Use of Restraint and Physical Intervention

Restraint or Restrictive Physical Intervention means using force or restricting liberty of movement when a child/young person is presenting behaviour that is placing themselves or others at risk of harm or causing serious damage to property.

Restrictions of liberty of movement, should be recorded as Restrictive Physical Intervention. See Section 12, Recording and Management Review.

Whereas RPI is designed to completely restrict a child/young person's mobility, PI provides the child/young person with varying degrees of freedom and mobility, for example:

1. Holding includes any measure or technique which involves the child/young person being held  by one person, so long as the child/young person 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/young person; 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/young person or obstructing a doorway to negotiate with a child/young person; but allowing the child/young person the freedom to leave if they wish.

These are less forceful and restrictive than RPI, and may be used to protect children/young people 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 of punishment.

The assessment and planning process for all children/young people in residential care must consider whether the child/young person 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/young person's arrival on the group of children/young people living in the home should also be considered.

Staff caring for disabled children/young people or children/young people who communicate without speech, have a responsibility to understand individual children/young people's communication style. They can then help children/young people to develop their skills in communication, so that the children/young people can better express their feelings and views on the use of restrictive and non-restrictive physical intervention.

If any risks exist, strategies should be agreed to prevent or reduce the risk. These strategies may include PI or RPI. Staff should continually review any risk assessments. See also Risk Assessment and Planning Procedure.

Where PI or RPI 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/young person'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/young person should be consulted regarding appropriate strategies and this must be drawn to the attention of those working with or looking after the child/young person and it must be stated in the Placement Plan. If in doubt, medical advice must be sought.

All staff will be trained in methods of behaviour management, including the use of Physical Intervention and Restrictive Physical Intervention 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/young people;
• Manage their responses and feelings arising from working with children/young people, particularly where children/young people display challenging behaviour or have difficult emotional issues;
• Understand how children/young people'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 Restrictive Physical Intervention.

The registered person is responsible for ensuring that all their staff have been adequately trained in the principles of PI and RPI techniques appropriate to the needs of the children/young people the Home is set up to care for as defined in the Home's Statement of Purpose.

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

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

Restrictive Physical Intervention in relation to a child/young person is only permitted for the purpose of preventing:

• Injury to any person (including the child/young person);
• Serious damage to the property of any person (including the child/young person); or
• A child/young person 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.

Restrictive Physical Intervention in relation to a child/young person must be necessary and proportionate.

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

When Restrictive Physical Intervention 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.

Restrictive Physical Intervention that deliberately inflicts pain cannot be proportionate and should never be used on children/young people.

There may be circumstances where a child/young person may be prevented from leaving the Home for example a child/young person 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 Restrictive Physical Intervention must be proportionate and in place for no longer than is necessary to manage the immediate risk.

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

Approaches to RPI should recognise that children/young people are continuing to develop, both physically and emotionally. Any use of RPI should be suitable for the needs of the individual child/young person. The context in which RPI is used should also recognise that, as a result of past experiences, children/young people will have a unique understanding of their circumstances which will affect their response to RPI 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.

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

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

In some extreme cases there may be the need for the application of 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". This 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/young person;
• The size of the child/young person;
• 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/young person'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/young person.

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

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.

A deprivation of liberty may occur where a child/young person is both under continuous supervision and control and is not free to leave the Home. The Home cannot routinely deprive a child/young person of their liberty without a court order, such as an order under section 25 Children Act 1989 to place a child/young person 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.

Where RPI has been used, the child/young person, staff and others involved must be able to call on medical assistance and children/young people 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 RPI.

Whether or not the child/young person 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.

If RPI is used upon a child/young person, the Registered Manager and child/young person'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/young person's parent(s) and, if so, who should do so.

Records of RPI must be kept and should enable the registered person and staff to review the use of control, discipline and RPI 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/young person.

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