RESTRICTIVE PRACTICE Ethical, legal and practical issues It’s not just about CQC! Do the right thing and be seen to do it!

Aims of the session Explore the balance between freedom and restriction Enhance the safety and well being of students Understand and answer some of the issues arising regarding restrictive practice and restraint Increase competence and confidence in specialist colleges in the area of restriction/deprivation Generate specific issues and questions to share with relevant bodies, including inspectorates

Physical restraint/intervention Seclusion/withdrawal Chemical intervention/restraint Electronic surveillance Institutional/cultural practice There are others Restrictive Practice

Restraint is illegal unless it can be properly justified For example If not acting is against your duty of care If it prevents significant harm to self or others Person consents to it**** It is an emergency situation Legal position

Mental Capacity Act The Mental Capacity Act 2005 set out five key principles: we must begin by assuming that people have capacity. people must be helped to make decisions if they need help. unwise decisions do not necessarily mean lack of capacity. decisions must be taken in the person’s best interests. decisions must be the least restrictive of freedom as is possible

Establish capacity/lack of Best interest meetings Involve IMCA Inform CQC Date to review decision Deprivation of Liberty Safeguards DOLS

Starting points Rights Dignity Freedom Choices Risk taking to promote learning and development for life

Some Lessons From Winterborne View Closed culture Lack of appropriate focus Lack of management supervision Restrictive culture and practice Lack of commissioning oversight It couldn’t happen here!

CQC, CSSIW comments Too few applications for DOLS Under developed training/knowledge of MCA/DOLS Not all staff covered or training updated Regional variations in frequency of applications Under reporting of DOLS applications sent to CQC Concerns re complexity of safeguards

More from CGC CSSIW “Improvement needed in recognising when restrictions, restraints and sanctions amount to a deprivation of liberty” “Lack of access to clear information and knowledgeable support, low levels of referrals to IMCAs,......lack of challenge to authorisations and rare use of reviews to challenge individual authorisations to confirm that needs are being met are matters of concern” “Some good practice involving people and their families/carers in decision making”

“Another Way” VODG Nov 2011 Putting people and families at the centre with co-production and personalisation Working together and leadership for commissioners and providers Integrated solutions, such as pooled budgets Positive behavioural support approaches which focus on the individual and on the triggers of challenging behaviour, not just on preventing such behaviour MacIntyre, Affinity Trust, Deafblind UK, NWPBS Salford

How do you know what is going on? What safeguards are there for individuals and support staff? What are you concerned about? Your role in minimising restrictive practice

Restraint good practice Last resort Best interests Proportionate, minimum time and severity Follows written guidance Part of a wider plan Risk assessed for all Reviewed and reported regularly Staff competence measured and recorded over time

Restriction by the back door? You see a person in the enclosed back garden with a member of staff standing close to the door in to the house. The person in question is showing some signs of distress. Is it restrictive? What more do you need to know? What makes it more/less restrictive?

Restriction by the back door again? You notice in the daily report that X has not gone out on a planned trip due to his ‘inappropriate’ behaviour Is this restrictive? What more do you need to know? What makes it more/less restrictive?

Restrictive? Appropriate? You notice in the log that Y has had 3 episodes of behaviour which required restraint. What more do you need to know? Is this restrictive or abusive? How do you ensure that the practice is appropriate?

Towards excellent practice A positive culture Environments Staff Systems Leadership

Environments Accessibility Comprehensible Quality

Staffing Numbers Quality, attitudes, values, reflection, support Skills, general and specific Leadership at all levels MacIntyre Great Interactions; recruiting people with good attitudes, developing specific skills and behaviours, placing duty on all employees for their own practice 1% improvement in 100% of interactions better than100% improvement in 1% of interactions!

Systems Holistic, personalised planning, involve person and family carers in decisions Minimal use of restrictive approaches as part of whole plan. (BILD code of practice) Regular transparent review and reporting of arrangements Training from accredited trainers, develop internal trainers? Records of trained staff, check competence over time

Leadership Visible, ‘present’ leadership Managers and leaders need good understanding and investment in the process don’t delegate it too far down the ‘food chain?’ Lead by example open culture of reflection and feedback Support for concern raising and whistleblowing Open and outward looking

So what? Improve Mental Capacity DOLS understanding All levels Individuals and family carers Are we referring enough? Improve capacity assessments Involve relevant people CQC to be informed if DOLS application

What will you do next? 1. as an individual 2. as a college 3. as NATSPEC Questions/comments? Next steps?

Some useful websites/publications The Challenging Behaviour Foundation, Physical interventions, A Policy Framework BILD 2008 Ethical Approaches to Physical Interventions BILD 2002 Reducing the use of restrictive practices with people who have intellectual disabilities David Allen BILD 2011

Name Martin Bertulis Practice and Planning Specialist Tel: