Restrictive practice — a failure of person-centred care planning?
Rebecca Bauers, Interim Director for People with a Learning Disability and Autistic People, and Chris Dzikiti, Director for Mental Health, talk about CQC’s new cross-sector policy position statement on restrictive practice, what it means for providers, and what people receiving healthcare services have the right to expect. As well as sharing the new policy, they discuss what forms restrictive practices can take, and explain how the use of blanket restrictions diminishes the therapeutic power of person-centred, trauma-informed care.
We know that the use of restrictive practices, including restraint, seclusion and segregation, can have a devastating impact on people and cause them trauma. Since our report Out of Sight — Who Cares?, we’ve repeatedly called for providers to act immediately to reduce the use of restrictive practice, and to ensure they provide person-centred, trauma-informed care at all times.
Earlier this year, members of our expert advisory group for people with a learning disability and autistic people told us we needed to address the issue head on and develop a clearer and stronger position on the use of restrictive practice.
In Rebecca’s July blog, we acknowledged this request and the need to focus on reducing restrictive practice as a priority. Today we’re sharing our new cross sector policy position, as part of our response to this.
Using our existing legislation, the policy position builds on the new powers we have to assess how local authorities and healthcare providers work together. We aim to make sure people receive care that promotes their recovery and supports them to lead their best lives.
We’ll apply this cross-sector position in all areas of our regulation. As a result, we expect all providers of health and social care to know what restrictive practice looks like, and to actively work to reduce its use in health and care settings.
What do we mean by restrictive practice?
Restrictive practice is defined as making someone do something they do not want to do or stopping them from doing something they do want to do, by restricting or restraining them, or depriving them of their liberty.
When restrictive practices are used, they can have a significant impact on a person’s mental health, physical health, and their emotional wellbeing. They could even breach their human rights.
We’re aware that there are limited situations where restrictive practice could be needed to keep people safe. However, restrictive practice must only be used to prevent serious harm. It must be the least restrictive option, applied for the shortest possible time. It must only be carried out with the correct authorisations beforehand. Any incident where restrictive practice is used must be followed by therapeutic support for the person. There must also be a detailed review of their care plan, which focuses on de-escalating and preventing any future incidents.
What does restrictive practice look like?
Most people know and accept that restraint, seclusion, and segregation are more extreme forms of restrictive practice. But there are more subtle forms of restrictive practice that easily become day-to-day normal responses to perceived risk or lack of time. There is the risk that without regular review, the use of restrictive practice can increase gradually over time without really being noticed, and passed off as “just the way we do things here”.
Examples of more subtle types of restrictive practice include:
- making people use incontinence products to manage their toilet needs because it’s easier for staff
- keeping walking frames out of reach, which restrict a person’s movements or keep them in a specific area
- making people use bibs or feeding cups
- making someone use a wheelchair when they’re willing and able to walk
- denying people access to visitors, friends, or food due to a lack of staff or time.
Many of these examples make it quicker or easier for staff to manage people in their care, rather than provide the person-centred trauma-informed care that we expect to see.
We’re also concerned that in some cases these types of restrictive practices have been used as a form of punishment in response to the way in which people communicate or express their distress. This is completely unacceptable.
Another form of restrictive practice is the use of blanket policies. Blanket policies are policies that are applied to everyone regardless of their individual needs, and are contrary to person-centred trauma informed care.
Examples of blanket policies might include:
- stopping people from using a kitchen
- set bedtimes
- remote CCTV monitoring
- restricted access to bathrooms and showers
- bedrooms being locked at certain times of the day.
We continue to encourage providers to challenge the use of blanket restrictions to ensure that they are not unintentionally restricting people’s liberty and human rights. Providers must also make sure that any blanket restrictions in place do not conflict with an individual’s tailored care plan.
Challenging the use of restrictive practice
Our new policy position is clear; we expect leaders of services, systems, and all those working in health and social care to take immediate steps to identify and reduce restrictive practices in their services, where possible. They must understand the events that led up to any incidents where restrictive practice was used, report on them, learn from them, and actively work to reduce them in future.
This position, outlined below, reaffirms our deep commitment to reducing restrictive practices across all health and social care services.
CQC policy position on restrictive practice
In all services CQC expects care to be person-centred. We expect providers to promote positive cultures which support recovery, engender trust between patients and staff, and protect the safety and wellbeing of all patients and people using services. They must listen to and seek to understand people, including how people communicate their needs, emotions, or distress. This understanding must be used to support adjustments that remove the need to consider the use of any restrictive practice. The focus needs to shift to one which respects all patients’ rights, provides skilled, trauma-informed therapy, follows the principle of least restriction, and promotes recovery.
We recognise that the use of restrictive practices may be appropriate in limited, legally justified, and ethically sound circumstances in line with people’s human rights. An example may be where there is no other option but to restrain a person to avoid harm to themselves or others. Restrictive practice must never be used to cause pain, suffering, humiliation or as a punishment. Regardless of which registered service any restrictive practice occurs in, CQC expects that the board or equivalent will analyse incidents and work to reduce them.
Wherever restraint, seclusion or segregation is perceived to be the only safe option, providers must consider whether services were provided which met the needs of the individual and are preventative in their approach to stop situations reaching crisis point. This must include considerations of any failures in people’s care, learning or gaps in listening to and understanding people, and the required proactive system wide joined up working. We expect providers to respond to any restrictive practice by organising timely therapeutic interventions for the person/s subjected to the restrictive practice, to address any trauma caused to them, and to support their future wellbeing.
We will take appropriate enforcement action wherever care falls below the fundamental standards people have a right to expect.
We will hold registered persons to account where we have evidence that they have failed to comply with regulations 12 (safe care and treatment) or 13 (safeguarding service user from abuse and improper treatment) in this context, and this has resulted in avoidable physical or psychological harm to people, or people being exposed to significant risk of it.
Our next steps
As part of our ongoing work, we’ll continue to raise awareness of the impact restrictive practices have on people. We’ll share examples of what good practice looks like and the important role leadership and culture play.
Internally, we’re developing guidance and training for our inspectors with support from the British Institute of Learning Disabilities (BILD), and the Restraint Reduction Network (RRN) to help us improve our reporting where we identify the use of restrictive practices during inspections.
The new policy and inspector guidance will be incorporated into our single assessment framework for inspecting services later this year.
In closing, we want to be clear, reducing restrictive practice is everyone’s responsibility. We expect everyone in health and social care to be actively working towards reducing the use of restrictive practice, to the point where its use is rare, and it is considered a failure of care across a system. In its place, we expect to see regularly reviewed, person-centred, trauma-informed care plans that are tailored to each individual’s specific needs.
We all can and must do better to eliminate the inappropriate use of restrictive practice in health and social care.