New Directions
Joint Learning Disability Service
Positive Behavioural Approaches to
Challenging Behaviour including safe
management of
Challenging Behaviour
Unique identifier
PACB
Master Document Held by:
Issue Date:
November 2011
Review Date: November 2013
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Policy Statement
The learning Disability services of Salford support people who from time to
time display behaviours that challenge. These services include home
environments, community settings, short break and day service settings. The
introduction of the government’s white paper Valuing People A New Strategy
for Learning Disability for the 21st Century and Valuing people Now 2009 have
built upon the existing relationships and working partnerships between health
& social services and the voluntary & independent sector. This policy will
provide a framework, which will support the development of local policies,
within the identified organisations, in relation to supporting people with
learning difficulties, who present with behaviours that challenge.
This policy aims to ensure safe practice within the area of challenging
behaviour, people with autism and learning Disability, without compromising
the rights, dignity and respect of the individual people we support. The policy
also aims to invite everyone in services to provide better person centred
plans, and communicate and deliver services in a more effective way and
enable people to remain living in Salford or return to live in Salford. The use of
positive approaches to challenging behaviour ensures that the person as a
whole is supported rather than just the behaviour e.g. underlying health
issues, quality of life.
People who have a learning Disability and behaviour’s that challenge will be
prioritized and will not be excluded from locally based services, however,
their existing service provision may change following assessment / review of
the person’s needs.
The aim of this policy is to provide a safe working environment for staff
members and to optimize the quality of therapeutic care offered to the people
we support within the learning difficulties service.
The purpose of the policy is to provide a foundation to provide learning
Disability services to provide support to people with challenging behaviour
using positive strategies but where necessary on a small number of occasions
due to the risk of harm restrictive physical intervention strategies need to be
implemented, where this is necessary staff should be using best practice to
provide a safe environment for people supported and staff.
Any restrictive physical interventions used must have been taught using a
BILD accredited model, and be the decision of a MDT including parents /
career’s, that it is least restrictive; it must be reviewed on a regular basis.
There may be times when restrictive physical interventions are used without
assessment these must be in emergency situations where the person
supported or others are at serious risk of injury in these incidents this must be
reported through safeguarding adult’s procedure
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Services in Salford start from the principle that behaviour has meaning.
Challenging behaviours occur for a reason and meet a need for the person
supported. Main reasons can include; traumatic past experiences, poor
quality of life and lack of stimulation, previous experiences of getting needs
met following incidents of challenging behaviour and difficulties
communicating verbally, un identified health need
Services will be locally based in Salford and be commissioned around an
individuals assessed need.
It is suggested that services use the benchmarking tool included within this
policy on at least quarterly to help services identify areas of good practice but
also opportunities for development within their services supporting people with
challenging behaviour.
A Co-coordinator will be appointed for people who have a learning Disability
and behaviours that challenge. This is to ensure that their support needs are
met effectively and appropriately and that appropriate reviewing structure is in
place.
Through a careful person centred behavioural assessment we can usually
identify the reason challenging behaviours are occurring. This will lead to
changes in the way the person is supported that will reduce their need to use
behaviours that challenge.
People require support to enhance their quality of life in relation to
relationships, community participation and daily living skills and require
significant density of preferred activities on a daily basis.
Any Interventions used, must be non-judgemental and non-punitive.
In response to the Human Rights Act 1998 all Restrictive physical intervention
methods used will not involve “inhuman or degrading treatment.”
Any interventions will be in accordance with current legislation including
Mental Capacity Act 2005 and associated Deprivation of liberty safeguards
Breakaway and / or Restrictive physical intervention will never be used as a
form of punishment, to inflict pain, discomfort or control of a person supported.
Use of Breakaway and / or restrictive physical intervention is a last resort
when all the other guidelines/procedures have been followed.
Any form of restrictive interventions within individuals support plan/guidelines
must be regularly reviewed and where possible looked to be reduced in there
restrictive nature, the guidelines must have clear proactive and reactive
strategies and all strategies must not be used to punish or withhold services
Support plans and guidelines will be in place to lessen the need for
interventions.
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Any prescribed Breakaway and Restrictive physical intervention techniques
must be assessed, planned, evaluated and implemented in conjunction with
M.D.T. IN order to maintain the best interests of the person supported.
It needs to be recognised that specific intervention may have to be agreed
and implemented to ensure the health and safety of the person or others,
which the individual may not agree with. These must be documented in the
care plan.
Staff need to ensure people supported have a good quality of life
incorporating a range of home and community based activities as identified in
their support plans and there should be significant density of preferred
activities.
Staff must ensure where appropriate individuals have a HAP (Health Action
Plan)
Any concerns that individual staff may have about the support their team is
providing or being asked to provide must be highlighted to their manager
immediately, if staff feel this is not possible then they must contact the
Learning Disability community team and share their concerns, immediately
1. Policy implementation
1.1 Currently all training related to the implementation of the policy is provided
free to any service that signs up to the policy, accessing free training is only
available whilst services are implementing the policy as outlined in section 6,
if a service is not meeting the standards then access to free training will be
reviewed.
1.2 The following training will be provided free to all staff who are supporting
people with learning disabilities who are from Salford.




Behaviour Awareness Training (requires staff to attend update every 2 years)
Breakaway Training (requires staff to be updated every 12mths)
Restrictive Intervention Training (requires staff to be updated every 12mths)
1st Line Manager training
1.3 The provision of free training is to be reviewed every 12 months.
1.4 If any major changes occur to the policy a training event will be facilitated.
1.5 Only staff supporting individuals with Restrictive Intervention Training in
their support plans should be trained in these techniques. The addition of
these techniques needs to follow a very clear structure as identified in section
two.
1.6 The Training team is managed by consultant clinical psychologist and
Clinical Nurse specialist for Challenging behaviour
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
1.7 Annually each service that has signed up to the policy will be sent a list of
all of their staff that had been trained during the previous 12 months, this time
period will run as of 2012 April to March
1.8 Any theory training needs to be on the use of positive behaviour
approaches to support people with challenging behaviour and not based any
forms of punishment or with holding services, the training will enable services
to develop proactive guidelines to support individuals.
1.9 Individual’s services must develop and submit their own local procedure.
1.10 Individual services must ensure that both the policy and local procedure
are part of their induction.
1.11 Breakaway and Restrictive physical intervention will be targeted training
to specific staff groups where individual support plans state the need for
training. Behaviour awareness training is available to all staff from Salford
supporting individuals with learning difficulties.
1.12 Any theory training needs to be on the use of positive behaviour
approaches to support people with challenging behaviour and not based any
forms of punishment or with holding services
1.13 Within Salford the model currently use for breakaway and restrictive
physical intervention is the CITRUS model (Creative Intervention Training in
Response to Untoward Situations) this model acquired BILD accreditation in
January 2009.
1.14 Any service that is providing or receiving a form of restrictive intervention
training is required to partake in an annual Audit of techniques, to ensure the
only the most appropriate techniques are being used and staff have training in
relation to the audit results.
1.15 All training sessions which teach breakaway or restrictive physical
intervention techniques must be provided within the BILD code of
conduct for trainers
1.16 Training must occur in an appropriate venue which must have been risk
assessed for its suitability, the Clinical Nurse Specialist for Challenging
behaviour must approve all venues for training following receipt of risk
assessment.
1.17 If any other model of restrictive physical Intervention is used by services
provided in Salford this must be a BILD accredited model and agreed with the
Challenging behaviour strategy group.
1.18 If services are delivering their own training then copies of all relevant
paperwork and policies needs to be forwarded to the Challenging behaviour
Strategy group for monitoring including teaching plans and evidence that
trainers are still accredited.
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
1.19 No techniques, which involve neck holds or putting pressure on people’s
airways must be used, Excess weight must not be placed on any one
particular area especially the neck or stomach
2 Restrictive Interventions
The service will undertake an annual audit of all restrict practices in services
based in Salford, including the holding of data around individuals and their
restrictions for the following areas , Mechanical restraint, Restrictive physical
interventions and use of PRN medication for behaviour management. All
services signed up to the Positive approaches policy must partake in the
yearly audit.
2.1 Mechanical Restraints
If any requests are made for any form of mechanical restraints e.g. splints,
additional equipment to be added to wheelchairs needs to follow the process
as described needs to be followed as per figure 1
If it is agreed via the best interest meeting, then it should also be
accompanied with a therapeutic plan on how to look to reduce any level of
restrictions. It is also required that any additional equipment either added to a
wheelchair or used as a separate piece of equipment needs to be reviewed
formally every six months. At the best interest meeting then there must be
somebody from the team providing the equipment present (e.g. orthotics for
splints.)
Any individuals who have existing mechanical restraints as part of their
support plans need to go through the same best interest-meeting route. This
does not mean that everyone’s equipment will be removed immediately, but it
is expected alongside any best interest decision that a therapeutic plan is
devised and implemented with the aim of reducing the restrictive nature of the
equipment e.g. length of time equipment is used
2.2 Medication
Where individuals are prescribed any PRN medication as part of their agreed
support plan i.e. it must be accompanied by separate guidance on the
administration of the PRN, including max number of doses over agreed time
period, when the medication regime will be reviewed, circumstances that the
medication can be administered, cross references to individual service
medication policies and actions to be taken if significant amounts of PRN are
used over a small number of days
Any use of covert medications used in the management of challenging
behaviour needs to be extensively evidenced as to its benefits. Any covert
medication needs to be clearly recorded in the person’s support plan and
agreed by a MDT (multidisciplinary team) including the person`s GP.
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
The administration of any covert medication should be clearly highlighted in
organisations medication policies, and any covert medication must be
declared via the annual restrictive practices audit.
2.3 Restrictive Physical Interventions by staff
People supported with any form of restrictive intervention must have this
clearly recorded in their support plan. The support plan must highlight why the
interventions are required, the risks if interventions are not used, reviewing
structure and proactive strategies that are being used to reduce the number of
times any physical intervention is required.
If the person has already restrictive intervention in their support plan
managers need to ensure that the support plan has the previously mentioned
sections.
If the person has or it is felt requires any form of restrictive interventions then
a health questionnaire must be completed for that individual
2.4 Emergency Interventions
The emergency use of restrictive physical interventions should only be used in
circumstances a person’s behaviour presents significant risk to self or others
and had not been previously identified via assessment process.
There is an increased risk of injury if emergency restrictive physical
interventions are more likely to lead to injury than planned restrictive physical
interventions, and staff need to be able to justify their actions
Any use of emergency use of restrictive interventions must be reported via
adult safeguarding policy.
If an staff have had to use an emergency restrictive intervention then an
urgent review of the individuals support plan needs to occur and serious
consideration need to take place as to if the individual needs the restrictive
intervention as part of their support plan
An effective risk assessment procedure together with well planned prevention
strategies will help keep use of unplanned restrictive physical interventions to
a minimum.
Before using a restrictive physical intervention in an emergency or as part of
an individuals support plan, staff involved should be confident that the
possible adverse outcomes associated with the intervention will be less
severe than the adverse consequences that might occur without the use of a
physical intervention.
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Request is made for Additional
equipment
Added to existing equipment
(e.g. wheelchair)
clinical Assessment is
Required to ensure there is
a clinical need for
equipment
Postural assessment result
Is that equipment has NO
clinical requirement i.e.
behavioural need
Clinical need
Postural assessment result
is that equipment has
Clinical need
Capacity assessment
Carried out
Capacity assessment
Carried out and best interest
meeting
If required
Before equipment is supplied
Then best interest meeting
Must be held if the person lacks
capacity
Equipment Supplied
The following individuals must be part of
the best interest meeting. Appropriate
advisor form service providing equipment
LD physio Individuals co-ordinator
Family/IMCA Service
Best interest meeting agrees
That it is appropriate for the
Equipment to be supplied
And it is a restriction
Best interest meeting decides
intervention is a deprivation of
liberty
Best interest meeting agrees
equipment is not necessary
If equipment to be supplied
the guidelines/support plans
also need to be provided
Individual lives in registered
residential service refer to local
DOLS team for assessment
Individual lacks capacity and lives in
supported living or family setting
Discussion to be had with legal team
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
3.Challenging Behaviour Pathway and strategy group
Since May 2009 the service has followed the challenging behaviour pathway
to help guide services and individuals through the support structures that are
available to services who are supporting individuals with challenging
behaviour. It is important that all staff and providers follow the pathway, as
this will ensure any support is offered in a structured and timely manor.
Person supported has Challenging Behaviour as per definition in Challenging
behaviour policy found in section 12
Discussion with service Challenging Behaviour lead
takes place and advice put in place for appropriate
support and advice, review of current guidelines and
support plans to ensure they are clear for staff to
follow
Staff have attend Challenging
behaviour consultation
Staff have attended Behaviour
awareness training
Person supported has had full health check,
including review of medication
Referral via LDHP, discussion about
referral has been had with service
Manger
Service has signed up to
Challenging behaviour
policy 2011
Staff are completing ABC forms,
and any other incident forms as
required by their service
Individual has current up to date
assessment and support plan and
identified co-ordinator
Service has developed appropriate
guidelines including the use of
PRN guidance
Discussion at
weekly LDHP
meeting
Discussion at
weekly Clinical
psychology meeting
To support and oversee the implementation of this policy the service will hold
five Challenging behaviour strategy meetings per year. With the purpose of
monitoring the implementation of the policy but also devising any future
changes in line with local, regional and national guidance.
The strategy group will have membership from commissioning, providers reps
including the independent sector, and appropriate members from Allied health
professions.
The strategy group will also request information as appropriate but as a
minimum standard all providers must submit on a quarterly basis the following
information
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Number of accident/incidents
Number of injuries to individuals and staff
Number of incidents that have been reported via Adult Safeguarding policy
Number of times breakaway techniques have been used
Number of times restrictive interventions have been used
Number of time PRN medication has been used in relation to Challenging
behaviour
To assist services supporting individuals with challenging behaviour, there will
be a series of challenging behaviour consultation sessions held every two
months. These are open sessions for people to attend to discuss any early
concerns they have about an individuals behaviour, support with changes to
guidelines.
If following discussions at the consultation session members of the
consultation panel have concerns, they will arrange to visit the service as
appropriate.
4 Service Responsibilities
4.1 This policy is applicable to all levels of staff working within the identified
organisations in Salford learning Disability services.
4.2 Each organisation will be responsible for the development of their own
local challenging behaviour procedure in accordance with this policy
framework
4.3 Each organisation will be responsible for the development and training of
their own staff in any local procedure that is developed and implemented.
4.4 Each partner organization will be required to complete a risk assessment
and care plan before any prescribed restrictive physical interventions, which
must be reviewed by the manager at least every six months
4.5The Challenging behaviour strategy group requires all services to complete
the core competencies benchmarking tool on an annual basis
4.6To ensure that this process of self evaluation of core competencies is
effective a random sample of services will be checked in person by a
member(s) of the Challenging behaviour Strategy group, each service will be
given 3 days notice of this random check
4.7 The training team will undertake an audit of all services who have signed
up to the policy, this audit will be in relation to the services implementation of
the policy and it’s responsibilities, this data will be presented to the
challenging behaviour strategy group
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
4.8 Only staff working within Salford are to be nominated for training, if it is
found that staff are working with people supported not originally from or living
in Salford the service has the right to charge the service for this training at
rates comparable to other training providers
4.9 Members of the training team must be delivering training within Salford
and have agreed to adopt this policy or equivalent in their own working
environment
4.10 Under Health and Safety at Work and RIDDOR legislation, you have a
legal obligation to report any incidents. This needs to be done as soon after
the incident as possible.
4.11 If any form of breakaway or restrictive physical intervention is required
then this must be recorded on the Use of restrictive physical Intervention
form, and a copy sent to the co-coordinator/manager
4.12 Services must maintain a list of any intervention that may be seen as
restrictive or lead to a possible deprivation of liberty. Where practices are
seen as restrictive then there must be a best interest meeting held before any
changes to support plan are implemented, if practices are seen as possibly
causing a deprivation than advice needs to be sought and consideration of the
use of the court of protection or other legislative processes.
4.13 services must have very clear whistle blowing polices that support staff
to report any concerns immediately of any colleagues practice which may
concern them.
4.14 Incident monitoring is a system whereby senior managers have an
overview of incidents/accidents on a regular basis and from this areas
that need addressing merge. This system has been developed with
Community, health and social care (CHSC) provider services. It is now
planned to extend this monitoring system to all provider services in
Salford.
4.15 If individual services have robust systematic methods with senior
managers reviewing incident/accidents already in place then they may
continue utilising it and support will be provided by the CB strategy to
ensure that it meets the objectives set by the CHSC system
4.16
Nominate managers to attend 1st line managers training course
4.17 Since 2009 all staff who have attended behaviour awareness,
breakaway or restrictive physical interventions training are stored on a
database, which will be made available to services at their request to confirm
staff attendees
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
5 Manager’s responsibility
5.1. Managers are accountable for ensuring this policy is implemented so that
all staff are aware of the contents of the policy.
5.2 Managers are requested to ensure appropriate staff are identified and
given access to relevant education and training.
5.3 Managers must ensure that any person supported, assessed as requiring
restrictive physical interventions has a completed health screen form, which is
signed by appropriate medical professional
5.4 Managers’ need to monitor supported people range of offered and
participated activities and offer guidance/support to staff teams to ensure
people supported are involved in a range of activities with depth of
experiences
5.5 Managers are responsible for ensuring that all staff that work with people
supported who have breakaway or restrictive physical interventions in their
support plan attend training every 12 months. Staff whose training is out of
date increase the risk of injury or inappropriate use of techniques
5.6 It is recommended that all staff attend behaviour awareness training every
2 years and it is the manager’s responsibility to nominate as required
5.7 To ensure staff nominated attend the course, and any cancellations or
changes to participants are made at least 48 working hours prior to the
commencement of the course. Any cancellations may result in charges to that
service.
5.8 If staff use restrictive intervention on individuals without this being within
their support plan this must be reported via Salford’s adult safeguarding
policy.
If physical restrictive techniques have been used as an emergency, then it’s
the manager’s responsibility to ensure appropriate action is taken to either
agree with MDT, including the co-ordinator the addition of techniques or other
suitable strategies.
5.9 It is not appropriate for staff to use the emergency principle more than
once and would be considered a breach of policy if this was to be the case.
5.10 Individual support plans will be written up and reviewed with any plans
needing Breakaway and / or Restrictive physical intervention being monitored
by managers
5.11 To investigate where appropriate in line with adult safeguarding policy
any areas of concern raised by their staff.
5.12 Managers should know who their challenging behaviour lead is, when
CB consultations are and be able to direct staff to them
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
6 Individual Staff responsibilities
6.1 Staff should always use proactive strategies whilst providing support
6.2 To familiarise themselves with policy and work within its boundaries.
6.3 To attend relevant training courses, i.e. Behavioural Awareness,
breakaway, restrictive Physical intervention Training.
6.4 All staff have the responsibility to use only the prescribed technique that
has been taught and is documented in the care plans of the people they
support.
6.5 Staff are responsible for the implementation of agreed behaviour
management plans and risk assessments
6.6 Staff must use a graduated response when working with people who
challenge
Use of proactive positive strategies at all times if incident occurs then
De-escalation must be attempted first
Followed by prescribed Breakaway techniques
Consideration of use of PRN medication to prevent restrictive physical
intervention should be considered
Only as a LAST RESORT will restrictive physical Intervention techniques
be used as per individuals support plans
6.7Staff taught in the techniques will not teach other staff the techniques
6.8Support staff are responsible for reporting any disagreements with the
behaviour management plan and / or any positive or negative changes to its
effectiveness / appropriateness, during a specified period of time, to their line
manager
6.9To take part in debrief sessions with manager and regular 1:1 supervision
6.10To discuss with their line manager any issues in relation to the use of
restrictive physical intervention techniques.
6.11Staff to use supervisions sessions to discuss concerns or issues to
identify if they require extra support or training.
6.12Staff must report any concerns regarding a colleague’s practice and
inappropriate use of restrictive physical intervention.
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
6.13When staff have received training in breakaway or restrictive physical
interventions this training must be update every 12 months. It is the
responsibility of individual staff to highlight to their manager when they are
due to be updated. If staff have not attended an update after 12 months then
the training has lapsed and are not deemed to be a safe user of the
techniques
6.14 Staff need to have understanding and knowledge of how to use own
services’ whistle blowing policy.
7 Training for Parents and PA’s
To support the development and implementation of the personalization
agenda, the service will offer training to PA (personal assistants) on an
individually assessed basis. This will be discussed with the individual’s
coordinator and commissioner to devise an appropriate package for the PA’s
so that an agreement around governance issues including monitoring
processes is set out
Over the last five years the lack of available of training available to parents
has been highlighted as a national issue, to further build on the training
currently offered in training it is proposed to link in with both national and
regional programs to parents to supplement the training offered by Salford
learning Disability services.
The service will continue to offer behaviour awareness training for parents
and careers, and in a small number of cases where risk issues are assessed
as being significant then breakaway training will be provided
Since 2011 the service has also provided breakaway and behaviour
awareness for people supported and this will continue with their managers
taking the responsibility for the governance as per section five
8 Breaches of policy
8.1 Breaches of policy should be dealt with via individual service human
resource policies and where appropriate safeguarding adults procedure
8.2 Breaches related to services not meeting the service specifications for the
policy as set out in section 6 will be dealt with via consultation with Clinical
Nurse Specialist, Consultant clinical psychologist and LD commissioners and
Adult Safeguarding Team
8.3 Serious breaches of the policy may require reporting to CQC or other
regulating bodies
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
9 Summary
This policy provides a framework that aims to protect the safety of both people
supported and staff. In the event of an issue arising that is not adequately
covered by this policy, then further advice/guidance should be sought.
Decisions or actions taken that are not inline with this policy, but that the
manager or professional team agrees are appropriate should be recorded in
the person supported care plan with a clear rationale as to why the action has
been taken.
Agencies that adhere to this policy are:














New Directions Joint Learning Disability Service
Salford City Council CHSC LD provider service
Salford NHS
Home focus
Life opportunities
Caring Hands
Pathos
Creative Support
Living Ambitions
IAS
Paragon
United Response
Paragon
Northern Care
10 Bibliography
BILD, 2010 Code of Practice for the use and reduction of restrictive physical
interventions (2010) BILD
Carr, E, Dunlap, G, et al Positive behavior Support: Evolution of an applied
science, Journal of Positive Behavior Interventions, Vol 4, No 1 pages 4-16
Department of Health, 2000, Domiciliary Care National Minimum Standards,
Care Act 2000, Department of Health
Dept of Health 2005, Mental Capacity Act 2005, Department of Health
Department of Health, 2008, The Mental Capacity Act Deprivation of Liberty
safeguards, Department of Health
Donnellan, A, LaVigna, G, et al, 1988, Progress Without Punishment:
Effective Approaches for Learners with Behavior Problems, IABA, USA
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Emerson, 1995, cited in Emerson, E (2001, 2nd edition): Challenging
Behaviour: Analysis and intervention in people with learning disabilities.
Cambridge University Press
Home office Department, 2000, Human Rights Act 1998, Home office
Department
Harris,J, Cornick,M, et al 2008,Physical Interventions: a policy framework,
BILD
LaVigna, G, Willis, T, et al 1993, The Periodic Service Review: A Total Quality
Assurance System for Human Services & Education, IABA, USA
National Patient Safety Agency, 2004, Understanding the patient safety
issues for people with learning disabilities, National Patient Safety Agency
NMC, 2002, The recognition, prevention and therapeutic management of
violence in Mental Health Care, NMC
Pitonyak, D, 2005 10 Things You can Do to support a Person with Difficult
Behaviours, Dimagine, USA
Whitehead, R, et al 2011, Encouraging Positive Risk Management:
Supporting Decisions by People with Learning Disabilities using a Human
Rights-Based Approach, Self-harm and Violence: Towards Best Practice in
Managing Risk in Mental Health Services, first Edition (Ed) Whittingham and
Logan, John Wiley & Sons, Ltd
Winterbourne View, BBC Panorma May 2011
11 Further information
Further information can be obtained by contacting:
New Directions
Salford Learning Disability
Turnpike House,
631 Eccles New Road,
Salford,
M50 1SW
Telephone Number 0161 793 2460
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
12 Terminology
Challenging Behaviour
Refers to ‘behaviour of such intensity, frequency or duration that the physical
safety of the person or others is likely to be placed in serious jeopardy, or
behaviour that is likely to seriously limit the use of, result in the person being
denied access to, ordinary community facilities’ (Emerson, 1995). These
include:
Violence that is directed toward other people (Emerson, Barrett, Bell et al,
1987; Harris and Russell, 1989; Emerson, 1995) and violence that is less
clearly targeted and arises from distress, confusion or panic are often
managed with a restrictive physical intervention.

Self-directed violence or self injury is another relatively common form
of challenging behaviour associated with the use of restrictive physical
interventions. Examples include hitting the head with a clenched fist, banging
the head against hard objects, skin picking and eye gouging.

Behaving with a reckless disregard for their own safety or for the
safety of others, (e.g. by wandering across busy roads or persistently setting
fires) may result in people being subjected to a restrictive physical
intervention.
Breakaway techniques
Breakaway techniques are designed to facilitate escape without causing pain
or unnecessary distress to the person supported, they are non-aversive.
Breakaway involves a variety of skills, which range from de-escalation and
calming to freeing yourself from grabs and holds.
Although physical contact may be required to escape during an incident
Breakaway
Techniques are not designed to contain behaviour and so are distinct from
restrictive physical intervention techniques
Restrictive physical intervention
Refers to the actions by which one person restricts the movements of another.
Examples include holding another person by the arm, tying someone to the
bed or chair, using a splint to limit the movement of an arm or leg and locking
a door so that an adult or child cannot leave a room. Restrictive physical
intervention involves limiting a person’s freedom of movement and continuing
to do so against resistance. It is, therefore, qualitatively different from other
forms of physical contact such as manual prompting, physical guidance or
support that might be used in teaching or therapy.
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
In some settings a staff or therapists may use a blend of prompts, physical
guidance and, for short periods of time, restrictive physical intervention, to
assist a person in completing an exercise or learning a skill. However, in such
circumstances, if restrictive physical interventions were to be sustained
against resistance over a period of more than a few seconds, the fundamental
character of the activity would have changed from ‘therapy’ or ‘teaching’ to
one of ‘managing challenging behaviour’. Urgent consideration would need to
be given to the sequence of events leading up the challenging behaviour and
it is unlikely that repeated use of a restrictive physical intervention would be
considered the most appropriate response. Because restrictive physical
interventions are intrusive, often distressing and potentially harmful, they
should always be considered a ‘last resort’ response to challenging behaviour,
to be employed only after other approaches have been fully explored.
It is helpful to distinguish between emergency interventions or unplanned
interventions that are used on the spur of the moment without previous
preparation or discussion, and planned interventions that implement agreed
procedures in response to anticipated incidents and clearly defined
behaviours. While there may be rare occasions on which emergency
interventions are appropriate, the emphasis in this book is upon preparation
and planning to ensure that, as far as possible, restrictive physical
interventions are always used in the best interests of the service user.
There are three broad categories of restrictive physical intervention:
1.
Direct physical contact between a member of staff and a service
user
Examples include:
 Using manual guidance to prevent someone wandering into a busy main
road
 Holding a person’s hand to stop stereotyped movements
 Holding a person’s arms and legs to prevent them from attacking someone
2.
The use of barriers, such as locked doors, to limit freedom of
movement
Examples include:
 Placing a child in a chair with a desk in front so that they cannot easily
stand up or move away
 Placing door catches or bolts beyond the reach of service users
 Locking doors
3.
Materials or equipment that restrict or prevent movement
Examples include:
 Strapping someone into a wheelchair
 Tucking sheets into a bed so that movement in restricted
 Placing splints on a person’s arms to restrict their movement
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Autism
Is a term used to describe a spectrum of conditions that arises during infancy
or childhood, which are characterised by impaired social interaction, delayed
or deviant language development, and a preference for sameness as shown
by stereotyped play patterns, abnormal preoccupations or resistance to
change. Autism often occurs in association with learning Disability, but can
also be present without any additional intellectual impairment. In addition,
many children and or young people who have a diagnosis of autism may
present with complex sensory impairments, including hypersensitivity or
hyposensitivity to touch or pain, which has particular relevance for restrictive
physical interventions.
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Section 13: Appendices
Restrictive practice audit
CB do’s and don’ts
Debrief form
People supported health questionnaire
Core competencies doc
Signing sheet
Policy acceptance record
Use of restrictive intervention’s form
ABC Form
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Implementation of Positive approaches to challenging
behaviour including the use of restrictive physical
intervention
To be completed by all service managers
Name of Service
Date policy / procedure /
guideline implemented
Do you have a local /
service specific procedure
for implementing the
policy /
Please answer Yes or No
Yes 
No 
Signed ……………………………………………
Date ………………………………………………
Designation ………………………………………
A copy of this form is to be forwarded to challenging
Behaviour Strategy group
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Use of Restrictive Practices Intervention Form
Date of Accident/incident:
Time of accident/incident:
Accident/incident form number:
Name of person completing form:
Witness name: (If applicable)
Designation:
Address:
Base:
Tel No:
Other people present in environment?
Names:
Which de-escalation techniques were used prior to the use of Restrictive physical
intervention?
Were breakaway techniques used, if so which ones:
How long in minutes did restrictive
physical intervention last? If any form of
physical intervention is used specific
details need to be recorded including
individual staffs actions
Is this intervention documented in the clients
care plan? Yes/no
Has support plan/risk assessment/guidelines
been reviewed following incident yes/no
If the manager of the service needs to record
the reason no changes were required
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
PRN medication administered? Yes/no
Name of meds:
1st Dose:
2nd Dose:
3rd Dose:
Time administered:
(please record times for all doses given)
Factual description of incident:
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Do’s & Don’ts of dealing with Challenging Behaviour.
Do’s
Don’ts
Do keep records
Do look at the care plan
Do keep risk assessments up-to-date
Do liaise with the MDT
Do be aware of the environment triggers
Do seek guidance and support
Do be aware of personal triggers
Do GET TO KNOW people supported
Don’t face a difficult situation on your own
Don’t speak too fast
Don’t stare at a person supported
Don’t lose your temper
Don’t SHOUT
Don’t ignore the person supported
Don’t ignore the behaviour
Don’t restrain on your own
Do be aware of non-verbal
communication
Do appear calm
Do keep your distance
Do remove other service users and
others from potentially volatile situations
Do use distraction methods
Do CARE
Do listen to the people supported feelings
Don’t restrain if property has been damaged
and there is no danger to others
Don’t PANIC
Don’t take it personally
Don’t breach confidentiality
Don’t stand over a service user
Don’t PATRONISE
Don’t forget to keep up to date with current
best practice
Do attend relevant training courses
Don’t get trapped in a corner
Do attend relevant refreshers
Don’t use medication as a control measure
Do refer to the relevant guidelines
Don’t use punishment
Do ensure that there is an escape route Don’t forget to fill out an incident form
available to you
Do ensure that you have someone else Don’t touch people aggravated or distressed
ready to intervene
Do ensure that incidents are reported to Don’t attempt to take weapons off of service
the relevant manager
users
Do carry appropriate identification
Don’t be rough
Do keep talking to the service user
Don’t try to do it all on your own
Do keep reassuring them
Don’t be ‘too busy’ to attend courses.
Do share your concerns with others
Don’t pat people
Do reflect upon your own practice
Don’t make assumptions
Do give choices
Don’t forget to update individuals guidelines
Do provide a way out of a situation
Do look at the before & after of incidents
Don’t use accusatory language
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Strictly Confidential
Health Assessment for Restrictive Physical Interventions
Name of Person Supported……………………………………………….
Date of Birth………………………………….Age…………………………………
Date of Last Health Assessment for Restrictive Physical
Intervention…………………
Please answer the following questions regarding any conditions, injuries or
illness that may affect the person supported well-being during approved
restrictive physical intervention techniques.
Are you aware if the person supported has, or is currently suffering from, or
undergoing investigations for any of the following conditions?
a) Any heart condition (including angina or high/low blood pressure)?
YES/NO
b) Any chest condition (chronic bronchitis or asthma)?
YES/NO
c)
YES/NO
Any neck, shoulder, knee, hip or any other musculo-skeletal trouble
(e.g. brittle bones, arthritis, joint replacements)?
d) Any back problems (including any sort of pain or discomfort)?
YES/NO
e) Any skin trouble (Dermatitis, Eczema, Psoriasis, Rashes)?
YES/NO
Any “blackouts” fainting attacks, Diabetes or Epilepsy?
YES/NO
f)
g) Down’s Syndrome?
YES/NO
h) Any major operations in past 5 years (or awaiting similar operations
to be carried out)?
YES/NO
i)
Any sensory impairment?
YES/NO
j)
Is the person excessively overweight/underweight for his/her
height? BMI score
YES/NO
k)
Any other medical condition or injury that may be affected by
restrictive physical intervention?
YES/NO
Please attach copy of individuals risk assessment and support plans relating
to the use of restrictive interventions
Please attach any meeting minutes in relation to best interest meeting that
have occurred prior to the restrictive interventions being in place or of the
review of the individuals risk assessment or support plan have been review
If the answer to any of the above questions (a-k) is YES, advice must be
sought from the service user’s GP or Consultant Psychiatrist, if applicable,
with regard to health implications prior to the use of any planned restrictive
physical interventions.
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Advice sought from GP
Doctor
Name of Practice
Advice Given
DATE:
Advice from other source
NAME OF PERSON:
TITLE:
Advice Given
SIGNATURE:
DATE:
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Team Debrief Form Following an Episode of Challenging Behaviour
Staff member undertaking de brief:
Date of incident:
What happened?
Which intervention was used (if any)?
What could we have done differently?
What have we learnt?
How do we feel following the incident?
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Further support offered to staff involved (e.g. counselling, occupational health etc.)
Learning outcomes to be discussed / shared at future team meetings.
Date:
Signed by person carrying out the debrief:
Signed by staff undertaking debriefing:
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services
Core Competencies for Services for People with Challenging Behaviour
Service Self Assessment Document
Service Outcome
Evidence
Score
+/0
The organisations value statement specifically mentions positive behavioural approaches to
challenging behaviour
1. Organisational values, policies and
practices reflect positive behavioural support.
Each person using the service has a person centred plan and health action plan
Every person supported has had recorded annual review within the last 12 months
2. The service adopts a constructional
approach to the provision of services.
(Goldiamond).
People are taking part in activates that develop their skills.
3. Work effectively with families and others
of importance to the person.
There is evidence of appropriate involvement of family members in the person’s life.
There is evidence of relationships with people not paid to be in the person’s life.
Job descriptions incorporate skills and roles that are in line with positive behavioural
approaches to challenging behaviour.
People with learning difficulties are involved in recruiting their staff.
4. Demonstrate recruitment, induction and
appraisal procedures that ensure that staff
are able to work in line with those values,
policies and practices.
5. Provide staff with training on positive
behavioural support.
6
Provide staff with training on the
specific needs of the people they
work with.
There are examples of service changes designed to promote control for people supported.
Personal development plans/ Appraisals for staff identify development actions that will
enhance staff skills in positive behavioural approaches to challenging behaviour
All staff have an introductory training to positive behavioural approaches to challenging
behaviour in their induction.
Within 1 year they will have more in depth training enabling them to support the development
of positive behavioural approaches to challenging behaviour plan.
First line manager level staff have attended further training in relation to positive behavioural
approaches to challenging behaviour
Staff training covers all identified health needs including medication.
Staff training covers supporting people’s relationships.
Staff training cover how to support people in meaningful activities.
- Positive Behaviour Support policy, including safe management of challenging behaviour in Adult learning Disability Services
Target
Date
The entire staff team must have completed
the training
7. Effectively support peoples individual
communication skills.
8. Organise structured programmes of
meaningful activity for people.
9. Organise activities in ways that promote
the development of new skills.
10. Implement multi-element intervention
strategies.
11. Use person centred risk management
approaches.
12. Maintain systems to monitor
performance and quality.
13. Provide regular supervision to staff.
14. Provide post incident support to people
with learning Disability and staff.
15. Keep records that preserve the persons
Staff training covers what is essential in the person’s life.
Staff training covers the support the person needs with daily living activities including travel.
People supported have a live communication passport.
Staff are trained and implement in the Total communication
There is clear evidence that total communication is being used with the individuals home
People supported who are non-verbal have augmented communication systems including
electronic speech systems.
The service uses a flexible rota planning system.
Each person has an individual activity plan that is monitored and reviewed.
Activity plans include some things that can be without supervision wherever possible.
People supported have range of community and home based activities undertaken on weekly
basis
Staff use a graduated support approach when promoting involvement.
The level of support the person requires for each activity is clearly identified.
Staff have training skills in teaching.
Managers use resources including staff to meet the plan.
Strategies in use by the service have proactive as well as reactive elements.
Strategies promote good quality of life not just reductions in behaviour.
Strategies include clear recording and monitoring arrangements.
The service has clear risk management plans.
The plans should reflect what is important to the person as identified in their PCP.
The service has key performance indicators around the needs of each person supported.
Achievement of these is recorded and feedback provided to staff.
Staff receive supervision at least 10 times per year and this is recorded and signed by both
participants
Actions are set and followed up.
Occupational health services are available.
Counselling service is available
Staff should be offered debriefing before the end of their shift or at earliest opportunity with
their line manager
Post incident support for people with learning difficulties should be identified within their care
plans.
The person supported life stories that are accessible to the service user and regularly
- Positive Behaviour Support policy, including safe management of challenging behaviour in Adult learning Disability Services
and the services history in an accessible
form.
16. Keep records that support the process of
assessment.
17. Use non-aversive forms of reactive
management.
18. Work within the BILD guidelines on the
use of physical intervention.
19. Work within the Royal College of
Psychiatry/Mencap guidelines on the use of
medication for challenging behaviour.
20. Safeguard the welfare of the people they
work with.
Results
updated.
The records should include a regularly updated chronology of significant life events.
There is a regularly updated chronology of key developments in the service.
Staff are able to contribute to the assessment process.
Staff are able to record the frequency, duration and intensity of behaviours.
Staff have had training in completion of incident/ABC forms
All staff are completing incident/ABC forms to satisfactory standard
Staff are able to conduct structured and objective observations.
Staff are skilled in a range of non-aversive reactive strategies.
The use of physical intervention is in line with the BILD guidelines including the use of
accredited physical intervention model
 The use of medication for challenging behaviour is in line with the RCP/Mencap
guidelines (Birmingham University).
Recruitment is in line with the Independent Safeguarding Authority Guidelines including
recruitment and selection policy
Suspected abuse is dealt with in line with local safeguarding procedures.
The service has an effective whistle blowing policy.
Maximum number of +
Service Team score
(divide your number of + by 58 and multiple by 100)
58
KEY
PCP Person Centred plans
HAP Health action plan
To complete the competency document score the service as follows if it is in place and achieved the enter +, if currently it is not in place the enter 0 (This
means an opportunity for your service or team to improve). Once all sections have been scored then you will be able to get an overall percentage score but
will also have identified areas for continual work, in research undertaken in the USA by the IABA, good teams usual score about 42% on the first audit but
quickly can achieve 85% and higher.
- Positive Behaviour Support policy, including safe management of challenging behaviour in Adult learning Disability Services
A.B.C. CHART
- Positive Behaviour Support policy, including safe management of challenging behaviour in Adult learning Disability Services
Name:
Date of incident
Date of Birth:
Time:
Behaviour
(Description of the event)
Consequence
(What happened after the event?)
Please use the statements below as a guide
Please use the statements below as a guide
Please use the statements below as a guide
Where did the behaviour take place? What
happened immediately before the behaviour?
Did the person supported say anything?
What time did the person supported start
Describe exact behaviour.
What happened immediately after behaviour?
What did you do ?, What did you say? Did you
give the person supported anything? Did you
spend time with the person supported? Did the
person supported appear calmer after the
behaviour?, Any other information ?
Antecedent
(What happened before the event?)
becoming agitated? What activity was the
person doing? How many people were
present?
- Positive Behaviour Support policy, including safe management of challenging behaviour in Adult learning Disability Services
Signed ……………………………………………….
Managers Signature…………………………………Date…………………..
- Positive Behaviour Support policy, including safe management of challenging behaviour in Adult learning Disability Services
POLICY SIGNATORY RECORD
The following proforma should be completed by all staff after they have read
the policy
The reason this needs to be completed is to:
This is a useful tool to use at team level to ensure all your team has read and
implemented the policy.
Method of monitoring policy for challenging behaviour strategy group
Line managers should ensure all the staff have signed the policy record and
should retain a copy for their own records the policy should be re-read and
signed every 12 months as a maximum
Staff signatures are taken as an agreement of understanding and
compliance
Staff Signature and job title
Date
Organisation
Line Manager
NB the completed signatory lists maybe requested by the Challenging
behaviour strategy group for audit purposes.
- Positive Behaviour Support policy, including safe management of challenging behaviour in
Adult learning Disability Services