Use of Restraint and Physical Interventions

1. Meaning of Restraint

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.

2. Meaning of Physical Intervention

Whereas Restraint is designed to completely restrict a child's mobility, Physical Intervention provide 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 in order 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 not a risk of injury or damage to property nor as a form as punishment.

3. Planning for Children

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.

If any risks exist, strategies should be agreed to prevent or reduce the risk. These strategies may include Physical Intervention and/or Restraint. Staff should continually review any risk assessments.

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 it 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 and this must be drawn to the attention of those working with or looking after the child and it must be stated in the Placement Plan. If in doubt, medical advice must be sought.

4. Staff Training

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 on an annual basis.

This training must ensure that staff are able to:

• 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 difficult 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 for have been medically assessed to demonstrate their safety for use in a context of 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 the medical assessment of the system remains up to date.

5. Use of Restraint

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, and understood.

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 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 in a way that is proportionate 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 needs of the child (as set out in their relevant plans) and an understanding of 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 suitable for the needs of the individual child. 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 only use techniques that are approved by the Home. 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, hyper flexion and pressure on or across the joints;
6. Not employ potentially dangerous positions.

6. Restraint: Special Cases

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 detail 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 where children have very complex care needs, a 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 which aims to bring about the circumstances where 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 for the small numbers of children who have 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.

7. Practice Issues

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.

8. Security Within the Home

The locking of external doors, or doors to hazardous materials, may be acceptable as a security precaution if applied within the normal routine of the Home.

9. Deprivation of Liberty

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.

10. Medical Assistance and Examination

Where physical Restraint has been used, the child, staff and others involved must be able to call on 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 from 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 the medical assessment of the system remains up to date.

11. Notifications

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

If a serious incident or the police/emergency services are called, the relevant senior manager must be notified and consideration given to whether a Notifiable Event has occurred, if so, see Notification of Serious Events Procedure.

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

12. Recording and Management Review

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 the opportunity for amending practice to ensure it meets the needs of each child.

Recording

All forms of Restraint should be recorded in the Restraint Log and an Incident Report must be completed.

The incident should be recorded in the Home's Daily Log and on the Daily Record for the individual Child(ren).

Any child who has been restrained should be given the opportunity express their feelings about their experience of the Restraint as soon as is practicable, ideally within 24 hours of the Restraint incident, taking the age of the child and the circumstances of the Restraint into account. In some cases children may need longer to work through their feelings, so a record that the child has talked about their feelings should be made no longer than 5 days after the incident of restraint. Children should be encouraged to add their views and comments to the Record of Restraint. Children should be offered the opportunity to access an advocacy support to help them with this. See Advocacy, Independent Visitors and Independent Reviewing Officers Procedure.

After any physical intervention or restraint, staff will complete a Restorative Conversation with the child or young person. This conversation will feed back into the child or young person's safe care plans. Particular attention will be given to feedback from the child or young person regarding whether an alternative form of de-escalation would have been helpful or more effective.

Where a child has an EHC plan or statement of special educational needs in which a specific type of Restraint is provided for use as part of the child's day to day routine, the Home is exempted from the recording requirement. Where these plans provide for a specific type of Restraint that is not for day-to-day use, on the occasions when such Restraint is used it must still be recorded. Any other Restraint used must always be recorded as a Restraint. As the EHC plan is designed to be a long term plan, any specified Restraints should be kept under review to ensure relevancy.

Management Review

The child's Placement Plan should be reviewed to incorporate strategies for reducing or preventing future incidents. The child must be encouraged to contribute to this review and, if a health care professional is involved with the child, any new strategies must be approved by that person.

The Manager of the Home should regularly review incidents and examine trends and issues emerging from this to enable staff to reflect, learn and inform future practice and, where necessary, should ensure that procedures and training are updated.

Within 48 Hours the use of intervention, staff should have discussed the incident with a senior member of the team. This is to ensure that any issues can be identified and any learning be acted upon to prevent, where possible, the need for further instances.

Further Information

Legislation, Statutory Guidance and Government Non-Statutory Guidance

Guidance: Positive Environments Where Children Can Flourish (Ofsted)