RESTRICTION AND RESTRAINT IN ADULT CARE POLICY

Restriction and Restraint in Adult Care Policy Version: 3.2 Date of Issue: 13 December 2019 Review Date: 12 June 2022 Page 1 of 28

RESTRICTION AND RESTRAINT IN ADULT CARE POLICY

Version 3.2

Name of responsible (ratifying) committee Safeguarding Committee

Date ratified 29 November 2019

Document Manager (job title) Head of Safeguarding and MH

Date issued 13 December 2019

Review date 12 June 2022

Electronic location Clinical Policies

Related Procedural Documents

Rapid Tranquilisation Guideline

Mental Capacity Act and Deprivation of Liberty Safeguards Policy

Prevention and Management of Aggression and Violence

Restrictive Physical Intervention and therapeutic holding policy for Children and Young People.

This policy includes the Use of Mittens.

Key Words (to aid with searching) Vulnerable adult, violence and aggression, mental capacity, Restraint

Version Tracking

Version Date Ratified Brief Summary of Changes Author

3.2 01/02/2021 Due to the second wave of the Coronavirus pandemic and continuing exceptional circumstances, the Trust Board have agreed that all

policies which are currently within review date will have their review date further extended by six months

-

3.1 09/04/2020 Alterations to the policy to take into account the provisions of the Coronavirus Act 2020

J.Haines

3 29/11/2019 • Clarification re roles and responsibilities in an episode of restraint

• Removal of the use of speed-cuffs

• Insertion of a debrief/SWARM template

• Insertion of a Risk Assessment Tool to be used by the Person in Charge

• Addition of MCA and Best Interests Assessments

Sarah

Thompson


CONTENTS

QUICK REFERENCE GUIDE ............................................................................................................. 3 1. INTRODUCTION ......................................................................................................................... 5 2. PURPOSE ................................................................................................................................... 5 3. SCOPE ........................................................................................................................................ 5 4. DEFINITIONS .............................................................................................................................. 6

4.1. Mental Capacity .................................................................................................................... 6 4.2. Deprivation of Liberty Safeguards (DoLS) ............................................................................. 6 4.3. Best Interests ........................................................................................................................ 6 4.4. Restraint ............................................................................................................................... 6 4.5. Manual Restraint ................................................................................................................... 6 4.6. Mechanical Restraint ............................................................................................................ 7 4.7. Chemical Restraint ............................................................................................................... 7 4.8. Imminent Danger .................................................................................................................. 8 4.9. Person in Charge .................................................................................................................. 8 4.10. De-brief/SWARM .................................................................................................................. 8 4.11. Hand Mittens ........................................................................................................................ 8 4.12. Bed Rails .............................................................................................................................. 8

5. DUTIES AND RESPONSIBILITIES ................................................................................................. 9 5.1 The Chief Executive .............................................................................................................. 9 5.2 Chief Nurse ........................................................................................................................... 9 5.3 Deputy Chief Nurses/ Divisional Nurse Directors/ Head of Safeguarding .............................. 9 5.4 Medical Staff ......................................................................................................................... 9 5.5 Sisters/Charge Nurses, Matrons, Senior Lead Nurses .......................................................... 9 5.6 The member of staff identifying the violent or aggressive behaviour will: ............................ 10 5.7 The Person in Charge will: .................................................................................................. 10 5.8 The Operational Security Manager (Engie) will: .................................................................. 11 5.9 The Local Security Management Specialist will: .................................................................. 12 5.10 Incident Review Panel will:.................................................................................................. 12 5.11 Security Advisory Group will: .............................................................................................. 12 5.12 Safeguarding Committee will: ............................................................................................. 12 5.13 Quality and Performance Committee .................................................................................. 12

6. TRAINING REQUIREMENTS ....................................................................................................... 12 7. REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................. 12 8. EQUALITY IMPACT STATEMENT ............................................................................................... 13 9. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS ........................................... 14

Appendix A – Hampshire Toolkit - Mental Capacity Assessment ................................................... 15 Appendix B – Hampshire Toolkit – Best Interests Assessment ...................................................... 16 Appendix C – Potential Risk of Restraint and Risk Assessment .................................................... 17 Appendix D - Risk Assessment ..................................................................................................... 21 Appendix E - SWARM: ................................................................................................................. 24 Appendix F: Care Plan for the Use of Restraining Therapy ........................................................... 26

Equality Impact Screening Tool ......................................................................................................... 27


QUICK REFERENCE GUIDE

Use of restraint will be reasonable, proportionate and used only when necessary for the shortest period possible

Prediction:

1. Risk assessment of patient history and current warning signs should feed into a prediction of risk. Risk factors such as delirium, affects of alcohol/drugs, confusion, communication difficulties all increase the risk of challenging behaviour.

Prevention:

2. All reasonable adjustments must be made to reduce the risk of escalating behaviour, considering environmental and physical factors. Planning where there is a known risk should start as early as possible (ideally pre admission for elective patients).

3. Use of the Portsmouth ‘Forget-me Not’ document and the Learning Disabilities Hospital Passports can help identify the appropriate reasonable adjustments in order to optimise care and also identify effective de-escalation techniques on an individual basis.

4. The Enhanced Care and Observation (ECO) Assessment document can also be used to identify level of risk and potential strategies to mitigate these risks.

5. All efforts must be made to avoid the use of restraint by the effective application of de-

escalation techniques. Management:

6. For patients assessed as having capacity, staff can exercise restriction and restraint if they reasonably believe it is necessary to prevent the person from harming others and that it is a proportionate response to the likelihood of the person causing harm and the seriousness of that harm.

7. For patients assessed as lacking capacity, staff can exercise restriction and restraint if they reasonably believe it is necessary to prevent the person coming to harm or harming others and that it is a proportionate response to the likelihood of the person suffering/causing harm and the seriousness of that harm.

8. Restriction and restraint cover a potentially wide scope of practice and interventions which can be applied through various methods e.g. use of psychological means (telling someone they can’t do something), physical, chemical, guiding, use of mittens and bed rails.

9. Where the restraint is a repeat issue then Deprivation of Liberty Safeguards should be in place unless the patient is being detained under the Mental Health Act.

10. Emergency physical and/or chemical restraint carries risks to the patient and staff and can

only be applied by trained and competent persons if there is evidence of the person behaving in a way that:

a. poses an imminent risk of danger to those in the immediate vicinity, e.g. other patients and/or members of staff.

b. means they are unable to receive urgent medical attention.

11. Physical restraint can only be applied by security staff that are trained and assessed as competent in the use of restraint.


12. Chemical restraint (rapid tranquilisation) can only be prescribed and administered by a suitably trained member of medical or nursing staff.

13. In the event of the application of physical or urgent chemical restraint, post incident a Safety

Learning Event (SLE) form must be completed by a member of the medical or nursing staff. A Use of Force form completed by the Security Team should be added to the SLE.

14. It is acknowledged that staff involved in restraint incident on staff may require a debrief after the incident and this should be encouraged and should include the multi-disciplinary team, including the security team if required.


1. INTRODUCTION

Portsmouth Hospitals NHS Trust (PHT) is committed to delivering the highest standards of health, safety and welfare to its patients, visitors and employees. The Trust believes that the management of challenging behaviour is an activity requiring humanity and respect for the rights of the individual, balanced against the risk of harm to themselves, staff and members of the public. Restricting or restraining any behaviour should only be used when it is proportionate and reasonable to do so. However, it is recognised that violent and aggressive behaviour can escalate to the point where physical or chemical restraint may be needed to protect the person, staff or other legitimate users of Trust premises and facilities from significant injury or harm, even if all best practice to prevent such escalation is deployed. Restraint is a last resort intervention and will only be considered when all other practical means of managing the situation, such as de-escalation, involvement of family where appropriate, verbal persuasion, voluntary ‘time out’, or gaining consent to taking medication, have failed or are judged likely to fail in the circumstances. The self respect, dignity, privacy, cultural values, race and any special needs of the patient should be considered in so far as is reasonably practicable. In the event of the application of physical or urgent chemical restraint a Safety Learning Event (SLE) must be completed by a member of the clinical staff and a Use of Force form completed by a member of the Security Team must be attached to the SLE. Used inappropriately, some restraint may be classed as a form of abuse or assault and if unreasonable may lead to investigation. If restraint of any kind is used it should be carefully recorded in the patient records and monitored.

2. PURPOSE

This policy provides guidance in relation to the nature, circumstances and use of approved restriction and restraint techniques currently adopted by the Trust. Its aim is to help all involved act appropriately and in a safe manner, ensuring effective responses in difficult situations. It sets out a framework of good practice, recognising the need to ensure that all legal, ethical and professional issues have been taken into consideration.

3. SCOPE

The policy applies to adults (people aged 18 years and over). (For children and young people please refer to the Restrictive practice Policy for Children and Young People). The policy includes all staff and persons within Portsmouth Hospitals NHS Trust regardless of contract type. It applies to others who are acting on behalf of the Trust, including contractors, students on placement and volunteers.


4. DEFINITIONS

4.1. Mental Capacity see Appendix A – Hampshire Toolkit Mental Capacity Assessment

The Mental Capacity Act 2005 sets out the legal definition of the status of an individual who lacks capacity. A person will lack capacity if they are unable to make a decision because of an impairment or disturbance in the functioning of the mind or brain.

To make a decision the person must be able to:

• Understand the information relevant to the decision

• Remember that information

• Weigh up that information in making a decision

• Communicate their decision The MCA permits the use of restraint if it is necessary to protect from harm and proportionate to the likelihood and seriousness of harm and it is the least restrictive option.

4.2. Deprivation of Liberty Safeguards (DoLS)

A deprivation of liberty occurs when the person is ‘under continuous supervision and control and is not free to leave’. It should be applied for if the person is trying to leave, lacks capacity re accommodation and requires restraint.

4.3. Best Interests see Appendix B – Hampshire Toolkit Best Interests Decision Making

Any action carried out on behalf of someone who lacks capacity must be in their best interest. In deciding best interest consider:

• Past and present wishes.

• Any beliefs and values that influence how they would make their decisions themselves.

• The views of the family and friends.

• The views of the professionals involved.

• How the decision will affect the person, their health and welfare, their comfort and pleasure and their future experience.

• Any restrictions on the persons freedom that may be necessary to carry out the decision.

4.4. Restraint

“Restraint is an intervention that prevents a person from behaving in ways that threaten to cause harm to themselves, to others, or to property.”

4.5. Manual Restraint

“Any manual method such as guiding, hands on etc. that immobilises or reduces the ability of a person to move his or her arms, legs, body or head freely.”


Manual restraint considerations Only as a last resort should Patients be restrained on the floor. Do not use a manual restraint in a way that interferes with the patient’s airway, breathing or circulation, for example by applying pressure to the rib cage, neck or abdomen or obstructing the mouth or nose. Do not use manual restraint in a way that interferes with the patient’s ability to communicate for example by obstructing eyes, ears or mouth. Undertake manual restraint with caution and extra care if the patient is physically unwell, disabled, pregnant or obese. Aim to preserve the patient’s dignity and safety as far as possible during manual restraint. As a guideline restraint should be no longer than 10 minutes. If this is exceeded justifiable actions must be recorded. Ensure that the level of force applied during manual restraint is justifiable, appropriate, reasonable and proportionate to the situation and applied for the shortest amount of time possible. One clinical staff member should lead throughout the use of manual restraint. This person should ensure that other staff members are:

• Able to protect and support the patient’s neck and head if needed.

• Able to check that the patient’s airway and breathing are not compromised.

• Able to monitor vital signs.

• Supported throughout the process.

• Monitor the patient’s physical and psychological health for as long as clinically necessary after using manual restraint.

4.6. Mechanical Restraint

Any material or mechanical device such as hand cuffs, leg restraints, spit hoods etc. that immobilises or reduces the ability of the person to move their arms, legs, body or head freely. The use of hand mittens and bed rails are the only form of mechanical restraint advocated by the Trust following a risk assessment. Mechanical restraints such as handcuffs will only be utilised by the Police/Prison Officer chaperoning the person and when in use the Police/Prison Officer must be in constant attendance.

4.7. Chemical Restraint

A drug or medication used to manage a patient’s violent or aggressive behaviour. Administration if necessary may be given against the persons wishes if they lack capacity and it is deemed in the patient’s best interests. Such drugs may of course be used with patients consent and may (with the persons consent) be used in circumstances in which treatment or harm is less immediate, for example, when caring for people with Dementia or other long term conditions.


4.8. Imminent Danger

Any situation or practices in a place of employment which are such that a danger exists which could reasonably be expected to cause death or serious injury.

4.9. Person in Charge

The most senior or appropriate person in an area/ward who takes responsibility for managing a threatening situation.

4.10. De-brief/SWARM

Term used generically as a way of describing the need for the person, staff and others to take ‘time out’ to reflect on the situation that has occurred and learn from it, ideally within 24 hours following an incident.

4.11. Hand Mittens

These are a safe form of restraint which restrict movement after looking at all of the least restrictive options. These are sometimes utilised (following a formal process) to reduce the patients tactile ability, always used in conjunction with discussion with next of kin.

4.12. Bed Rails

Should only be used when a risk assessment within the Care Plan has been completed and their use is to maintain safety of the patient.

Unacceptable Methods of Restraint

Elevated bed height – It increases the risk of injury resulting from a fall out of bed. Patients are occasionally nursed on low beds to reduce the risk of harm should they fall. A low bed is acceptable when appropriately risk assessed. This includes raising the patients legs above the patient hips which for some patients may stop them being able to get out of bed due to the position of the bed. Wheelchair safety straps The straps on wheelchairs should always be used. However these are used for patient safety and not as a means of restraint. Reclining chairs Reclining chairs should be used for the purpose of patient comfort and not as a method of restraint. Locked doors Doors should not be locked in an acute care setting. Coded locks and push button exits are excluded. Arranging furniture to impede movement Any equipment/furniture included is to be used for its intended purpose only. Using furniture to impede movement increases the risk of falls through trips. Removal of walking aids, outdoor shoes and sensory aids such as spectacles/hearing aids This can cause confusion and disorientation and increases the risk of patient harm from falls. Further details regarding the potential effect of restraint can be found in Appendix C.

.


5. DUTIES AND RESPONSIBILITIES

5.1 The Chief Executive

• To ensure the provision of adequate resources to enable effective implementation of this policy

• To maintain effective reporting mechanisms into the Board in connection with this policy

5.2 Chief Nurse

• To ensure the provision of adequate training resources to enable the effective implementation of this policy

• To monitor decisions made under the management of challenging behaviour in adults at risk

• To create and maintain effective reporting mechanisms to the Board in connection with this policy

5.3 Deputy Chief Nurses/ Divisional Nurse Directors/ Head of Safeguarding

• To manage and organise Divisional resources to enable effective implementation of the policy which may include provision of extra staff or security staff on some shifts for some patients. It must be determined on an individual basis if the patient requires the presence of a clinical member of staff or a security officer.

• To monitor and review divisional performance in connection with this policy.

• To report issues related to the implementation of this policy via the divisional governance structure.

• To ensure all staff are compliant with training in the use of restraint.

5.4 Medical Staff

• Liaise with Nursing Staff to identify and review the level of restraint.

• Prescribe and administer chemical restraint medications.

• Involvement in the debrief.

5.5 Sisters/Charge Nurses, Matrons, Senior Lead Nurses

• To work together with medical staff and the MDT team to identify, instigate and review the level of any physical restraint used.

• To ensure any restraint used is amended appropriately according to the patients needs.

• To carefully consider requests for additional resource to assist in alleviating constraints as a result of challenging behaviour incidents.

• Agency or bank staff should not routinely be allocated to provide the role of the person in charge.


• In the presence of a security officer a qualified member of the nursing team or clinician constitutes must assume overall responsibility for the patient.

• To ensure Safety Learning Event Forms (Datix) are completed including the ‘dropdown’ restraint section. They are then reviewed and action plans implemented immediately.

• To ensure the SWARM template is completed on all incidents of restraint.

• To assess whether methods of post incident support including referrals for more formal debrief or counselling for staff are needed.

• To ensure staff attend mandatory training on this subject.

5.6 The member of staff identifying the violent or aggressive behaviour will:

• Report the incident to the Person in Charge of the area.

• Wherever possible and if it safe to do so move other patients away from the vicinity.

• Attempt to diffuse and deescalate the situation by reassurance and other acceptable methods for example diversional activities.

• Ensure removal of harmful objects from immediate vicinity of the patient.

5.7 The Person in Charge will:

• Ensure that wherever possible de-escalation techniques are used throughout a restraint process.

• To avoid prolonged physical intervention / immobilisation (no longer than 10 minutes), consider rapid tranquillisation (which may be safer where appropriate) as an alternative.

• Take responsibility for any restraint that takes place and conduct the risk assessment of the circumstances that will determine whether restraint is appropriate and justified – see Appendix D – Risk Assessment.

• If considered necessary request assistance from security in the first instance via 2222. If staff are in fear for their safety, the Police should be contacted stating ‘We are in fear of our safety’

• Have a sufficient understanding of restraint processes, of the law and of the policy to ensure a satisfactory outcome for all involved.

• He or she should ensure that the restrained person’s ➢ head and neck is appropriately supported and protected. ➢ airway and breathing are not compromised. ➢ vital signs (pulse, BP and RR) are monitored.

• For safety reasons, during a restraint it is only permissible to hold / apply pressure to the person’s limbs. Avoid and direct pressure being applied to the neck, thorax, abdomen, back or pelvic area.

• Avoid restraining persons on the floor. If, however, the floor is used then this should be used for the shortest period of time and only for the purpose of gaining reasonable control. In the rare and exceptional situations where the restrained person needs to be


held in a face down prone position, this should be for the shortest possible time to bring the situation under control.

• The level of force applied must be reasonable, necessary and proportionate to a specific situation, and be applied for the minimum possible amount of time (no longer than 10 minutes).

• Any person subject to restraint must be physically monitored throughout the incident. Post-restraint, the person who has been restrained will be reviewed for placement on the appropriate observations level, for a period of up to 24 hours. During this time physical observations must be recorded and the observing nurse be fully aware of the possibility of restraint/positional asphyxia.

• Where it is believed that we are depriving someone of their liberty completion of both an urgent and standard DoLS authorisation should be completed and sent to [email protected]

• Inform and involve appropriate medical staff with appropriate urgency.

• Ensure a care plan is in place whilst the patient is receiving restrictive practice and remember to regularly assess the need for continued clinical oversight.

• Arrange for family, friends or carer to be contacted / be involved if it is thought they may have a calming influence on the person.

• Ensure the incident is reported via the Safety Learning Event (SLE) in accordance with Trust policy.

• Ensure the SWARM template (see Appendix E) is completed as part of a debrief within 24 hours. The patient involved in the incident should be offered the opportunity where appropriate to contribute to the immediate debrief and discuss the incident with a member of staff, an advocate or carer.

• Ensure the operational Security Team provide a Use of Force Form to attach to the SLE.

• Ensure Care Plan document is completed and filed in patient records (Appendix F).

5.8 The Operational Security Manager (Engie) will:

• Ensure the Service Level Agreement (SLA) between the Security provider and the Trust is achievable, and report any deficiencies in the agreement to his/her line manager at the earliest opportunity.

• Provide appropriately trained security staff to respond, support and assist hospital staff where there is potential or actual violence and aggression.

• Liaise with relevant external agencies as appropriate.

• Be involved in the de-brief and any subsequent follow up activity.

• Provide regular updates to the Security Advisory Group (SAG).

• Ensure operational security involvement in planning the Trust response to an expected situation where the need for restraint is considered probable.

• Ensure all security staff are fully aware of the Trust Policies & Procedures relating to Aggression, Violence and Harassment (AVH)

• Discuss with the Trust any changes in legislation or guidance around restraint and any changes to working practices.

• Identify training needs of operational security staff in relation to restraint.

• Ensure all security staff apply a uniform approach to any request for restraint.

mailto:[email protected]

mailto:[email protected]


• Operational Security staff to complete a Use of Force form to be made available as an attachment to the SLE.

5.9 The Local Security Management Specialist will:

• Ensure the Security Advisory Group is aware of any use of force in restraint incidents, the outcome and any learning that needs to take place.

• Identify from incident data and risk assessments all high risk areas and support managers to implement appropriate arrangements.

• Provide liaison and support to the Trust Solicitor, Police and Crown Prosecution Service (CPS) as necessary.

• Liaise with Police, CPS and external agencies in accordance with Secretary of State Directions and the Security Management standards for providers.

• Be part of the de-brief and any subsequent follow up as required.

5.10 Incident Review Panel will:

• Review all uses of Mechanical Restraint

5.11 Security Advisory Group will:

• Monitor compliance with this policy regarding control and restraint, and provide reports to the Restrictive Practice Group where deficiencies are identified.

• Receive detailed reports on all incidents where restraint is used, and agree action as required.

5.12 Safeguarding Committee will:

• Monitor overall compliance with this policy.

• Review any incidents arising due to inappropriate application of physical or rapid chemical restraint.

5.13 Quality and Performance Committee

The Governance and Quality Committee is responsible for ensuring that appropriate action is taken to ensure the effective implementation of policies, and will monitor the use of this policy via Safeguarding Committee reports.

6. TRAINING REQUIREMENTS

• All clinical staff will be made aware of the practice guidance in the prediction, prevention and management of escalating behaviour by their line manager through use of this policy.

• All identified staff must be compliant in the use of restraint as part of the Level 2 Mental Health Training Strategy.

• Operational Security staff will be trained and assessed as competent in the application of the control and restraint techniques adopted by the Trust.

7. REFERENCES AND ASSOCIATED DOCUMENTATION

Rapid Tranquilisation (Adults) Policy– found in drug therapy guidelines


Mental Capacity Act 2005 (includes DoLS) 2019

Aggression and Violence from Service Users 2019

CQC Interim Report: Review of restraint, prolonged seclusion and segregation May 2019 Reducing the need for restraint and restrictive intervention HMGov June 2019 Human Rights framework for restraint E&HR Commission March 2019

Restrictive Physical Intervention and Therapeutic Holding Policy for Children 2019

8. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This policy has been assessed accordingly. Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do. We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust: Respect and dignity Quality of care Working together Efficiency This policy should be read and implemented with the Trust Values in mind at all times.


9. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assurance compliance.

Minimum requirement

to be monitored

Lead Tool Frequency of Report of Compliance

Reporting arrangements Lead(s) for acting on Recommendations

Incident data will be monitored by the Mental Health and Capacity Board, Safeguarding Committee and Security Advisory Group

MH & C Board

Datix reports

Quarterly Security Liaison Group, Safeguarding Committee reports to the MH & C Board and feedback to relevant Divisional Management Teams.

Divisional Teams


Appendix A – Hampshire Toolkit - Mental Capacity Assessment (Click on image to open and complete PDF and record in Patient Notes)


Appendix B – Hampshire Toolkit – Best Interests Assessment (Click on image to open and complete PDF and record in Patient Notes)


Appendix C – Potential Risk of Restraint and Risk Assessment

The use of chemical or clinical holding can potentially cause adverse physical and psychological consequences (Micek et al (2005) Nirmalan (2004) and Watson, (2001). In physical terms these include:

• Aspiration pneumonia

• Muscle atrophy

• Loss of bone density

• Nosocomial infection

• Strangulation

• Tachycardia and hypertension

• Pressure ulcers

• Limb injury

• Incontinence

Psychological effects include:

• Cognitive decline

• Emotional isolation

• Confusion and agitation

• Increased agitation and anxiety

• Depression and anger

• Loss of dignity and personal freedom to the patient

• Distress and feelings of shame for family members

Health care practitioners are responsible for ensuring that risk assessments are carried out on the use of restraint. Before the application of restraint an individual assessment should be carried out to consider:

• The environment

• Patient’s behaviour

• Patient’s underlying condition and treatment

• Patient’s mental capacity

• Duty of care

Often behaviour such as wandering is problematic for staff; however this does not necessarily mean that preventing this behaviour is in the best interests of the patient concerned. Having identified the reason for the behaviour, appropriate strategies should be discussed with other members of the multidisciplinary team and if applicable treatment of the underlying cause. This should be documented in the nursing/multidisciplinary notes with referral and discussion with the patient’s consultant and family members (where appropriate).

Treat Underlying Condition

Understanding a patient’s behaviour and responding to individual needs should be at the centre of patient care. All patients should be assessed comprehensively in order to establish what sort of therapeutic behaviour management might be of benefit.


This will involve identifying the underlying cause of the behaviour (agitation, wandering, absconding etc.) and deciding whether the behaviour needs to be prevented. Possible causes to consider are:

• Hypoxia

• Hypotension

• Pyrexia

• Full bladder or bowel, constipation

• Pain or discomfort

• Electrolyte or metabolic imbalance

• Anxiety or distress

• Drug dependency or withdrawal

• Brain insult/injury or cerebral irritation

• Reaction/side effect of medication

• Intoxication (due to alcohol, drug overdose or drugs of abuse)

• Hallucinations, delusions, paranoia and personality issues

• Infection

• Dehydration

• Malnutrition

• Mental illness

• Delirium

If a patient’s mental health is an issue, the Mental Health Services can be contacted for advice/support.

Therapeutic Approaches and Management Strategies

Therapeutic approaches used to reduce confusion and agitation includes a positive environment and good communication skills. Every effort should be made to reduce the negative impact of the environment which may include poor attitudes or poor communication skills of staff. Examples of environmental factors which can have a negative impact include: extreme staffing shortages impacting on quality of care or levels of supervision, restricted observation in patient areas, high levels of noise or disruption, boredom or lack of stimulation for patients.

Environment Strategies

• Provide a visible clock

• Minimise excessive noise and light

• Maintain a day-night routine

• Maintain a consistent Unit temperature

• Facilitate rest periods and also periods of patient activity

• Use diversional therapy – provide television/radio

• Use reminiscence with familiar objects from the patient’s own home e.g. photos

• Reduce monitoring and lines as far as is practically possible

• Cluster care to avoid repeated disturbances.

• Wherever possible reduce the number of bed moves, particularly later in the day.

Communication Strategies


• Engage the patient in meaningful activity – ask the patient and/or relatives and carers what the patient likes to do, what they would be doing if they were at home etc.

• Orientate patient to time, person and place

• Reality orientation – use of diaries and memory aides

• Communicate clearly and concisely with the patient

• Provide repeated verbal reminders

• Identify and correct any sensory impairments i.e. glasses and hearing aid

• Maintain a patient’s dignity

• Use empathetic communication and touch

• Involve a patient’s family and friends in care

• Ensure continuity of staff

• Where the patient has known mental health issues or learning disability issues, refer them to the appropriate health care teams

• Provide communication aids

• Do not argue with a patient with dementia

• Consider the use of the Portsmouth Forget me not document to describe ‘ what matters to me’ and use the information to understand potential triggers that may cause agitation and take steps to reduce.

Clinical holding should only be used as a last resort and only when alternative methods of therapeutic behaviour management have failed, perhaps consider the risk of “doing something versus the risk of doing nothing”. Its use should be proportional to the risk of the situation. The method used should be the least restrictive and be effective and safe. Inappropriate use of restraint may be viewed as a form of abuse. Restraint needs to be reasonable and proportionate; otherwise staff may face allegations of assault. Staff have a moral obligation to do no harm; they need to balance the risks and benefits associated with all forms of restraint. Decisions should therefore balance the best interest of the patient to ensure safety and promote the patients well-being and safeguard their interest. When all other alternative therapies have failed and as a last resort, it is deemed that there are situations where it would be seen as lawful to use reasonable force to restrain a patient. These are:

• To prevent self-harm or risk of physical injury

• Where staff are in immediate risk of physical assault

• To prevent dangerous, threatening or destructive behaviour

• To provide necessary assessment/treatment deemed in the patient’s best interest

Any clinical holding used by a health Care Professional is a potential exploitation of a patient’s rights under the Human Rights Act (1998). Consequently Health Care Professionals, patients and their families may feel uneasy with the adoption of clinical holding. However, Health Care Professionals also have a responsibility to act in the ‘best interests’ of an incapacitated patient and thus protect them from harm. Once the decision has been made to implement clinical holding the risk assessment and care plan should be followed.


Discontinuation of Clinical Holding Having implemented clinical holding the healthcare team must continually monitor for physical and psychological adverse effects. If the risks outweigh the benefits, then clinical holding must be stopped immediately. The effect of clinical holding or pharmacological restraint should be evaluated throughout, utilising the specified care plan (appendix F).The restraint should be discontinued at the earliest opportunity. This may be because the patient’s behaviour no longer renders the need for clinical holding or that the clinical holding has worsened the patient’s agitation. Reasons for discontinuation should be clearly documented.


Appendix D - Risk Assessment RISK ASSESSMENT RECORD & CLINICAL DECISION MAKING TOOL WHEN CONSIDERING THE USE OF RESTRAINING THERAPIES This record must be used in the assessment, monitoring and evaluation of any patient who may require physical or chemical restraint in order to maintain the patient’s own safety or to protect patients and staff from harm. However, restraint must applied in the event of an emergency in the first instance and always in the best interests of the patient.

Does the patient behaviour have potential to endanger? (please tick, may be more than one)

No

Restraint

Inappropriate Staff Self Others

Describe this behaviour: (this may be a combination of factors) Yes No Wandering and may decide to leave the ward Falling more than once Confused and / or disinhibited Agitated / aggressive (may accidentally remove lines/tubes, climbing out of bed) Resistive to assessment / treatment

OR

Repetitive removal of non life-threatening medical devices (please tick, may be more than one)

Potential removal of any one of these life sustaining devices/treatments

IVI Peripheral Dressings CPAP Chest Drain

NGT O2 Mask Inotropes Arterial Line

Catheter PEG CVP ICP Monitoring

Drains Epidural EVD/Lumbar drain Tracheostomy

Strategies to consider Yes No

Review drug therapy

Diffuse situation/use of minimum of staff

Utilise verbal de-escalation techniques

Remove harmful objects

Involve family or significant others

Provide orientating stimuli (clock, newspaper, radio)

Utilise enhanced care (1:1)

Diversional activities (music, T.V.)

Optimise environment

Identify any Reversible Causes and Treat

Pyrexia, Hypoxia, Pain

Withdrawal (nicotine, drugs, alcohol

–CIWA score) Bowel/Bladder

Fear, anxiety

Communication, memory

impairment

Name…………………………………………

Hospital No………………………………….

NHS No………………………………………

Consultant……………………………………

Date…………………………………………..

Yes


Is the assessing nurse able to maintain patient safety through the above strategies?

No Yes Yes No

Continue overleaf

Identify least restrictive restraint to be used (please tick, may be more than one)

One to one supervision

Appropriate use of Bed Rails

Appropriate use of clinical holding

Appropriate use of Hand Mittens

Appropriate use of Pharmacological Restraint

Patient settled and outcome successful. Document strategies used / inform MDT

Patient remains unsettled

Inform medical team of potential need for form of restraint and document.

Has assessment been documented of patient’s Mental Capacity Date Time and Best Interests by duty Medical Team / MDT? Patient wishes / relatives?

In view of above decisions and current management plan is restraint appropriate?

Document clinical reasoning

Decision making by Duty Medical/Senior Nursing or Therapy staff of safest, least restrictive option regarding type of clinical holding to be selected in accordance to individual patient’s condition and situation specific.

The Care plan must now be implemented, see appendix F

See Medical Guidelines

- Aggressive and violent patients

- Acute confusional state

- Ensure maximum daily dose is specified


Print Name Date Time

Commence Care Plan

Date and time restrictive measures implemented

Date and time restrictive measures ceased

Signature of risk assessor

Signature of senior nurse in charge

Relative/carer informed regarding use of identified

To be filed in the Nursing Records

Repeat and review risk assessment to ensure that restraining measures remain the most appropriate, least restrictive option


Appendix E - SWARM: Restraint Interventions and Challenging Behaviour Events

General Information:

Datix ID Number: Care Group:

Date of Incident: Name of Patient/NHS Number:

Date of SWARM: Chaired By:

Signature of Chair:

Attendees:

Event Details:

Brief description of incident and actions taken

Harm or injury to the patient, staff or member

of the public involved

Other relevant factors

• Mental health condition

• Person with Learning Disabilities &

Challenging behaviours

• Dementia/Neurological impairment

• Previous episodes of challenging

behaviours or restraint interventions

(known mental health problem/learning

disability with challenging behaviour/previous

violence and Aggression or restraint

incident/known dementia/neurological

impairment)

What de-escalation or behavioural

management techniques were employed?

Were these timely?

▪ Mental Capacity assessed

▪ Mental Health review , designation

and time

▪ Any Sections applied

▪ Deprivation of Liberty Safeguard

Authorisation applied

Was restraint used?

▪ Purpose and type of Restraint e.g

mechanical, prone, chemical(safety of

patient/other patients/staff/property

▪ Was the restraint applied


proportionate response to the level of

risk? (type / duration)

▪ If medication was used were they

within PHT Rapid tranquilisation

guideline?

▪ Did the patient receive post chemical

sedation monitoring as per PHT rapid

tranquilisation Policy?

Immediate Post Incident Actions:

▪ Nursing / Medical Care plan review

▪ Medication review

▪ ECO Booked/ECO Charts

▪ Mental Health review / Section

applied

▪ DOLS

Was the staffing adequate on the ward at the

time of the event?

Have you requested a Use of Force form from

the Operational Security Team?

Exacerbating Factors

Duty of candour -Patient / relatives aware?

Was the patient/relative involved in agreeing a

care plan for future reoccurrences

Actions from the SWARM/Learning identified/Support to team

1.

2.

3.

4.

5.

6.

Recorded in the medical notes

Datix Update:

Who will be responsible for updating the SLE

on Datix:


Appendix F: Care Plan for the Use of Restraining Therapy

Type of restraint applied: (e.g. mittens or sedation)

Undertake the following interventions

Recommended Time Intervals

Date/time Initial

Date/time Initial

Date/time Initial

Date/Time Initial

Monitor respirations, pulse, BP & oximetry Check skin integrity & circulation Offer hygiene and toileting Offer food & fluids

15 minutes for 1st hour

If agitated continue every 15 minutes

If settled every 4 hours

If mittens are applied wash, dry hands thoroughly, check fingernails

At least once every 8 hours

Consider removal of invasive lines etc


Assess ongoing need for restraint


Document in the nursing notes


TO BE FILED IN THE NURSING RECORDS

Name……………………………….Hospital No………………………… NHS No……………………………. Consultant…………………………. Date…………………………………


Equality Impact Screening Tool

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and

policy changes/amendments

Stage 1 - Screening

Title of Procedural Document: Restriction and Restraint in Adult Care Policy

Date of assessment 11 August 2019 Responsible Department

Corporate

Name of person completing assessment

Sarah Thompson Job Title Head of Safeguarding/Mental Health

Does the policy/function affect one group less or more favourably than another on the basis of :

Yes/No Comments

• Age NO

• Disability

Learning disability; physical disability; sensory impairment and/or mental health problems e.g. dementia

NO

• Ethnic Origin (including gypsies and travellers) NO

• Gender reassignment NO

• Pregnancy or Maternity NO

• Race NO

• Sex NO

• Religion and Belief NO

• Sexual Orientation NO

If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below

www.legislation.gov.uk/ukpga/2010/15/contents

http://www.legislation.gov.uk/ukpga/2010/15/contents


Stage 2 – Full Impact Assessment

What is the impact Level of Impact

Mitigating Actions

(what needs to be done to minimise / remove the impact)

Responsible Officer

Monitoring of Actions

The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance Committee

Clinical Service Centre Procedural Document: Clinical Service Centre Governance Committee

Corporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee