and was

When considering the minimisation of  The ‘Safewards’ Project from research,

 Preventing suicide in England: One year  Service User Involvement in Mental

We are here to help.

Source: Sam O’Brien, Service User Consultant

Good practice in patient care must involve all workers sharing

The multi-disciplinary team worked with the home manager and

This information led to a new care plan, agreed by all involved to be in

The key to success in this situation was close multi-disciplinary work

4.6. Working in partnership with people in need of care and

In Bert’s case it was fortunate that he had that experience of wearing

Appendix A – More details on workforce

What we expect people to be able to do is dependent upon the person’s individual

Unit number Name Level

MCA01 Awareness of the Mental Capacity Act 2005 3

Other qualifications include:

How to ensure the candidate has the http://www.6cs.england.nhs.uk/

Supervision regular—planned in advance but also

When considering the minimisation of The ‘Safewards’ Project from research,

Preventing suicide in England: One year Service User Involvement in Mental

Qualified Teacher Status

NHS Protect: Meeting needs and reducing distress

The NHS Constitution

Crisis Prevention Institute: www.crisisprevention.com