Restrictive Physical Intervention

Contents

1. Planning for Children
2. Definition of Physical Interventions
3. Who may use Physical Interventions
4. Staff Training and Criteria for using Physical Interventions
5. Locking or Bolting of Doors
6. Notifications
7. Medical Assistance & Examination
8. Recording and Management Review

1. Planning for Children

As part of the assessment and planning process for all children, consideration must be given to whether the child is likely to behave in ways which may place him/herself or others at risk of Injury or may cause Damage to Property. The likely impact of the child’s arrival on the group of children /young people already living in the home should also be considered.

If any identified risks exist, consideration must be given to the Strategies that will be adopted to prevent or reduce these risks. These Strategies may include Physical Intervention. Staff in the home should continually review Safe Care Plans.

Where Physical Intervention may be necessary, for example, if it has been used in the recent past or there is an indication from a Safe Care Plan that it may be necessary, the circumstances that give rise to it and the Strategies for managing it should be outlined in the child's Placement Plan.

In developing such a plan, consideration must be given to whether there are any medical conditions which might place the child at risk should particular techniques or methods of physical intervention be used. If so, any health care professional currently involved with the Child, should approve 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.

Staff should always follow a restorative approach and act as a good parent would with the child/young person's best interest being at the forefront of your practice. Within Derbyshire Children Services Residential Children's Homes, our ethos is to practice restorative and social pedagogical approaches to caring for children and young people, specifically in relation to Additional Measures and physical interventions. Although we have a clear outline of prohibited and permissible physical interventions, our ethos seeks to avoid the use of physical interventions and instead looks to develop a culture of shared values and norms in the homes. Each home is a shared life space for staff and children/young people. Staff should role-model the shared values and norms and aim to convey and negotiate them with the children/young people to agree to shared boundaries. By doing so the need to resort to physical interventions is reduced.

All staff are trained in Social Pedagogy and Restorative Practice and attend regular consultation sessions with Horizons. There is an expectation that all staff attend these sessions and any measure they implement is appropriate and restorative rather than punitive.

NOTE The existence or absence of a Placement Plan or other behaviour management plan does not prevent staff from acting as they see fit in the management of highly confrontational or potentially harmful behaviour. However, staff may only deviate from agreed plans where they are able to demonstrate that the plan would not be sufficient to prevent injury or damage to property and the alternative actions they take are consistent with the principles contained in this Procedure. Any deviation from an agreed plan or from the principles contained in this Procedure must be recorded and reported as an Emergency Intervention to the Home Manager and child's social worker as soon as practicable thereafter. This may lead to discussion on Person Specific Interventions.

2. Definition of Physical Interventions

Restraint also includes restricting the child’s liberty of movement, and changes to the physical environment of the home or removal of physical aides. These should all be recorded as restraint.

There are four broad categories of Physical Intervention.

1. Restraint: Defined as 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.
   • The locking or bolting a door in order to contain or prevent a child from leaving;

The significant distinction between the first category, Restraint, and the others (Holding, Touch and Presence), is that Restraint is defined as the positive application of force with the intention of overpowering a child. The intention is to overpower the child, completely restricting the child's mobility. The other categories of Physical Intervention provide the child with varying degrees of freedom and mobility.

2. Holding: This 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;
3. Touching: This 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;
4. Presence: 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.

Restriction on liberty of movement can involve adaptations to the environment such as using high door handles or removing physical aids. It also refers to behaviour support strategies such as requiring a child to take ‘time out’ in a specific area of the home, asking a child to spend time away from the group to regain control of their behaviour (i.e. if a child is struggling to maintain a socially acceptable level of behaviour at the meal table, asking them to move away from the group to another area, can be defined as restricting their liberty of movement). Where there may be no need to use restrictive physical intervention (i.e. the child goes willingly once instructed to do so) the incident must still be recorded. This is to ensure the intervention can be monitored and to ensure that children are not being scapegoated or unduly being isolated from the group.

Where the likely application of this strategy is a reasonable assumption due to a child’s previous behaviour or level of emotional needs, it should be included in the Education, Health and Care Plan /Care plan. This should be monitored as part of the normal review process. This strategy should be clearly recorded on the child’s Individual Behaviour Support Plan. In this instance, there is no requirement to complete an incident report, unless the behaviour displayed is new, unusual or falls under any other category of incident.

3. Who may use Physical Interventions

Only trained staff may use techniques that are approved by the home; such 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, middle of the back and sexual areas;
5. Avoid hyperextension, hyper flexion and pressure on or across the joints;
6. Not employ potentially dangerous positions.

4. Staff Training and Criteria for using Physical Interventions

4.1 Staff Training

All staff must be trained in methods of behaviour management, including the use of physical intervention and restraint that are agreed by the Home.

This training must ensure that staff are able to:

• Manage their own feelings and responses to the emotions and behaviours presented by children and understand how past experiences and present emotions are communicated through behaviour;
• 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;
• Staff try to diffuse challenging situations as far as possible and do not physically intervene unless they need to and only as a last resort – to prevent injury to the young person, injury to others and/or serious criminal damage. Derbyshire County Council has a physical intervention policy and all Residential Children’s Workers are trained in the PROACT-SCIPr-UK® (Positive Range of Options to Avoid Crisis and use Therapy Strategies for Crisis Intervention and Prevention) method of physical intervention. This was introduced into Derbyshire’s schools and children’s homes in 2007. The PROACT-SCIPr-UK® philosophy places the emphasis on pro-active work to prevent the escalation of challenging behaviour, rather than using a reactive approach. Further Derbyshire approaches also relate to promoting restorative practice and working in a Social Pedagogical way.

4.2 Criteria for using Physical Interventions

Restraint also includes restricting the child’s liberty of movement, and changes to the physical environment of the home or removal of physical aides. These should all be recorded as restraint.

There are different criteria for the use of Restraint and other forms of Physical Intervention, such as Holding, Touching and Physical Presence.

1. Restraint, which is the form of Physical Intervention used with the intention of overpowering a child, may only be used where there is likely Significant Harm or Serious Damage to Property;
2. Other forms of Physical Intervention, such as Holding, Touching or Presence, are less forceful and restrictive than Restraint, and may used to protect children or others from Injury which is less than Significant or to prevent Damage to Property which is less than serious;
3. Restraint may not be used to force compliance or as a punishment where Significant Harm or serious damage to property are not otherwise likely;
4. Before Restraint or any other form of Physical Intervention is used, staff must be satisfied that it is necessary because there is a risk of injury or damage to property and that:
   1. The injury or damage is likely in the Predictable Future;
   2. The intervention is Immediately Necessary;
   3. The actions or interventions taken will be as a Last Resort;
   4. That any force or intervention used is the Minimum Necessary to achieve the objective.

A child/young person can be prevented from the leaving the home if it is felt they are at significant harm in the following circumstances:

• Sexual Exploitation;
• Gang Related Activities;
• Use of drugs.

Any restriction of a young person’s liberty should be for the minimum amount of time possible and in response to immediate danger. Staff will need to ensure that in the recording of this incident they clearly outline all the steps taken to prevent the need to restrict the child’s liberty using physical means.

If a young person continually requires this level of intervention to help them to remain safe, there must be clear evidence of a planning meeting with the placing authority to consider the appropriateness of the placement. It may be recognised that this is a process of testing and an agreement regarding strategies will be set and reviewed in conjunction with the local authority, this will need to be clearly documented and any agreement must not conflict with regulations regarding ‘Deprivation of Liberty’. See below.

5. Locking or Bolting of Doors

It is acceptable to use electronic mechanisms or other modifications which are necessary for security, for example on external exits or windows, so long as this does not restrict children's mobility or ability to leave the premises if they wish to do so.

A children’s home cannot routinely deprive a child of their liberty without a court order, such as a Section 25 Order to place a child in a licensed secure children’s home or in the case of young people aged 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.

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.

It is also acceptable to lock doors to physically restrict the normal movement within or from the home to reduce the risk of Significant Injury or Serious Damage to Property and so long as the criteria set out above (Section 4.2, Criteria for Using Physical Intervention) are met i.e. where the injury or damage to property is likely in the predictable future, that the locking of the door is immediately necessary, used as a last resort and for the minimum amount of time necessary to de-escalate the situation*. If such methods are used in the home, the following must apply:

1. The home’s Statement of Purpose must clearly state the policy and strategies for using such methods;
2. Placing Authorities must have their attention drawn to the use of such methods and the individual Placement Care Plans for Children should refer to them and describe the circumstances where such strategies may be used;
3. Such restrictions for one child do not impose similar restrictions on other children.

*If such strategies are used upon a child on a frequent or extended basis, it may be a form of restriction of liberty, which is not acceptable; therefore, the social worker must be notified to give consideration to an application being made for a Secure Accommodation Order.

6. Notifications

If Physical Intervention 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 Designated Manager (Restraint)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.

7. Medical Assistance & Examination

Where Physical Intervention 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 Intervention.

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.

8. Recording and Management Review

If a child has an Education, Health and Care Plan in which a specific type of restraint is used as part of the day to day child’s 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 us, the restraint used must be recorded. Any other restraint used must always be recorded.

8.1 Recording

All forms of Physical Interventions should be recorded in the Physical Interventions Log and an Incident Report must be completed (see template in Local Resources).

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

Ideally within 24 hours the child involved in the restraint should be able to express their feelings about this experience and should be encouraged to record their views to the record of restraint.

8.2 Management Review

The child's Individual Placement Care Plan/Safe Care 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.