Agenda item 8a
Herefordshire Public Services
DRAFT v2.0
Positive approaches to behaviour that challenges (including restrictive physical interventions)
Positive approaches to behaviour that
challenges (including restrictive physical interventions)
Date of issue
Date for review
Approved by `
January 2012
January 2014 (or earlier as appropriate)
Purpose
To provide clear approaches and actions in order to promote high standards of
practice in relation to supporting adults and children that might display behaviour that
challenges.
This operational guidance document has been produced as a good practice model
and sets out how the expectations of Herefordshire Public Services (HPS) for all
providers of health and social care for adults and children must be met.
It applies to all services commissioned by or on behalf of Herefordshire Public
Services.
This document should be read alongside relevant Adult Protection / Safeguarding
procedures.
Introduction
HPS acknowledge that some people using services may require support for behaviour
that challenges, including the use of physical interventions, in order to prevent them
from harm and to protect others.
As part of their role working in health and social care services in Herefordshire, staff
may be called upon to support individuals who may challenge the service that they
use.
In these circumstances staff will require a range of knowledge, skills and competence
to enable them to work with and support service users effectively, safely and within the
law, whilst facilitating choice, control and independence.
HPS considers that physical intervention is only appropriate when it is used to prevent
harm to the person and it is a proportionate response to the likelihood and
seriousness of harm to that person or other people.
Good quality care planning and service delivery helps to minimise the situations where
restrictive physical interventions are necessary. Best practice uses de-escalation
techniques and therapeutic approaches to help a person when they are exhibiting
behaviour that challenges.
The best way of dealing with any serious situations that could lead to physical
intervention is to prevent them from happening in the first place. A proactive approach
to forseeable risks is important.
Staff will need to have a range of skills that will enable them to work effectively with
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service users and their families and prepare them for the types of difficult situations
that might reasonably be expected to arise.
Primary interventions should be in place to address a service user’s support needs in
terms of health, communication, coping strategies and the environment.
Secondary interventions should be used in an attempt to defuse, downplay, interrupt
or redirect potential triggers to prevent escalation.
Any form of restraint or restrictive physical intervention must only ever be used as a
last resort. This operational guidance document provides the necessary detail to
ensure that physical intervention is only used when necessary and then in an
appropriate manner.
This document builds upon the principles and framework set out in the HPS Policy
Statement.
Both proactive and reactive strategies must be in place to meet the specific needs of
an individual, whilst not limiting opportunities or having an adverse impact upon the
welfare or quality of life of the service user.
This operational guidance applies to any service commissioned by HPS and is
expected to be adopted by all services, unless the service can evidence an alternative
guidance document that is deemed satisfactory by the Physical Intervention Coordinator.
Duty of Care
Service users have the right to do what they want and to go where they want unless
limited by law. The inappropriate use of physical intervention is abuse and against the
law and can constitute assault, battery or false imprisonment, which can lead to
criminal prosecution.
All health and social care services have a duty of care to keep service users safe from
harm and to ensure their safety. This includes minimising the need for any restrictive
physical interventions.
There is a fine line between putting a service user at risk and enabling a service user
to make their own choices and to take reasonable risks and it is therefore crucial that
services have in place clear operational practice guidance and appropriate training for
staff.
All staff working within health and social care have a duty of care towards those they
support and to follow agreed safe systems of work and comply with this operational
practice guidance.
It is the duty of everyone to raise concerns about poor practice or inappropriate use of
any form of restrictive physical intervention and to report any such concerns in line
with current Adult Protection or Safeguarding procedures
Principles
The following principles must, at all times, underpin practice that supports individuals
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Positive approaches to behaviour that challenges (including restrictive physical interventions)
when they display behaviours that are challenging:
1.
All support provided to adults and children should be underpinned by the core
values of individuality, choice and control, dignity and respect, inclusion and
equality;
2.
Other than in an extreme emergency, the decision to use any form of behaviour
management or restrictive physical intervention must be based on individual
circumstances and in accordance with an up-to-date risk assessment and
behaviour management plan;
3.
Any form of action to manage behaviour that challenges must be in the best
interests of the service user and aimed at reducing risk, not securing compliance.
Restrictive physical interventions must not be used so that something can be
achieved more easily;
4.
Service users must be assumed to have capacity unless it is established that
they do not. This means that, unless the person does not have capacity, a
restrictive physical intervention may only take place with their consent or in
emergency to prevent harm or criminal damage;
5.
Proactive approaches should be adopted to support and prevent behaviour that
challenges, including the use of Primary and Secondary Preventions. Restrictive
physical intervention must only be used as an absolute last resort after all other
options to manage a situation have been reasonably exhausted. Under no
circumstances must techniques that rely upon pain or the use of dangerous
postures be used as a means of gaining control;
6.
On any occasion when a behaviour management action or restrictive physical
intervention is used a record must be kept and a debrief exercise carried out to
support service users and staff and to reflect and learn from the situation.
7.
Any behaviour management action, including restrictive physical intervention
must only be performed by staff that are fully trained and up-to-date.
Definitions of physical intervention
For the purpose of this Operational Guidance physical interventions are defined as:

Physical restraint – a physical restriction that prevents a service user moving
around as they want;

Physical intervention – direct physical intervention by another person which can
involve the use of techniques to physically manage individuals movements;

Denial of practical or staff resources to manage daily living;

Chemical restraint – the use of drugs and prescriptions to change a service
user’s behaviour;

Environmental restraint – designing the environment to limit a service user’s
ability to move as they might wish, including using furniture to limit movement;

Electronic surveillance – this includes tags, exit alarms on doors and television
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cameras to monitor a service user’s movement;

Medical restraint – various medical procedures impinge upon a service user’s
life – such as catheters or feeding tubes. Individuals may attempt to remove
these (for whatever reason) and people may take steps to prevent this;

Mechanical restraint – including use of straps, lap belts, bed rails etc to limit the
movement of the service user;

Forced care – restraining a service user so that care might be carried out.
For a physical intervention to carried out legally, the following criteria must be in place:
Either:

The service user has capacity and has approved that a restrictive physical
intervention can take place in agreed circumstances, or

The service user lacks capacity and it will be in their best interests, or

The service user has capacity, but it is an emergency situation to protect them
or others that might be harmed by their behaviour.
And

It is reasonable to believe that it is necessary to restrain the person to prevent
harm to them, and

The restrictive physical intervention is a proportionate response to the likelihood
of the person suffering harm and the seriousness of that harm, and

The restrictive physical intervention is used for the minimal time possible.
The use of restrictive physical interventions should only be undertaken in an urgent or
emergency where staff judge that they must intervene to protect the person, someone
else or themselves. Full risk assessments need to be undertaken and the least
restrictive action should be justified by properly trained staff.
Planning, prevention and risk assessment
There will be situations where staff can predict aggressive or violent behaviour, for
example if the service users has a history of behaving in any particular manner. Under
these circumstances there is time for proper preparation, planning and risk
assessment to utilise resources from all areas, without compromising safety.
On admission to the service and prior to the use of any restrictive physical
intervention, the following contra-indications should be considered:
Does the person have a history of:

Cardiac problems

Gastro-intestinal conditions

Recent fractures or muscular problems

Sever respiratory conditions
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
Recurrent dislocations

Hemiplegia

Recent surgery

Bone density issues

Epilepsy
Note – this is not an exhaustive listing. If any doubt exists, a medical assessment must
be undertaken for any planned physical reactive strategies.
Situations that may result in the need for physical intervention can often be prevented
by:

Close working between service users, their families, carers and staff – to assist
with information sharing, planning and advance decision making.

Increasing staff understanding of an individual’s behaviour – raising awareness
of factors that might lead to the likelihood of aggression such as pain, high
levels of arousal, abuse, confusion, poor self-esteem or inactivity.

Developing support, activity and intervention plans – based upon a formal and
comprehensive assessment, these plans should include a range of
engagement, preventative and proactive approaches geared to the needs,
preferences and interests of the individual.

Developing risk assessments – considering, documenting and mitigating
potential risks to minimise the likelihood of behaviour that can be challenging.
The use of physical interventions can be minimised by adopting primary and
secondary preventative strategies:
Primary prevention includes:

Ensuring the right number of staff with the right levels of competence are on
duty;

Person centred plans being up-to-date and responsive to an individual’s needs;

Creating opportunities for service users to engage in meaningful activities,
which include opportunities for choice and a sense of achievement;

Helping service users to avoid situations that are known to provoke episodes of
behaviour that can challenge;

Developing staff expertise in working with service users who display behaviours
that can challenge;

Talking to service users, their families and advocates, as appropriate about the
manner in which they prefer to be supported, and in particular at times when
they are displaying behaviours that can challenge;
Secondary prevention includes:
Recognising the early stages of a behavioural sequence that may develop into a
challenge or risk situation and employing non-physical defusion or de-escalation
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techniques or other agreed strategy.
All preventative strategies should be carefully selected and reviewed to ensure they
do not limit opportunities or have an adverse effect on the welfare or quality of life for
service users.
It is acknowledged that risk cannot be eliminated and positive risk taking should be
encouraged. Appropriate steps must be taken to reduce the negative impact of any
potential situation to an acceptable level. Staff will need to balance the risks of
physically intervening against the risks of what might happen if they do not intervene.
In certain situations it may be considered in the best interest of a service user to
consider the use of physical intervention as part of a risk management strategy or to
enable the provision of safe care.
A documented risk assessment should be included on each service user’s personal
file, detailing the worst reasonable outcome from a circumstance, the likelihood of this
occurring and the measures agreed to mitigate the negative outcome. The measures
should include primary and secondary preventative strategies and clear guidance on
what to do if these should be unsuccessful. The assessment must state clearly the
anticipated benefits of taking any physical intervention.
Use of PLANNED physical intervention
‘The method (of intervention) chosen must balance the risk to others with the risk to
the patient’s own health and safety and must be a reasonable, proportionate and
justifiable response to the risk posed by the (user) patient’. Mental Health Act 2007,
code of Practice, 15.19)
‘Anybody considering using restraint must have objective reasons to justify that
restraint is necessary. They must be able to show that the person being cared for is
likely to suffer harm unless proportionate restraint is used. A carer or professional
must not use restraint just so they can do something more easily. If restraint is
necessary to prevent harm to the person who lacks capacity, it must be the minimum
amount of force for the shortest time possible’. (6.44 Code of Practice, Mental Health
Capacity Act 2005)
‘A proportionate response means using the least intrusive type and minimum amount
of restraint to achieve a specific outcome in the best interest of the person who lacks
capacity. On occasions when the use of force may be necessary, carers and
healthcare and social care staff should use the minimum amount of force for the
shortest possible time. (6.47 Code of Practice, Mental Capacity Act 2005)
The use of force to manage a circumstance or to disengage from harmful physical
contact initiated by a service user will involve different levels of risk. Responses
should be pre-planned, where possible and clearly documented for staff to see.
Physical intervention must always be considered as a short term solution.
Methods should be selected carefully to impose the least restriction of movement
required to prevent harm, while attempts should continue to be made to achieve the
desired outcomes with less restrictive interventions.
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Planned physical intervention should:

Be agreed in advance by a mutli-disciplinary meeting working in consultation
with the service user and or advocate;

Be documented and incorporated into the user’s care plan or person centred
plan, with a clear explanation of when the intervention may be appropriate,
within the context of the individual’s broader personal needs;

Take into account the capacity of the service user, as well as issues of
informed consent and best interest;

Only be implemented by staff who have completed appropriate training,
accredited by BILD;

Recorded in writing so that the methods deployed and the circumstance can be
monitored and investigated, as appropriate;

Be risk assessed and aimed at reducing risk, not securing compliance;

Always be based on the minimum necessary force required.
The plan must be signed-up to and agreed by the service user and or their advocate
and a senior member of the service management team on behalf of the service.
In most situations it is likely that two staff members will be present. In this
circumstance, one person must be identified as the co-ordinator. This person will be
responsible for leading the intervention and for communicating with the service user.
Consideration must be given to the skill, confidence and availability of staff as to who
is best placed to co-ordinate during an incident. This decision must be recorded.
Where only a single member of staff is available, detailed arrangements about how
best to manage a forseeable situation must be clearly documented in a risk
assessment.
EMERGENCY circumstances
Unplanned or emergency use of physical interventions may be necessary in
unforeseen circumstances or when preventative strategies have failed. It is recognised
and acknowledged that the risks to all concerned may be greater in an emergency
situation. An effective risk assessment procedure together with well planned
preventative strategies will help keep emergency situations to a minimum.
Staff should be aware that, in an emergency, the use of physical intervention can be
justified if it is reasonable to prevent injury or serious harm. Any force used must be
reasonable and proportionate, taking into account as best possible the prevailing
circumstances.
Where possible any intervention in an emergency situation should be led by the
person most appropriately trained and skilled to deal with such an incident.
In no circumstances should pressure be applied to the neck, thorax, abdomen, back or
pelvic area. Neither should weight be placed on the service user’s chest wall or force
the head and or neck into the chest.
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Any use of emergency physical intervention must be documented, recorded on the
service user’s file and reported to the Physical Intervention Co-ordinator within five
working days of the incident.
Within 10 working days of the emergency incident the service manager is responsible
for carrying out and documenting a review of the circumstance and putting in place
appropriate strategies to minimise the risk of a repeat of the emergency situation. A
copy of the review and plan should be forwarded to the Physical Intervention Coordinator within 15 working days of the incident.
Physical care during intervention
If during the use of a restrictive physical intervention any of the following occur, then
the intervention must be terminated immediately and medical assistance sought.

Breathing difficulties (hyperventilation / hypoventilation)

Seizure activity

Vomiting

Cyanosis (blue colouration of body parts)

Mottling – paleness / yellowness of the body part

Broken bones

Other signs of medical distress
The second person in attendance during the incident is designated as the ‘Monitor’
and must monitor and record the service user’s vital signs, as far as is practically
possible. The overall physical and psychological well-being of the service user should
be continuously monitored throughout the process.
If in doubt seek medical assistance urgently.
Post intervention support
Incidents that involve behaviour that challenges and or the use of physical intervention
can be distressing and lead to a range of emotional reactions. In order to minimise any
negative impact this may have, the service must ensure that support is made available
to the service user and separately to the staff involved, with consideration given also
to others that may have witnessed the episode. This may include debriefing, providing
advice and information or enabling time-out.
Consideration must be given to providing ongoing support, as appropriate, to service
users directly or indirectly involved, staff, carers or other family members or visitors
who witnessed the incident, whether professionals or not.
Immediate support to debrief this situation should be made available and prior to staff
leaving duty. This is not a form of support that a staff member can opt out of. Service
users and others may decline this type of support.
A record of the support offered / given and by whom should be kept as part of the
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recorded information.
Staff and service users should be given separate opportunities for debriefing. It is the
service manager’s responsibility to ensure appropriate support is in place. All
discussions should take place in a helpful and supportive environment and within the
usual limits of confidentiality.
Post incident analysis of the situation should involve a discussion of why the incident
happened, what worked well and not so well, enabling a more positive proactive
strategy for the future.
The service must review the incident, reflect about how it was handled and use the
learning to inform and improve future practice. A documented learning log should be
produced and shared with staff, as appropriate – a copy should also be sent to the
Physical Intervention Co-ordinator. A record of the incident must also be noted in the
service user’s personal file and reported in accordance with health and safety
requirements.
The service user, their advocate and other key people should be involved in the post
incident analysis, either in a shared meeting or individually as suits them best.
Any concerns about the use of the physical intervention or if a service user is unhappy
about the manner in which they have been treated then the Adult Protection or
Safeguarding Procedures must be initiated.
Record Keeping
A physical intervention record must be completed for each incident and include as a
minimum:

The date, time and duration of the incident;

Antecedents - what led to the incident;

The level of aggression or violence;

What action was taken, with details of all techniques tried and used, by whom
and for how long;

What were the key stages of the intervention and the timings;

Who was in attendance and in the vicinity and what their role was;

Details of health and vital signs monitoring;

How long it took to bring the situation under control and duration of the overall
situation;

Details of any injuries to the service user, staff or others and how these were
dealt with;

The eventual outcome of the intervention;

Subsequently the details of any post incident support should be recorded for
completeness.
It is important that ambiguous terms are avoided, with a clearly detailed account of the
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incident being kept. The report must be written up within 24 hours and must be kept in
a Restrictive Physical File within the service, with access made available for the
purpose of service monitoring or quality assurance. A summary note of restrictive
physical interventions used within the service should be forwarded by the service
manager to the Physical Intervention Co-ordinator on a monthly basis to allow for
follow-up support, as appropriate.
Where an injury has been sustained during a restrictive physical intervention, this
must properly be recorded in the health and safety incident book.
Training and Implementation
All staff must be made aware of this operational guidance.
All staff working in health and social care services in Herefordshire should have
access to training, as identified through the service’s training needs analysis and risk
assessment processes. Issues in relation to behaviours that challenge is a mandatory
requirement as part of any staff member’s induction and subsequently, as appropriate.
Staff will receive training in the appropriate use of physical interventions relevant to
their work setting and the levels of risk identified at their workplace using this guidance
document.
Staff that carry out functions in relation to risk assessment, primary and secondary
prevention and positive behaviour support must have the necessary knowledge, skills
and competences to fulfil such work.
Staff that might be required or expected to carry out any intervention to manage
behaviour that challenges must be appropriately trained and up-to-date with that
training.
All staff employed within this service will have been designated as someone who can
or cannot use restrictive physical intervention in an agreed and planned manner, in
line with documented approach for an individual service user. A list of staff approved
to use restrictive physical intervention must be kept up-to-date at all times.
For those staff designated as approved, training must be provided to the extent of any
likely intervention. For some this may simply awareness, for others it may mean
comprehensive breakaway and hold manoeuvres.
All training in relation to restrictive physical interventions must be delivered by an
Approved Training Centre that is accredited to deliver such training in accordance with
the current BILD code of Practice.
It is the responsibility of service to ensure that only trainers that are suitably qualified,
skilled, experienced and competent are permitted to deliver the required training.
Participants on any form of physical intervention training must be deemed competent
by the trainer before they are authorised to carry out any form of intervention. The
trainer will maintain a record of trained staff and make this available to the Physical
intervention Co-ordinator.
All staff that are trained to carry out restrictive physical interventions must also be
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appropriately trained to administer emergency medical support. Correct procedures
must be taught during training, with emphasis on monitoring vital signs.
Further information

Guidance for Restrictive Physical Interventions – Department of Health, 2002

BILD Code of Practice for the use and reduction of physical interventions, Third
Edition, 2010
In addition to the guidance above there is a range of legislation that applies to physical
intervention. This includes:

The Human Rights Act 1998

Health and Safety At Work Act 1974

Care Standards act 2000 (Amended 2005)

Mental health Act 1983 (Amended 2008)

Mental Capacity Act 2005

Health and Social Care Act 2008

The Deprivation of Liberty Safeguards 2009

Criminal Law Act
Further advice, information or guidance can be obtained from the Physical Intervention
Co-ordinator.
The Physical Intervention Co-ordinator is responsible for updating HPS
Commissioners on policy development, relevant health and safety information and upto-date sector guidance.
Review
This document has been produced on behalf of Herefordshire Public Services to
ensure that all services providing health and or social care services in Herefordshire
have a consistent and acceptable approach to managing behaviours that challenge.
A review of the content will be carried out every two years on the date identified on the
front page, unless amendments or changes are required in advance of that date.
The Head of Improvement within the People Services Directorate will ensure this
document is reviewed and updated appropriately.
th
AJH / 30 January 2012
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