Restrictive Physical Intervention

This policy aims to establish a clear statement of understanding and intent in relation to positive behaviour support, with a focus on child centred service provision.

A 'whole child' focus through the relational model of care, where:

• Every child can feel safe and secure, able to overcome emotional barriers and express their worries and concerns;
• Parents, families and carers are central to our developments. We are committed to making our children’s lives better today, tomorrow and in the future;
• Through commitment to equality, dignity, and respect we develop confident, positive citizens of the wider world through adherence to the United Nations Convention on the Rights of the Child, and to British values;
• Through understanding that this is a form of communication for an emotionally overwhelmed child.

A useful concept to bear in mind when carrying out any restrictive practice is that of Social Validity. During any restrictive practice we should be conscious both of how our intervention may look to others not involved in the interaction and how we would like ourselves, family members or friends to be interacted with in similar circumstances.

The principles of responding to behaviours of concern include:

• Set and maintain clear boundaries; Do not avoid and do not delay;
• Work together with the child;
• Be truthful, consistent and reliable;
• Make time to listen, talk and take a real interest in the child;
• Take the child seriously;
• Encourage and reward positive actions;
• Involve children in decision making;
• Communicate clearly;
• Do not say "yes" when you mean "maybe". Do not say "maybe" when you mean "no"; Do not make promises you cannot keep;
• Apologise when necessary;
• Humour defuses;
• Making fun frustrates;
• Body language, volume and tone of voice can give important clues to what you want;
• Be calm, be assertive, be confident;
• Explain what is wrong and the impact on any others;
• Think and plan ahead; Always know where your colleagues and children are;
• Be aware and acknowledge your own feelings.

All adults have a duty and a responsibility to maintain the safety and wellbeing of the children and their colleagues. This policy focuses on how we may use physical intervention with children, what processes we have in place to ensure we are recording and reporting all instances of restrictive physical intervention (RPI); and how we are working to reduce its use in our care and educational settings.

This policy has been written considering the need to comply with the requirements of the Manual Handling Operations Regulations, 1992 (revised 1998 edition), and the Health and Safety at Work Act, 1974. It takes full account of the Equality Act 2010, the Children and Families Act 2014, the European Convention for the Protection of Human Rights and Fundamental Freedoms and the EU Charter of Fundamental Rights. It also complies with and supplements the relevant provisions of the Education Act 1996 and the Education and Inspections Act 2006.

This policy must be read in conjunction with the following policies:

• Anti-bullying Policy;
• Child Protection and Safeguarding Policy;
• Behaviour Policy;
• Exclusion Policy;
• Health & Safety Policy;
• Adult’s Code of Conduct;
• Confidential Reporting Policy.

Children with social, emotional and mental health needs and/or autism sometimes behave in ways that others can find challenging and which, on some occasions, may be dangerous; potentially resulting in harm to the person displaying the behaviour, other children present, adults or the public. Such behaviours may initially appear to be unpredictable and can be frightening for all concerned including the child displaying the behaviour.

The primary duty of the Caldecott Foundation as a care and education provider is to ensure the people we support are safe from harm. The fundamental but complex need to balance the right to freedom, dignity and respect, with ensuring safety from harm is at the heart of this policy and guidance (The Restraint Reduction Network (RRN) Key Strategy 1).

There are a variety of approaches and strategies that can be used to prevent situations from developing into incidents likely to cause harm such as: de-escalation, low arousal techniques and other examples of Positive Behaviour Support. However, on some occasions it may be necessary to use, always as a last resort, a strategy that includes a restrictive practice. Any form of restrictive practice will only be used in order to maintain the welfare and safety of the children we support and others. Adults will be trained in approved techniques and any unplanned interventions outside of an individual’s safety plan will be investigated to ensure that action taken was proportionate and applicable at the time to prevent harm to the individual or others.

British Institute of Learning Disabilities define a restrictive practice as:

The implementation of any practice or practices that restrict an individual’s movement, liberty and freedom to act independently without coercion or consequence. Restrictive practices are highly coercive actions that are deliberately enacted to prevent a person from pursuing a particular course of action - BILD Code of practice 4th edition.

The Children’s Homes Regulations (2015) define restraint as:

Using force or restricting liberty of movement Regulation 2 (1)

The Guide to the Children’s Homes Regulations including the quality standards (April 2015) includes additional information. As well as the definition above the guide states:

9.42 Restraint also includes restricting a child’s liberty of movement. This includes, for example, changes to the physical environment of the home (such as using high door handles) and removal of physical aids (such as turning off a child’s electric wheelchair).

As defined above restriction of liberty of movement can involve adaptations to the environment such as using high door handles or removing physical aids, but it may also refer to strategies such as requiring a child to take 'time out' in a specific area of the home, asking a child to spend time away from the group to regain control of their behaviour i.e. if a child is struggling to maintain a socially acceptable level of behaviour at the meal table, asking them to move away from the group to another area, or temporarily denying them access to a part of the home which they would ordinarily have access to. Any such measures must be taken in line with relevant legislation. Specifically, Regulation 21 c(i-iv) of The Children’s Homes Regulations (2015). This states:

The registered person must ensure that:

Any limitation placed on a child’s privacy or access to any area of the homes premise

1. Is intended to safeguard each child accommodated in the home;
2. Is necessary and proportionate;
3. Is kept under review and, if necessary, revised; and
4. Allows children as much freedom as is possible when balanced against the need to protect them and keep them safe.

Whether or not there is the need to use restrictive physical intervention (i.e. the child may go willingly once instructed to do so) a record of the incident must be recorded (see Appendix 1: Policy and Practice Guidelines on the use of Elevated Risk Techniques (ERT’s), Recording and Reporting. This is to ensure the intervention can be monitored and to ensure that children are not being unduly or routinely isolated from the group or areas of the home.

Regarding physical intervention, the crux of common law (both criminal and civil) is that:

• Any threat of non-consensual touching is an assault;
• Any actual touching is battery;
• Any wrongful hindrance to mobility is false imprisonment.

The law recognises that there are situations where some restrictive practice is necessary as an act of care. For example, if someone has a learning disability, mental illness or related issue, that puts someone at risk, adults may have a legal duty to restrain the person in his or her own interests.

Where someone takes on a caring role, he or she owes a ‘duty of care’ to the person. This means that the adult must do what is reasonable to protect the person from reasonably foreseeable harm. If someone’s actions could put other people at risk, adults have a duty of care to respond positively, which might include as a last resort restraining the person to prevent harm.

A restrictive practice is only justified in law if there is the presence of a clear and immediate danger. The term ‘immediate’ in this context refers to seconds as opposed to minutes. It does not justify action taken to prevent a possible danger unless incident data clearly shows that a given behaviour or cue quickly results in escalation to a dangerous level, in which case a planned intervention may be justified in the short term, whilst furthermore positive and proactive strategies are developed (see British Institute of Learning Disabilities Code of Practice).

As well as the presence of a clear and immediate danger adults must also be able to demonstrate that all other available less restrictive options have been tried and failed before the use of a restrictive practice.

PRICE training offers guidance and a series of non-restrictive and non-aversive techniques to avoid/reduce the use of restrictive practices. There is an expectation that alternatives to a restrictive practice would increase with adult training, experience and knowledge of the individual (RRN Key Strategy 4). If you can find no alternative to using a restrictive practice then you should use it.

To ensure that we follow best practice, when managing signs of stress and behaviour that physically challenges us we follow and adhere to the guidance within the BILD codes of Practice and the RRN guidance, the guidelines include the 6 key strategies to the reduction of the use of restraint. The 4 day PRICE course that is delivered to all care and teaching teams at the Caldecott Foundation covers BILD and Restraint Reduction Network Training Standards 2019. All adults who take part in the training are certificated to evidence that they adhere to the values and principles and have a working knowledge of the following areas:

1. Leadership:

The organisation develops a mission, philosophy and guiding values which promote non-coercion and the avoidance of restraint. Leaders commit to developing a restraint reduction plan which is implemented and measured for continuous improvement for those children who have needed physical intervention at any point. Children who are able to self-regulate with verbal support from adults do not need a restraint reduction plan.

2. Performance Measurement:

The organisation takes a 'systems' approach and identifies performance measures which determine the effectiveness of its restraint reduction plan.

3. Learning and Development:

The organisation develops its employees with the knowledge and skills to understand and prevent crisis behaviour. Training is provided which gives adults the key competencies and supports the view that restraint is used as a last resort to manage risk behaviour associated with aggression, violence and need for immediate support.

4. Providing Personalised Support:

The organisation uses restraint reduction tools which inform adults and shape personalised care and support to pupils.

5. Communication and Child Focus:

The organisation fully involves pupils in the management of their own behaviour, identifies the needs of pupils and uses these to inform provision and development.

6. Continuous Improvement:

The principle of post-incident support and learning is embedded into organisational culture.

Trained adult carers may only use techniques that are approved by the home; such techniques should comply with the following principles:

• Not impede the process of breathing - the use of 'prone face down' techniques must never be used;
• Not be used in a way which may be interpreted as sexual;
• Not intentionally inflict pain or injury or threaten to do so;
• Avoid vulnerable parts of the body, e.g. the neck, chest and sexual areas;
• Avoid hyperextension, hyper flexion and pressure on or across the joints;
• Not employ potentially dangerous positions.

If Physical Intervention is used upon a child, the Home Manager and child's social worker should be notified within one working day (working days being defined as Monday – Friday, excluding bank holidays). If a placing authority requests information within a different timescale this should be adhered to if appropriate.

If a serious incident or the police/emergency services are called, the Responsible Individual must be notified and consideration given to whether a ‘Notifiable Event’ has occurred, if so, see Notification of Significant Events Procedure.

The social worker should make a decision about whether to inform the child's parent(s) and, if so, who should do so.

A children’s home cannot routinely deprive a child of their liberty without a court order, such as a Section 25 order to place a child in a licensed secure children’s home or in the case of young people aged 16 who lack mental capacity, a deprivation of liberty may be authorised by the court of protection following an application under the Mental Capacity Act 2005.

Locking of external doors, or doors to hazardous materials, may be acceptable as a security precaution if applied within the normal routine of the home.

Where Physical Intervention has been used, the child, adults and others involved must be able to call on medical assistance and children must always be given the opportunity to see a Registered Nurse or Medical Practitioner, even if there are no apparent injuries.

If a Registered Nurse or Medical Practitioner is seen, they must be informed that any injuries may have been caused from an incident involving Physical Intervention.

Whether or not the child or others decide to see a Registered Nurse or Medical Practitioner it must be recorded, together with the outcome.

The Registered person should regularly review the effectiveness and application of this system.

If a child has an EHC Plan in which a specific type of restraint/physical intervention is used as part of the day to day child’s routine, the home is exempted from the recording requirement. Where these plans provide for a specific type of restraint that is not for day to day use, the restraint used must be recorded. Any other restraint used must always be recorded.

This policy and Practice guidelines should be read in conjunction with our existing Restrictive Physical Intervention Policy.

All principles relating to the use of physical intervention still apply as included in the policy and as delivered on the Positive Management of Challenging Behaviour Training by a qualified PRICE Instructor.

What are Elevated Risk Techniques (ERT’s)?

ERT’s are defined as techniques which:

• Use clothing or belts to restrict movement;
• Restrict breathing or impede airway;
• Place someone in seclusion;
• Extend or flex joints or put pressure on joints, neck, chest or abdomen or groin area;
• Hold someone who is lying on the floor or force them to the floor.

Within the context of this policy we are referring specifically to techniques which may:

• Restrict breathing or impede airway - i.e. "Supine", in which young people are lying on the floor, have the potential to restrict breathing due to an increased risk of choking. Adults training in this technique reflects this risk and also offers guidance on how to minimise and manage the risk;
• Hold someone who is lying on the floor i.e. with "Supine" Adults training routinely advises that the use of restraint on the floor should be avoided. However it is also acknowledged that, on some occasions, the risk of releasing a child who has dropped to the floor may outweigh the risk of continuing a physical intervention. In such scenarios adults are expected to follow advice given on training and within this policy.

We do not promote the use of techniques which:

• Use clothing or belts to restrict movement;
• Place someone in seclusion;
• Extend or flex joints or put pressure on joints, neck, chest or abdomen or groin area.

When do we use Elevated Risk Techniques?

ERT's can ONLY be used in supporting young people where the current Phase 1 and 2 Techniques, when applied correctly are not sufficient to keep everyone SAFE.

In most cases this will have been assessed through a process of meetings in response to extreme behaviour which has been previously displayed (i.e. through the Serious Incident meeting). Within this process, the Registered Manager, in conjunction with the Senior PRICE instructor, should carry out a review of incidents to ensure that the above premise is met. They will review the incidents of physical intervention to look for the following:

• Is the current concerning behaviour being displayed part of a pattern of behaviour?
• Is there a clear understanding for the current concerning behaviour?
• Is there evidence in the Individual Risk Assessment and Behaviour Support Plan of proactive methods and strategies to pre-empt and prevent the behaviour? Have these identified strategies been consistently and confidently applied?
• Are the incidents of physical intervention necessary? Have incidents been managed effectively by adults;
• Can alternative behaviour support strategies be applied which have not currently been attempted? i.e. Primary or secondary prevention or an alternative physical intervention.
•  

Only once all are satisfied that there are no alternatives and the use of the ERT is necessary shall the follow process begin:

1. Evidence to be gathered (Copies of Physical Intervention reports/IBSP/Placement Plan/Accident reports) and report written giving clear rationale for the need for the techniques to be used;
2. Internal professionals meeting to ensure all workers supporting the child are clear about the action why we are taking the proposed action and what strategies are being employed;
3. Proposal for a programme of training and review with a PRICE Instructor who has successfully completed the Advanced Instructor Course;
4. External professionals meeting or consultation including all relevant stakeholders to put proposals forward in which new IBSP is agreed by those with Parental Responsibility;
5. Once the proposed plan has been accepted by those with Parental Responsibility only then will the training be given to adults working with the identified child. This will make clear that the taught techniques can only be used with the identified child and then only when all other alternatives have been deemed ineffective for that specific incident. Each incident should be viewed individually and dynamically risk assessed, the use of ERT, even if included on the child's IBSP, should not be the automatic response if other, less invasive, techniques would be sufficient to keep everyone safe;
6. In exceptional circumstances, where the safety and wellbeing of children or adults is potentially at risk, training may be delivered prior to the completion of the process above. In such a situation the above process will be completed retrospectively and the outcome of this may be the removal of the use of ERT techniques where suitable alternatives can be identified.

If a child suffers from a serious pre-existing medical condition (including but not limited to the following) then a medical assessment/examination should be completed by a health care professional (GP/Nurse) to risk assess the likely impact of ERTs.

• Heart defects;
• Epilepsy;
• Asthma;
• Obesity;
• Cystic fibrosis.

The preferred/suggested techniques may be demonstrated and explained. If medical advice is against the use of the technique/response then alternative actions/strategies and/or placement should be considered.

Who can be taught ERT’s?

• Adults who are already trained in the use of PRICE techniques through the Positive Management of Challenging Behaviour Course and are deemed competent at phase 1 and 2 techniques;
• Adults who hold a current first Aid certificate;
• Adults who are deemed by the Caldecott Foundation to be of sound character to deploy such techniques.

How will the ERT’s be taught?

Teams (adults from homes and school) will only be taught specific techniques to meet the requirements of the relevant plans for individual children.

However, where the Statement of Purpose for a home allows for emergency referrals adults who regularly/primarily work within these settings may receive ERT training as part of their standard training package to ensure safety of all those likely to be coming into contact with emergency referrals. This is at the discretion of the Registered Manager in consultation with the Responsible Individual.

The ERT training will always be delivered separately to the "standard" PRICE training and by TWO instructors who have completed the PRICE Advanced Instructors course.

ERT’s will be refreshed separately, ideally every 6 months but at least annually.

Recording and Reporting

• Any use of ERT techniques will be recorded on the ERT Incident report which will be an addendum to the Physical Intervention/SLEUTH report. This is a bright orange form which clearly evidences the use of an ERT;
• The child must be offered the opportunity to see a medical practitioner following the use of an ERT technique;
• Adults must complete and record a health assessment/medical check of any child involved in the use of an ERT as indicated on the incident report. This includes checking on the child’s welfare following the intervention as follows:
  • Every five minutes for thirty minutes (six checks);
  • Every thirty minutes for the next two hours (four checks).
  • Reports must be written immediately after any incident.
• The report should be seen a member of the home’s management team as soon as possible and will be reviewed by the Senior PRICE instructor within one working day. (As with any incident any concerns or potential safeguarding issues should be reported in line with organisational policies);
• The Senior PRICE instructor should be informed immediately, via e-mail, of the use of ANY ERT. The e-mail should include the name of the child and adults involved, the time of the incident and the incident number. Any immediate concerns or injuries to any party should also be summarised in the e-mail;
• If the incident occurs over a weekend the use of an ERT should be reported to the on call manager and a copy of the report given to the Senior PRICE instructor on the next working day. In the absence of the Senior PRICE Instructor incidents should be given to another PRICE instructor who has completed the Advanced Instructors course. Where possible (e.g. annual leave) this responsibility will be designated and communicated in advance;
• Incorrect use or unauthorised use of an ERT technique on a child may result in disciplinary action being taken;
• Use of an ERT technique by an untrained adult may result in disciplinary action being taken.

Introduction

Risk

The word risk can often be interpreted or experienced as something threatening or dangerous. So, it may often be more useful and engaging to use language that reflects what we really mean, by asking people what helps them to feel safe or in what circumstances do people feel unsafe.

‘Personalised Support Assessment’?

At the point of referral, it is important for any service to gain good quality information on which to make a decision, as to whether the services provided would be suitable for the needs of the person being referred. It is about building up a picture of a person’s strengths, needs, views and aspirations.

'Strengths Assessment'?

It helps to build a unique and full picture of a person. Identifying what they have achieved and enjoyed previously (what has worked in the past); what qualities and resources they have in place (what is working for them now); and what their priorities are (what they want to do in the future).

'Strengths-Based Care/Support Plans'?

As the first part of support planning, strengths have been recognised and identified. The next task is to think about how they are to be used for the benefit of the person.

This can be through applying them to what the person wants to achieve, but also to ways of managing problems and difficulties.

Managing Concerns

As the second part of support planning, giving people a voice to express what troubles or concerns them; it can also be a means by which adults express concerns they may have about potential risks in a person's life, even where there may be disagreement about perceptions.

Focus on 'Risk History'

We cannot ignore previous risks, but neither can we misrepresent them. So, this is about producing an accurate time-line of risks, but more importantly the detail of what caused the risks. Wherever possible, this should engage the person's own perspective of what happened and why?

Positive Risk-Taking?

Literally taking risks for positive outcomes. It requires carefully considered and reasoned decision-making.

NOTE: The positive relates only to the outcome identified, not the risk itself.

A Dynamic Risk Assessment in relation to RoL?

With the above in mind, maybe it looks like this?

Risk questions to consider:

1. Who is at risk?
2. What is at risk?
3. Will the person benefit from doing what they intend to do?
4. If there is a benefit what is it?
5. Does the situation relate to any known risks in the person’s history?
6. What are the person’s own feelings and wishes regarding the possible risk?
7. Can an alternative course of action be found that has more acceptable degrees of risk?
8. How can the risk be minimised?