Use of Restraint and Physical Intervention

Restraint means using force or restricting liberty of movement.

‘Using force’ includes physical restraint techniques that involve using force, i.e. the positive application of force with the intention of overpowering a child. Practically, this means any measure or technique designed to completely restrict a child's mobility or prevent a child from leaving, for example:

• Any technique which involves a child being held on the floor;
• Any technique involving the child being held by two or more people;
• Any technique involving a child being held by one person if the balance of power is so great that the child is effectively overpowered; e.g. where a child under the age of ten is held firmly by an adult.

‘Restricting a child’s liberty of movement’ includes, for example, changes to the physical environment of the home (such as using high door handles) and removal of physical aids (such as turning off a child’s electric wheelchair). Some children, perhaps due to impairment or disability, may not offer any resistance, but such measures should still constitute a restraint.

Restrictions such as these, and all other restrictions of liberty of movement, should be recorded as Restraint. See Section 12, Recording and Management Review.

Restraint involving a child being held on the floor is not permitted in the Home. Should a child go to the floor, Homes staff should immediately cease the physical intervention.

Changes to the physical environment of the home and removal of physical aids that restrict a child’s liberty are not permitted. Homes staff will strictly observe the restriction involving non-permissible measures and will only employ techniques as part of their professional training in Team Teach.

Whereas Restraint is designed to restrict a child's mobility completely, Physical Intervention provides the child with varying degrees of freedom and mobility, for example:

1. Holding includes any measure or technique which involves the child being held firmly by one person, so long as the child retains a degree of mobility and can leave if determined enough.
2. Touching includes minimum contact to lead, guide, usher or block a child; applied in a manner which permits the child quite a lot of freedom and mobility;
3. Presence is a form of control using no contact, such as standing in front of a child or obstructing a doorway to negotiate with a child, but allowing the child the freedom to leave if they wish.

These are less forceful and restrictive than Restraint, and may be used to protect children or others from less serious injury or damage to property, but must never be used to force compliance where there is no risk of injury or damage to property, nor as a form of punishment.

Where there has been a need to use physical intervention Homes staff are to treat any measure used as a Restraint and complete a physical intervention record. The record should note the physical interventions used and the reasons for the measures.

The assessment and planning process for all children in residential care must consider whether the child is likely to behave in ways which may place them or others at risk of Injury or may cause damage to property. The impact of the child's arrival on the group of children/young people living in the home should also be considered.

Homes Managers will complete an impact risk assessment for each child being considered for placement in the Home. The impact risk assessment will assess the suitability of the child and the Home's and staff's capacity to meet the child’s needs.

Staff caring for disabled children or children who communicate without speech have a responsibility to understand each child’s communication style. They can then help children develop their communication skills, so that they can better express their feelings and views on the use of restraint and restrictive practices.

If any risks exist, strategies should be agreed upon to mitigate or eliminate them. These strategies may include Physical Intervention and/or Restraint. Staff should continually review any risk assessments. See also Risk Assessment and Planning Procedure.

Where Physical Intervention or Restraint is likely to be necessary, for example, if it has been used in the recent past or there is an indication from a risk assessment that it may be necessary, the circumstances that give rise to such risks and the strategies for managing them should be outlined in the child's Placement Plan.

In developing the Placement Plan, consideration must be given to whether there are any medical conditions which mean particular techniques or methods of physical intervention should be avoided. If so, any health care professional currently involved with the child should be consulted regarding appropriate strategies, which must be drawn to the attention of those working with or looking after the child and stated in the Placement Plan. If in doubt, medical advice must be sought.

Each child living in the home will have an individual care, behaviour management, and risk management plan. Initial information in these plans will be informed by that received from the placing authority prior to the child being placed in the home. The homes Manager will develop plans for each child, which will be reviewed in partnership with children and relevant agencies at statutory reviews or, after any incidents, to identify whether any additional strategies are required to care for children and safeguard them and others from the risk of harm. Homes staff will refer to each child’s plans to ensure they provide care and protection in line with the agreed protocols and procedures set out in the children’s plans.

All staff will be trained in methods of behaviour management, including the use of Physical Intervention and Restraint that are agreed by the Home. This training will be refreshed annually.

This training must ensure that staff can:

• Manage their own feelings and responses to the emotions and behaviours presented by children;
• Manage their responses and feelings arising from working with children, particularly where children display challenging behaviour or have complex emotional issues;
• Understand how children's previous experiences can manifest in challenging behaviour;
• Use methods to de-escalate confrontations or potentially violent behaviour to avoid the use of physical intervention and restraint.

The registered person is responsible for ensuring that all their staff have been adequately trained in the principles of Restraint and any Restraint techniques appropriate to the needs of the children the Home is set up to care for, as defined in the Home’s Statement of Purpose.

Those commissioning training in Restraint for staff should be satisfied that the training fits with their approach to Restraint or existing Restraint system and is appropriate to the needs of the children the Home is set up to care for. They should see evidence that any Restraint techniques the training advocates have been medically assessed to demonstrate their safety for use in caring for children who are still developing, physically and emotionally. The registered person should routinely review the effectiveness of any Restraint system commissioned. In particular, they should check that the medical assessment of the system remains up to date.

Homes staff will all be trained in the PACE Model (Dyadic Developmental Psychotherapy) to de-escalate situations arising from difficulties or disputes, thereby reducing the need for physical intervention.

Homes staff will be trained in Team Teach (Non-Aggressive Physical and Psychological Intervention). This strategy will be used only as a last resort, after all diversionary and diffusion techniques have failed.

Homes staff will strictly observe the restriction involving non-permissible measures and will only employ techniques as part of their professional training in Team Teach.

The Homes manager will ensure staff receive refresher training annually and will test their competency by running practice sessions in which staff must demonstrate their ability to diffuse situations in line with prescribed techniques.

Restraint must be used only in strict accordance with the legislative framework to protect the child and those around them. All incidents must be reviewed, recorded and monitored, and the views of the child sought, dependent on their age and understanding.

Restraint in relation to a child is only permitted for the purpose of preventing:

• Injury to any person (including the child);
• Serious damage to the property of any person (including the child); or
• A child who is accommodated in a secure children’s home to prevent them from absconding from the home.

‘Injury’ could include physical injury or harm, or psychological injury or harm.

Restraint in relation to a child must be necessary and proportionate.

This does not prevent a child from being deprived of liberty where that deprivation is authorised in accordance with a court order. See Section 9, Deprivation of Liberty.

When Restraint involves the use of force, the force used must not be more than is necessary and should be applied proportionately, i.e. the minimum amount of force necessary to avert injury or serious damage to property for the shortest possible time.

Restraint that deliberately inflicts pain cannot be proportionate and should never be used on children.

There may be circumstances where a child may be prevented from leaving the Home, for example, a child who is putting themselves at risk of injury by leaving the Home to carry out gang-related activities, use drugs or to meet someone who is sexually exploiting them or intends to do so. Any such measure of Restraint must be proportionate and in place for no longer than is necessary to manage the immediate risk.

In a Restraint situation, staff should use their professional judgement, supported by their knowledge of each child’s risk assessment, an understanding of the child's needs (as set out in their relevant plans) and the risks the child faces. Professional judgements may need to be taken quickly, and staff training and supervision of practice should support this.

Approaches to Restraint should recognise that children are continuing to develop, both physically and emotionally. Any use of Restraint should be appropriate to the individual child's needs. The context in which Restraint is used should also recognise that, as a result of past experiences, children will have a unique understanding of their circumstances, which will affect their response to Restraint by adults responsible for their care.

Trained staff should use only approved techniques. Approved techniques should comply with the following principles:

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

Homes Managers will keep any restrictive intervention measures contained in children’s plans under review to evaluate the effectiveness and appropriateness of techniques in line with the child’s development and presenting behaviour.

In some cases, such as in residential special schools that are also registered children’s homes or children’s homes caring for children with complex care needs, Restraint may be necessary as a consequence of a child’s impairment or disability. A child’s EHC plan may contain details about planned and agreed approaches to Restraint or Restraint techniques to be applied in the day-to-day routine of the child. This could include, for example, the use of a device, such as outlined below.

Homes that care for children where, as a result of their impairment or disability, Restraint is a necessary component of their care should include information relating to this in the Statement of Purpose.

In some extreme cases, when a child has very complex care needs, the child may need to be restrained by mechanical or chemical means. Any use of such Restraint should follow a rigorous assessment process and, as with any Restraint, be necessary and proportionate. Wherever such Restraint is planned, it should be identified within a broad-ranging, robust behaviour support plan that aims to create the circumstances in which continued use of such Restraint will no longer be required.

For example, mechanical restraint may be needed to limit self-injurious behaviour of extremely high frequency and intensity, such as in a small number of children with severe cognitive impairments, where measures such as arm splints or cushioned helmets may be required to safeguard children from the hazardous consequences of their behaviour. Such devices should be put in place by persons with relevant qualifications, skills and experience.

Likewise, chemical restraint (being medication not prescribed for the treatment of a formally identified physical or mental illness but instead being prescribed for use “as needed” or “PRN - pro re nata”) should only ever be delivered in accordance with acknowledged, evidence-based best practice. The Home should employ staff who have the relevant qualifications, skills and experience to administer this type of restraint in line with NICE Guidelines on Managing Medicines in Care Homes and CQC and Ofsted joint Guidance on Registration of Healthcare at Children's Homes.

Any use of Restraint carries risks. These include causing physical injury, psychological trauma or emotional disturbance. When considering whether Restraint is warranted, staff need to take into account:

• The age and understanding of the child;
• The size of the child;
• The relevance of any disability, health problem or medication to the behaviour in question and the action that might be taken as a result;
• The relative risks of not intervening;
• The child’s previously sought views on strategies that they considered might de-escalate or calm a situation, if appropriate;
• The method of Restraint which would be appropriate in the specific circumstances; and
• The impact of the Restraint on the carer’s future relationship with the child.

Staff need to demonstrate that they fully understand the risks associated with any Restraint technique used in the Home. Techniques used for Restraint that may interfere with breathing and holds by the neck that may result in injury to the spine are not permissible in any circumstances.

Following any use of restraint, Homes staff should check the child for physical injury and record any injuries caused by physical intervention on a body map, attaching it to the physical intervention record.

Following any use of restraint, Homes staff should record the child’s views and any agreed strategies to reduce the need to intervene physically on the physical intervention record.

Homes staff should update the child’s presenting behaviour and risk management plans and detail any amendments to the use of physical intervention in children’s plans.

Locking external doors or doors to hazardous materials may be acceptable as a security precaution if done as part of the Home's regular routine.

All hazardous substances in the Home are to be stored in accordance with COSHH procedures to reduce risk to children.

Homes staff are responsible for ensuring any hazardous chemicals are stored safely in the home.

Children, unless agreed in the Care Plan, should be supervised when using hazardous substances, for example, when cleaning areas in the Home, such as the kitchen, that may require hazardous chemicals.

All hazardous substances in the Home have been risk-assessed, and data product sheets are available for the Home's staff to follow when using them.

Should a child be suspected or known to have ingested hazardous chemicals, Homes staff should follow the advice contained in the product risk assessment and data product sheet and seek medical advice/support as required.

A deprivation of liberty may occur where a child is both under continuous supervision and control and is not free to leave the Home. The Home cannot routinely deprive a child of their liberty without a court order, such as an order under section 25 Children Act 1989 to place a child in a licensed secure children’s home, or, in the case of young people aged over 16 who lack mental capacity, a deprivation of liberty may be authorised by the Court of Protection following an application under the Mental Capacity Act 2005.

Homes staff are to observe and apply any deprivation of liberty safeguards agreed by the Court.

Conditions of any deprivation of liberty safeguards are to be recorded in the child’s Care Plans and risk management plans that should be kept under review by the Homes Manager.

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

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

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

The registered person should regularly review the effectiveness and check that the medical assessment of the system remains up to date.

Following any use of restraint, Homes staff should check the child for physical injury and record any injuries caused by physical intervention on a body map and attach it to the physical intervention record.

Homes staff should offer children access to an independent medical professional and record their views, wishes and feelings on the physical intervention record.

Following any use of restraint, Homes staff should offer children access to a telephone.

Following any use of restraint, children should be offered access to an independent Advocate.

Following any use of restraint, children should be offered the Home's complaints procedure.

If Restraint is used upon a child, the Home Manager and the child's social worker must be notified within one working day.

If out of hours, the on-call Manager should be notified.

The Responsible Individual should be informed of any use of restraint in the Home. If a serious incident occurs or the police/emergency services are called, the Home's Manager and Responsible Individual must be notified, and consideration given to whether a Notifiable Event has occurred; if so, see the Notification of Serious Events Procedure.

If a serious incident has occurred that requires the involvement of the Police or emergency services, Homes staff should also notify the child’s IRO and placing Social Worker.

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

Records of Restraint must be kept and should enable the registered person and staff to review the use of control, discipline and Restraint to identify effective practice and respond promptly where any issues or trends of concern emerge. The review should provide an opportunity to amend practice to ensure it meets the needs of each child.

Legislation, Statutory Guidance and Government Non-Statutory Guidance

Guidance: Positive Environments Where Children Can Flourish (Ofsted)

Restraint and restrictive practices: positive environments for children – Ofsted: social care