4.4.3 Restrictive Physical Intervention

1.1

Introduction

1.2

Definition

1.3

Terminology

Key terms within this document and accompanying procedural guidance:

• Worker/staff - includes those directly employed by the Directorate of Children’s Resources including full time, part time and sessional staff, mainstream foster carers and those working within the division on self-employed contracts or through recruitment agencies;
• Learning difficulty - the 1933 Education Act defines learning difficulty as ‘ a condition that exists if a child has a greater difficulty in learning than the majority of children of his age, or a disability which either prevents or hinders him from making use of educational facilities of a kind generally provided for children of his age in schools within the LEA’;
• Autism - is a term used to describe a spectrum of conditions that arises during infancy or childhood and which are characterised by impaired social interactions. Autism often occurs in association with a learning disability, but can also be present without any intellectual impairment. In addition many autistic individuals present complex sensory impairments, including hypersensitivity or hypo sensitivity to touch or pain, which has a particular relevance to RPI's;
• Challenging behaviour - refers to “ culturally abnormal 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, or result in the person being denied access to, ordinary community facilities” (Emerson 1995 etc in BILD). In service settings, it is most likely the risk to self or others that are most frequently managed with a RPI. Including:
  • Violence - directed at others or less specific and arising from distress, confusion or panic;
  • Self directed violence or self injury - examples are banging the  head against hard objects or skin picking;
  • Reckless disregard for own safety or safety of others - e.g. Trying to leap out of a first floor (or above) window or of a  roof; 
  • Serious damage to property may require a RPI (see below). 
    
    

1.4

Legal Context

Restraining a child/young person at the right time, in the right way and for the right reasons is lawful. The best defence is to show that the interests of the young person were the paramount consideration.

In all circumstances:

• Where you are responsible for the care of a child/young person any action you take to restrain them must be lawful; 
• The method used to restrain the child/young person must have been approved by the Directorate and in compliance with the training provided; 
• The act of restraint must be proportionate, a minimum use of force must be applied and for the shortest period of time possible;
• Any RPI must be able to be justified as being in the best interests of the child, based upon an assessment of the circumstances balanced against the risks of not employing a restrictive physical intervention.

Civil Law

In the context of restraining a child legal action taken by that child against the worker or the employer/organisation is a civil action. A central issue is likely to be whether it was reasonable and necessary to restrain the child/young person. It is sometimes necessary to restrain a child because of a duty of care to them or another person. However, a complaint may also arise that there was a failure to discharge a duty of care; in other words, harm was sustained by the young person or others because of the negligence of the worker (because of their failure to act in the situation). Workers whose work falls below the ordinary standard of the ordinary skilled worker doing the type of job they are doing may be found to be negligent. 

Criminal Law

Under criminal law restraining a child could be assault if it is done in an abusive way¹. It will not be assault where the restraint was necessary and justified e.g. restraining a child:

• To prevent them harming themselves or others; or
• To prevent serious damage to property (although property damage on its own is not sufficient reason to restrain a child;
• To prevent a child running away where you reasonably believe they will put themselves at serious risk of harm; or
• To prevent a child escaping from a secure establishment where they reside subject to a legal order.

Excessive force² must not be used in any RPI therefore any action taken by a worker must be able to be justified as proportionate to the situation and circumstances at the time.

¹ The act of assault must be accompanied by hostile intent, the act does not have to take place but the victim must fear that it will. It can occur without physical contact with the victim - actions like shaking a fist or threatening words fall within the definition.  

² Excessive force depends on all the circumstances, including the age, size and actions of all the people concerned, the type of perceived danger and anything that might affect how people are reacting or acting.  

For further detail on the relevant statutes see Section 2, Legal Framework.

1.5

Key Principles and Values

• Children and young people have the right to expect proportionate, consistent responses, irrespective of the setting;
• Those with a duty of care are expected to use their judgement and act reasonably and in the best interests of those for whom they are caring/responsible;
• Decisions must be based on ethical practice which means that workers will consider all relevant factors and will engage in opportunities to discuss with colleagues and supervisors the ethical issues that physically restraining a child raises;
• A child centred approach will inform the use or otherwise of RPI. All techniques used will be non-pain compliant and based on a variety of approaches that are appropriate to each young person’s needs, understanding and propensity towards violent or aggressive behaviour;
• The implementation of RPI's involving the limiting of a child/young person’s freedom against continuing resistance will be recorded and monitored to identify patterns of response. Management action will be taken as required;
• De-escalation techniques are the preferred option. RPI will only be used as a last resort and must be reasonable, proportionate, and used for the minimum time necessary using the minimum level of control necessary;
• Any worker or young person who has been involved in a physical restraint will be actively encouraged to discuss and reflect openly on the incident;
• The Directorate is committed to ensuring all relevant staff are appropriately trained in RPI intervention by a British Institute of Learning Disability (BILD) accredited provider;
• The Directorate is committed to a robust approach to recording, monitoring and evaluating incidents of RPI at operational and strategic levels;
• DLSCB will clarify how incidents of RPI may be referred through safeguarding procedures and which may result in formal strategy meetings;
• If a worker faces a complaint or has legal action taken against them in relation to a RPI they have carried out, DDCS will ensure they are supported appropriately.

N.B. In preparing this policy account was taken of the DDCS’s ‘Good Practice Guidance for Schools’. It is recommended that staff within schools refer to this procedural document and associated pro forma for responding to, and managing physical interventions including RPI's locally.

All efforts should be made to reduce the need for RPI's (Restrictive Physical Interventions) as far as practicable. Research has shown (Holding Safely The Scottish Institute for Residential Care 2005). The following provides the basis on which this can be achieved both organisationally and at an individual level:

• Maintain a positive culture/approach;
• Promote ethical practice;
• Maintain a child-centred approach;
• Understand high risk behaviour or violent behaviour;
• Promote an awareness in staff of their own reactions to aggressive or violent behaviour and the effect of their mood on others;
• Promote self control in children and young people;
• Use authority appropriately;
• Maintain a policy to manage behaviour positively;
• Promote positive relationships.
  
  

Maintain a positive culture/approach

In a residential establishment a positive culture is developed and maintained through consideration of the physical environment as well as the creation of the right ethos in the unit. 

A safe, pleasant and well-maintained building with space for young people to have time alone particularly when tensions are running high may prevent/reduce the likelihood of high-risk behaviour. 

It is a management responsibility to create the right ethos where staff share a sense of purpose, understand and support the aims of the establishment and display consistency in managing behaviour. 

In other settings within the Directorate of Children's Services promoting a positive approach to children who are 'looked after' and upholding the appropriate values consistent with this approach is largely dependant on the effective induction, training and management or support to staff and carers. Ongoing support and advise in particular to the Directorate's foster carers will be fundamental to maintaining the desired approach, values and associated behaviours. 

Ethical practice

Violating the child's right to freedom of movement can only be ethically justified if the circumstances are exceptional and restraining them is the only practicable way to secure their welfare.

Although this guidance provides advice on situations where using restraint may be justified it is never simply a question of following rules. Judgments must be made and decisions taken which should be based on the following:

• The best interests of the child;
• Reasonableness and proportionate to;
• A comprehensive risk assessment;
• Having regard for other young people or adults present; and
• Respecting the safety and dignity of all concerned.
  
  

Child centred approach

A child-centred approach means putting the needs of children first above all other considerations. Staff and carers must always act in the best interests of the child and aim to see things from the child's point of view. Clearly this is particularly challenging when faced with violence or aggression from a young person.

To safeguard and promote the welfare of children/young people who are in receipt of our services, all those working with them should have a shared understanding of the five outcomes of what they need in order to thrive:

• Be healthy;
• Stay safe;
• Enjoy and achieve;
• Make a positive contribution;
• Achieve economic well-being.

These outcomes are described as the universal ambitions for every child and young person whatever their background or circumstances. Furthermore the Government has a particular focus on improving the outcomes for 'looked after' children/young people, children with special educational needs and young people not in education training or employment.

Implicit in the above is the need to actively engage children/young people in identifying the care they need to keep them safe and to base any response on the young persons needs arising from his/her personality, age, ethnic, religious or cultural background, stage of development, gender and history.

Understand high-risk or violent behaviour

To understand a child/young person's high risk or violent behaviour it is important to understand what is causing it. In some cases internal processes such as disturbed brain activity, or auditory hallucinations may prompt behaviour, but in most cases there will also be other triggers.

Children with whom we work are dealing with a range of difficulties in addition to the developmental issues that all young people face. Whether they are placed in a residential unit or in a foster placement it is likely that individual stressors may become exaggerated.

Children/young people who have a learning disability and/or a diagnosis of Autism may have additional needs that must also be considered when seeking to understand their behaviour.

To support young people effectively knowledge of child development, the impact of adverse experiences or impairments on that development, and for workers in a residential setting the understanding of group processes is vital.

Develop and maintain self-awareness 

Promote self-control in children/young people

There are young people who lose control in the run up to being restrained, and other young people who are fully in control when being violent or committing other high risk behaviours. In either case the number of times a young person has to be restrained can be reduced through helping them learn self-mastery. Primarily by staff and carers:

• Demonstrating self control;
• Shaping young people's behaviour in ways which do not involve punishment;
• Interacting in ways which invite cooperation rather than convey coercion;
• Showing respect for the legitimate interests and property of others;
• Promoting impulse control by encouraging discussion and consideration of choices rather than impulsive action.

Young people must also have the opportunity to discuss and reflect on the difficulties that led to their placement, and be helped to develop the strength and resources to make appropriate choices.

Giving young people opportunities for achievement also helps them feel good about themselves.

Use authority appropriately

Child centred practice does not preclude clear boundaries being set and identification of what is negotiable and what is not negotiable. Clear communication with the child/young person is a prerequisite to ensure they are aware of what is expected of them and the potential consequences if they breach the expectations.

Clear boundaries can give young people a sense of security but a sense of fairness and a spirit of care underlying all interactions and decision-making must be implicit in the boundaries set.

Develop and maintain a behavioural management policy

Each 'setting' within the Division of Children's Specialist Services should have a local protocol for responding to problematic behaviour so that young people, their parents, and staff know what the response is likely to be to particular behaviours. This protocol must be informed by the training provided by the accredited provider and this policy and guidance.

The benefits of local protocols are that children's needs can be more effectively met if there is an understanding about what a particular unit, carer or service is likely to be able to offer to the young person. A clear 'local' protocol on managing behaviour may reduce the need for physical restraint and will place RPI firmly within a holistic and child-centred approach.

As stated earlier it should be the level of risk, which determines how staff should respond not the particular setting in which the risk is presented.

Promote positive relationships

The plan must identify:

• The triggers that cause the young person distress;
• The early warning signs that all is not well;
• Ways in which workers can calm the situation.

Within this context planned RPI's are a part of a structured approach within a child's care plan to deal with challenging behaviours that are known to apply to particular individuals.

The child/young person's involvement

Proper consideration must be given to the child's views of their care and the plans and decisions, which affect them:

• When carrying out any assessment, care plan, behaviour plan or review, the child's views must be at the centre of the activity;
• There must be a discussion with them about the actions that will be taken if their behaviour presents serious risks;  After children/young people have been restrained it is important that a discussion takes place with them to ascertain their thoughts and feelings about what has happened and record them accordingly;
• In a group setting young people should be given the opportunity to be consulted on identifying behavioural limits within the setting and the localised approach to managing behaviour

Behavioural management plans should be reviewed and updated frequently and must be reviewed after each and every incident of RPI.

All staff/carers must fully understand the nature of the risks presented by a particular child/young person and the interventions identified in the plan to deal with that behaviour.

Such plans must be compliant with the broader strategies agreed by the establishment, unit or department for dealing with behavioural difficulties.

Risk Assessment

The Environment:

• There must be a general risk assessment for each workplace which addresses the risk of violence, which is accessible to all staff and read and understood by staff;
• This workplace risk assessment should identify particular environmental hazards in the context of restraining a young person e.g. (stairs, kitchens, particular corridors/passageways);
• It should be reviewed at least annually and must be reviewed after a particular incident of RPI;
• For foster carers, awareness of home safety will be regularly reviewed and support given by the supervising Social Worker to address environmental issues in the context of effective behavioural management and appropriate records maintained;
• Workers from within other settings (e.g. transport) must familiarise themselves with the localised guidance regarding the risks and the control measures for that particular setting

Each event:

Each time consideration is given to responding to problematic behaviour presented by a child/young person there will normally be consideration (albeit a quick mental assessment) of the risks of reacting in a particular manner. These thought processes will normally included assessment of the following:

• Who is at risk of harm and what is the nature of the risk?
• What is the probability of harm and how serious will it be?
• Would the prime reason for restraining the young person be about keeping them safe?
• Will the consequences of restraining the child/young person be less or more harmful than the behaviour itself?
• Who else will be affected by the restraint?
• What would the consequences be of not restraining the child?
• Are there are alternatives I could use?
• Can the child be safely restrained based on the training received by the worker(s)? 
• What is the least restrictive and most respectful way of restraining the child to prevent harm?
• Have additional/previously unidentified risks been presented?

The outcome of this quick risk assessment must be in line with the child's 'behavioural management plan' unless there are clear reasons based on the assessment of the risk of harm that justify overriding it.

Any emergent risks or difficult behaviours must be discussed with the supervisor and action agreed and recorded on how they will be managed in the future. 

No matter what method you have been trained in you may only physically restrain a child when it is the only practicable means of securing the welfare of that child/young person or others and that there are exceptional circumstances which lead you to believe that:

• A child will cause physical harm to themselves or others;
• The child will run away and put themselves or others at serious risk;
• Or a child will cause significant damage, which is likely to have a serious emotional effect or create physical danger.

NB Staff in children’s homes may only use techniques that have been approved and for which they have been trained to use in the specific home in which they are working. If they go to work in another home, they must be trained to use the techniques which that home has approved before the new staff member can work with their children.

You should not use physical restraint when:

• You can restore safety in another practicable way e.g. through the use of recognised de-escalation techniques;
• You are not in control of yourself;
• You consider it unsafe to do so (e.g. the young person has a weapon);
• You know the young person has a medical condition that may be adversely affected by being restrained;
• You are not confident based on all the circumstances that the young person can be restrained safely (e.g. the presence of the public or other young people who could be adversely effected).

Clearly there may be occasions when events/behaviour occurs which may not have been foreseen or the young person may not have a behaviour plan or trained staff may not be on hand. Unless the situation is urgent, advice/assistance should always be sought. However the 'duty of care' remains and any response must be:

• Reasonable;
• Proportionate;
• Motivated by the maintenance of safety and prevention of injury; and
• Consistent with the circumstances and with any training the worker may have received.

Recording must be:

• Accurate and timely;
• Appropriately filed and cross referenced (the main record off the RPI should be the first record of the restraint and other documents should be cross referenced to it);
• Typed or legible if handwritten;
• Signed by the individuals concerned (including witnesses for witness statements, by others involved in any follow up discussions).

N.B. Any notes kept for personal reasons in relation to an incident of RPI will be treated by courts as evidence and the court could order that they be produced. In criminal proceedings the police may seize such notes as evidence. In addition, such notes must be treated as confidential information to respect the privacy of the individuals concerned. Therefore they must be kept securely and in accordance with the principles of the Data Protection Act 1998.

As a minimum the written record must include:

1. The name of the child concerned;
2. Details of the child’s behaviour leading to the use of the measure;
3. A description of the measure used;
4. The date, time and location of the use of the measure (amended see below);
5. The name of the person using the measure, and of any other person present;
6. The effectiveness and any consequences of the use of the measure;
7. A description of any injury to the child concerned or any other person and any medical treatment administered;
8. Confirmation that the person authorised by the registered provider to make the record has spoken to the child concerned and the person using the measure about the use of the measure; and
9. The signature of the person authorised by the registered provider to make the record;
10. Where a measure of restraint is used on a child the record must include;
11. The duration of the measure of restraint; and
12. Details of any methods used to avoid the need to use that measure.

If the young person sustains an injury, this must be recorded and reported in the manner agreed in the local protocols.

As a minimum the written record must include:

• Details of injury/ies sustained by the child/young person;
• Details of any medical help required;
• Confirmation that the child was asked about his or her physical condition after the RPI and that their general physical condition had been checked and by whom;
• Whether there has been a need to make an entry into the accident book.

Views of the Young Person

Timing

The timing of a discussion about what has occurred is critical but the young person should be encouraged to discuss the incident.

Some children will want to be comforted in the period immediately after the event and as part of that may see the opportunity to discuss the event as helpful, others may welcome a period of calm but not be ready to talk and others may be angry and resentful and resistant to any discussion. It is the worker/carer's responsibility to find the right time to talk with the child about how they can be helped to manage similar situations differently.

Careful judgment is required and there should be sensitivity to the young person's needs, the process may require time but if you have to insist then the reasons why you are insisting should be shared with the young person so as to avoid anything which suggests the decision is about asserting power.

The discussion

Consideration should be given as to who may be the best person to discuss the incident with the young person. It may be beneficial for this person to be the worker/carer who perhaps took the lead in the RPI in order that the discussion can continue the process of restoring the relationship. However, as with the timing of the discussion, sensitivity to the young person's needs and wishes is essential.

Children with a disability may have particular communication needs, which must be considered when seeking to understand their views of what happened. The specialist communication approaches identified in the care plan must be used to communicate with the young person.

 A creative approach to communicating perhaps by using drawings or symbols, offering a computer or using a diary may also be appreciated by the young person and may help them feel more comfortable in reflecting on what happened.

Considering environmental issues may assist in helping the young person to engage in the process e.g. going somewhere quiet, or even somewhere busier depending on the young person's preference.

A constructive and meaningful discussion will contain the following elements: The young person's view:

• Of the experience of being restrained;
• As to why the worker/carer restrained them;
• Of events leading up to the RPI;
• Of the part played by others (if appropriate);
• Of what they were trying to achieve by their behaviour;
• Of the process of regaining self control.

In addition the worker/carer should be aiming to:

• Help the young person identify the link between thoughts feelings and behaviour;
• Develop an action plan identifying what the young person and worker/carer will do if a similar situation arises in the future;
• Identify action to repair where necessary relationships between the young person and their carers;
• Provide support to deal with any difficult memories that restraint may have brought up;
• The period after the young person has been restrained is a time when he or she can reflect on how to deal with consequences, poor choices and repairing relationships.

In a residential setting it may be appropriate to consider issues arising from the RPI, with the residents as a group as issues arising from a restraint may affect all of the young people in the unit not just the young person who experienced the RPI. Such group discussions can help young people and staff to learn together from the event. 

Recording

A record of the discussion should be made as soon as possible but no later than within a week of the incident and should include:

• Date of discussion and the name of the worker/carer;
• Young person's account of events leading up to the RPI;
• The young person's views about the reasons why the worker/carer restrained them;
• Any views the young person may have about how things may have been done differently;
• The young person's view on the impact on relationships with workers/carers;
• Action the young person would like to take in the future;
• Action which the young person would like the worker/carer to take in the future.
  
  

Assisting staff/carers to reflect

The process of providing learning opportunities for young people to reflect on what happened should be mirrored by opportunities for staff/carers to learn from their experiences and should be undertaken in a similarly structured way.

The focus of 'structured reflection' is to ensure the emotional well being of the worker/carer involved in the RPI. It is recognised that "most people cope after a critical incident, but they recover more quickly if they have a procedure to follow which enables them to talk through what happened, how they reacted and consider what they want to learn from the experience" (Positive Listening and Debriefing' p5 Team Teach 2005)

In summary 'structured reflection': 

• Gives workers/carers the opportunity to express difficult emotional pressures created by the act of physically restraining a young person;
• Provides an opportunity for workers/carers and their manager/supervisor to clarify what happened;
• Facilitates learning from the experience and assists in helping people integrate the learning into their lives and future responses.
  
  

Timing 

The timing of the discussion following an incident of RPI will vary according to the worker/carer's needs, shift arrangements and practicalities of the service e.g. if the incident involves a foster carer then it may not be possible to hold the discussion immediately after the event. Ideally the discussion should be held when the worker/carer is calm, rested and willing to talk.

In a residential setting it may be useful to hold a general discussion at either the end of the shift or in a team meeting. Such discussions will normally focus on the welfare of the child and any practical aspects of the event that need to be considered.

The one-to-one discussion

This discussion would normally be facilitated by the worker/carer's manager/supervisor and might include:

• What has been learnt about the young person as a result of the RPI and the events leading up to it;
• What the worker/carer has learnt about themselves
• What the worker/carer thinks the young person's view is of the events leading up to the RPI;
• What the worker/carer thinks the young person's understanding is of why they have been restrained;
• What appeared to work;
• What didn't work so well;
• What could be done differently in the future;
• Any communication or support issues arising;
• Any improvements made or further training provided to improve responses to such situations in the future.
  
  

Recording

A record of the discussion outlined above should be made and may include the following headings:

• The story (events leading up to and including the RPI);
• The learning (what has been learnt about themselves, what they did, what worked well and what didn't);
• Any actions required;
• Signed by the worker/carer and the person facilitating the discussion.

What should be counted?

Numbers can never tell the whole story so the electronic records should be monitored in conjunction with the narrative information but may include:

• Incident number;
• Day, date time and length of restraint;
• Child's name;
• Names of key workers/carer involved carrying out the restraint;
• Location of the RPI;
• Any obvious trigger (e.g. bedtime, home visit etc.);
• Whether significant injury was sustained, complaints, police involvement, medical checks;
• Nature of risk (injury to self, others, property, criminal offence, absconding etc.);
• External agencies informed (e.g. Ofsted, parent/guardian, Social Worker, police,);
• Parents informed if appropriate;
• Supporting Records completed (e.g. physical restraint log, serious incident record, RIDDOR, Accident Book, Ofsted notification, witness statements, recorded review).
  
  

Analysis