PowerPoint Presentation: Managing Challenging Behaviour Training for Home Care Produced by Bob Wade Training for Home Care 2012: Overview: Overview What is Challenging Behaviour Factors in difficult situations Primary Prevention Secondary Prevention Dealing with Incidents Restrictive Physical Intervention Legislation and Guidance After an Incident Active Support to help individuals manage difficult situations What is Challenging Behaviour?: What is Challenging Behaviour? ???? Your views ???? What is Challenging Behaviour? : What is Challenging Behaviour? Behaviour that is considered unacceptable and abusive Verbal abuse (racist comments, threats, bullying) Physical abuse (assault) Self-destructive behaviour Destructive to other people Destructive to items in the environment Destructive to property Illegal behaviour HARMFUL BEHAVIOUR - abuse What is Challenging Behaviour?: What is Challenging Behaviour? “Behaviour of such intensity, frequency or duration that the physical safety of the person or others is placed in serious jeopardy or behaviour which is likely to seriously limit or deny access to the use of ordinary community facilities” (Emerson et al 1994) – often quoted “Behaviour … of such an intensity, frequency or duration as to threaten the quality of life and/or the physical safety of the individual or others and is likely to lead to responses that are restrictive, aversive or result in exclusion.” [Royal College of Psychiatrists, British Psychological Society & Royal College of Speech & Language Therapists (2007)] Day-to Day Definitions : Day-to Day Definitions Abusive? Unacceptable? Staff definitions? Service User definitions? Relatives definitions? Other professionals definitions? Perceptions of people about individuals' behaviour Who defines? Principle of Person-centred care? What is Challenging Behaviour?: What is Challenging Behaviour? “on an everyday basis the term challenging behaviour is socially defined. Different people, or groups of people, will have different ideas about what is meant by challenging. The same person, showing the same behaviour, may be seen as challenging by staff in one setting and not by staff in another.” ( Emerson et al 1994) Simpler definition: Challenging behaviour is a combination of two criteria:  Behaviour that we don’t like;  Behaviour that we think we need to respond to. What is Challenging Behaviour?: What is Challenging Behaviour? Two general views then: Emphasis on Individual's behaviour which is challenging, this can lead to negative responses by other people Emphasis on people's negative response to behaviour which can itself lead to individual's behaviour What is Challenging Behaviour?: What is Challenging Behaviour? SCIE: combining both views: “Working with people with dementia can be very rewarding. But situations can arise that are difficult for the person with dementia or those supporting them – or both parties.” So, not challenging behaviour, but Difficult Situations , difficult for a vulnerable individual, difficult for those supporting them, or for all parties. Dealing with difficult situations in a person centred way is the theme of this course What factors are involved in Difficult Situations: What factors are involved in Difficult Situations ? ? ? ? ? ? ? ? ? Individual Factors: Individual Factors Physical States Disability Illness Pain Maturity Sexuality Fatigue Sleep disturbance Medication side effects Mental States Learning difficulties Mental illness Perceptions Expectations Self-image Individual Factors continued: Individual Factors continued Emotional States anxiety fear confusion loss dependency temperament frustration Personality Communication abilities Knowledge and insight Training Interaction: Interaction Communication Verbal Non-verbal (tone of voice, facial expression, body posture, body movement, space, pace) Subject Clarity, understanding Listening Written Actions Behaviour Relationships: Relationships Patterns of interaction over time – patterns of behaviour Expectations Cultural norms in relationships Learned helplessness and dependencies Past experiences Groups and group behaviours Environment: Environment Physical Room design and layout, Objects Stimulating/boring Noise, light, temperature, ventilation, Crowded Social Relationships Territory, Privacy, Rules Culture, gender, age, ehtnicity Time (specific times, experience of time e.g. waiting) Situation (working alone, cash, drugs) Effect of Care Setting (institutionalisation) and organisations (policies, procedures, rules, culture, training) Model of Factors in Difficult Situations: Model of Factors in Difficult Situations Environment social & physical Worker Other Staff Other Service Users Relatives Other Professionals Individual Interaction Difficult Situations Managing difficult situations: Managing difficult situations Prevention - Primary Prevention - Secondary Dealing with incidents Reviewing incidents and forward planning Primary Prevention: Primary Prevention Ensuring numbers of staff and their level of competence corresponds to needs of service users. Staff should not be left in vulnerable positions Care plans which are responsive to individual needs and include current information on risk assessment Creating opportunities for service users to engage in meaningful activities which include opportunities for choice and a sense of achievement Developing staff expertise Talking to service users, their families and advocates about the way they prefer to be managed when they pose a significant risk to themselves and others Helping service users to avoid situations which are known to provoke difficult situations (e.g. settings where there are few options for individualised activities) – avoidance strategies Primary Prevention continued: Primary Prevention continued you communicate with others in a manner which: is appropriate to them encourages an open exchange of views and information minimises any constraints to communication is free from discrimination and oppression acknowledges the rights of everyone present and is supportive of those rights you maintain the environment in a way which encourages meaningful interactions you take actions to maintain calmness and safety in a manner which minimises any restriction of movement and which does not deny people’s rights Secondary Prevention: Secondary Prevention Recognising the early stages of a behavioural sequence that is likely to develop into difficult situations and employing 'defusion' techniques to avert any further escalation Secondary Prevention continued: Secondary Prevention continued Diversion strategies – diverting into other activities Use of space – finding alternative spaces Use of people – finding alternative people Removal of triggers – objects, situations, people Refocusing – providing time and space to calm down and talk through the problem, getting the individual to describe the problem, think about it and refocus about it, rather than acting out anger etc. Providing face-saving alternatives from which a person can choose Enable individual to find alternative ways to express their feelings Protect potential victims at whom the behaviour may be directed Informing the team, getting help Dealing with Incidents: Dealing with Incidents you take constructive action to minimise identified abusive and aggressive behaviour which is consistent with: any inherent risks the maintenance of effective working relationships agency policy and procedures evidence of effective practice you acknowledge opposing interests and take constructive action to address them you take prompt action to protect those at whom the abusive and aggressive behaviour is directed you take constructive action to defuse abusive and aggressive behaviour you call for any necessary assistance and support without delay Dealing with incidents continued: Dealing with incidents continued you act in a manner which is likely to promote calm and reassurance and make this clear to all involved you manage physically aggressive behaviour in ways which are consistent with statutory and agency requirements and use the safest possible methods for: the individual, you, others you complete records accurately and clearly and store them according to agency requirements. Defusing: Defusing What do you control – yourself, defusing yourself Relaxation techniques – breathing, releasing rigidity in body Defusing your mind – positive thoughts, care values/principles, it's not personal Defusing others – communication Non-verbal Space, allow both you and individual an exit Place furniture between you Stay with individual's direct vision Avoid physical contact Maintain eye-cheek contact Defusing continued: Defusing continued Defusing others - communication Verbal Maintain verbal contact, avoid silence Use individual's name, repeat frequently Find ways of expressing own distress, without being overwhelmed Keep statement simple Repeat requests Assertiveness techniques – clear communication Self-disclosure, partial agreement, side-stepping, gentle confrontation, simple and specific statements Exit Strategy – what happens next Physical Intervention: Physical Intervention “Ensure that restrictive physical interventions are used as infrequently as possible, that they are used in the best interests of the service user, and that when they are used, everything possible is done to prevent injury and maintain the person's sense of dignity. Restrictive physical intervention should be seen as one part of a broader strategy to address the needs of children and adults whose behaviour poses a serious challenge to services.” “As a general rule, restrictive physical interventions should only be used when other strategies (which do not employ force) have been tried and found to be unsuccessful or, in an emergency, when the risks of not employing a restrictive intervention are outweighed by the risks of using force.” “Restrictive physical intervention should employ the minimum reasonable force [applied for the shortest period of time] to prevent injury or avert serious damage to property.” - proportionality Physical Intervention: Physical Intervention “The use of restrictive physical interventions should be minimised by the adoption of fully documented risk assessment and preventative strategies whenever it is foreseeable that the use of force might be required.” “However, staff should be aware that, in an emergency, restrictive physical interventions are permissible if they are necessary to prevent injury or serious damage to property.” The organisation must have a policy on the use of restrictive physical interventions Should describe both good practice and unacceptable practice Use of RPI must always be recorded in incident book with numbered pages All staff who may use RPIs must receive specialised training (BILD Code of Practice accredited trainers) and only employ methods they have been trained in PI – some definitions: PI – some definitions Restrictive vs. non-restrictive physical interventions: Restrictive PI involve the use of force to control a person's behaviour Non-restrictive PI do not involve force to control e.g manual guidance to assist a person walking, use of protective helmet to prevent self injury, removal of environmental cause of distress (adjusting temperature, light, background noise) Types of RPI: Bodily contact (holding a person's hand to prevent them hitting someone Mechanical (use of arm cuffs or splints to prevent self injury) Environmental (forcible seclusion, use of locked doors) Planned intervention Emergency intervention RPI – Legal Considerations: RPI – Legal Considerations Human Rights Act 1998 – protection from abuse by state organisations Criminal Law – criminal offence to use physical force or threaten to use force, criminal offence to lock individual in a room Civil Law – for damages if results in injury (including psychological) Health and Safety – responsibilities to keep people safe, assess risks, have and use safe systems of work Health and Social Care Act 2008 & Regulations & CQC 'Essential Standards for Quality and Safety' Legislation and Guidance: Legislation and Guidance Mental Capacity Act 2005 & Codes of Practice CSCI Guidance 'Rights, Risks and Restraints' 2007 Valuing People 2001 – legal and civil rights, promoting independence, choice, inclusion, person centred planning Department of Health (2000) No Secrets Guidance Department of Health (2001) 'A Safer Place: Combating Violence against Social Care Staff Department of Health (2002)'Guidance for Restrictive Physical Interventions' BILD (2001) Code of Practice for Trainers in the Use of Physical Interventions Department of Health 'Independence, Choice and Risk' 2007 After an Incident: After an Incident you encourage those involved in incidents to contribute to reviewing the incident you offer time, space and support so that everyone involved can express their feelings and examine their behaviour you explore constructively with everyone involved the reasons for, and consequences of, the abusive and aggressive behaviour you make referrals to the appropriate people if specialist help is required you make clear and constructive contributions to team discussions about incidents of abusive and aggressive behaviour and agency practice in dealing with them you manage your own feelings aroused by the incident in a way which recognises your right to have such feelings and recognises that not all incidents are capable of prevention you complete records accurately and clearly and store them according to agency requirements you provide accurate and clear information to others so that issues and needs can be addressed. Recording: Recording Why? - legal requirement, accountability, passing on information, identifying patterns, trends ABC analysis Antecedents, what led up to the incident Behaviour, details of the incident Consequences, actions taken following, reactions, responses Analyse – patterns of behaviour leading up to incident (individuals, interactions, relationships, environment, identifying triggers, identifying changes in risks Analyse – what effect do the Consequences have on individuals, interactions, relationships, environment Future planning for avoidance, diversion, defusion, staff training Examples of Difficult Situations Dementia: Examples of Difficult Situations Dementia Examples of Difficult Situations Dementia: Examples of Difficult Situations Dementia See Resource on Disk – 'Difficult situations SCIE' Handout – Refusing Help & Exercise Refusing Help Handout – A Different Reality & Case Study & Exercise A Different Reality Help & Support for Difficult Situations: Help & Support for Difficult Situations Support Plans and risk assessments Policies & Procedures – Challenging Behaviour, Mental Capacity – handouts, sign book Informal – phone office, pop into office More formal – supervision, tema meetings/supervision Training including resources given out www.scie.org.uk Dementia Gateway www.southwestdementiapartnership.org.uk www.dh.gov.uk Active Support to help individuals manage difficult situations: Active Support to help individuals manage difficult situations you work with individuals, key people and others within and outside your organisation to examine the reasons why individuals behave in particular ways identify situations, events, environments, actions, people, and the behaviour of others that might cause the behaviour you support individuals to: explore and communicate their feelings about their behaviour identify how they can overcome or avoid situations that may cause the behaviour recognise and understand the consequences of their behaviour understand the affects of their behaviour on others understand why the behaviour is unacceptable to others you support individuals to understand what might happen and the actions that would have to be taken, if they behave in ways that are: unacceptable to your organisation’s policies and procedures outside the law Active Support: Active Support you support individuals to seek and acquire specialist support to help them understand and deal with their behaviour and the reasons for it. you support and respond to individuals in a manner which values and respects them as individuals you ensure that your own behaviour and actions do not lead to situations that cause the behaviour in individuals Work with individuals to agree ways to manage their behaviour: Work with individuals to agree ways to manage their behaviour you encourage individuals to identify: the benefits of behaving in ways that are acceptable and are not challenging to others identify ways in which they can reduce their challenging behaviour you provide active support to enable individuals to identify, plan and ensure that they carry out the plans that will help them to prevent, modify and control unacceptable behaviour you work with individuals to find alternative ways to deal with and avoid situations, events, environments, actions, people and the behaviour of others that lead to the behaviour you support individuals to: achieve goals and boundaries for their behaviour review whether the goals and boundaries are being achieved review whether the goals and boundaries are helpful in dealing with behaviour you seek additional support for yourself, to enable you to work effectively with individuals who have challenging behaviour. Support individuals to evaluate actions to manage behaviour: Support individuals to evaluate actions to manage behaviour you support individuals to examine, as calmly as possible, incidents of difficult situations and the events that led up to them you work with individuals to communicate their thoughts and feelings at the point when the difficult situation occurred you encourage individuals to evaluate any changes in their behaviour when they use alternative ways of dealing with the situations, events, environments, actions, people and the behaviour of others you support individuals to: communicate which actions that have been successful in helping them to manage difficult situations and those that have been less successful examine why some actions have been successful and others less successful agree changes to plans and alternatives to help them to better manage difficult situations you seek additional support, expertise and specialist help when the management of the difficult situation is outside your scope of experience to deal with you record and report on processes and outcomes: within required timescales, within confidentiality agreements, according to legal and organisational requirements. Summary: Summary What is Challenging Behaviour Factors in difficult situations Primary Prevention Secondary Prevention Dealing with Incidents Restrictive Physical Intervention Legislation and Guidance After an Incident Active Support to help individuals manage difficult situations Restraint: Restraint Often one response to perceived challenging behaviour is to attempt to control it through some kind of restraint – so the next slides discuss restraint in its broadest sense PowerPoint Presentation: Restraint Care to Train Ltd Produced by R.G.Wade Care To Train Ltd References taken from CSCI Rights, Risks and Restraint guidance 2007 and Guidance for Inspectors 2007 What is Restraint? : What is Restraint? Mental Capacity Act 2005 definition: ' the use or threat of force to help do an act which the person resists, or the restriction of the person’s liberty of movement, whether or not they resist.' ' Restraint may only be used where it is necessary to protect the person from harm and is proportionate to the risk of harm.' CSCI guidance takes a wide view of the definition of restraint and incorporates other widely used terminology such as ‘physical intervention’ or ‘restriction of liberty’ in its scope. Types of Restraint : Types of Restraint Physical restraint can be defined as stopping an individual’s movement by the use of equipment that is not specifically designed for that purpose. This could be through the use of bed rails, belts, tables or chairs etc. Physical intervention is direct action by one or more members of staff holding or moving the person, or blocking their movement to stop them going where they wish. This should not be confused with interventions such as guiding and prompting that are intended to support the person. Mechanical restraint is the use of belts, arm cuffs, splints or helmets to limit movement to prevent self-injurious behaviour (SIB) or harm to others. Types of Restraint : Types of Restraint Environmental restraint is designing the environment to limit people’s ability to move as they might wish. This could be through locking doors, using coded electronic keypads, complicated door handles, narrow doorways, not providing corridor rails, steps or stairs, poor lighting or heating etc. Chemical restraint is the use of drugs and prescriptions to change or moderate peoples behaviour. This is also known as covert medication Forced care is the act of ‘forcing’ someone to receive care. This could be food, medication, clothing etc. Threatening or verbal intimidation this could be used to make a person subservient or scared of doing what they want to do. It may also be acts calculated to lead people to believe they have no option but to remain in a particular care setting, or make them fear repercussions should they choose to resist or leave. Types of Restraint : Types of Restraint Electronic surveillance - examples include the use of electronic tags, exit alarms, CCTV and pressure pads to monitor or restrict movement. Cultural restraint can be the result of constantly telling people not to do something, or that doing what they want to do is not allowed, is illegal, or is too dangerous. It could also include being got up or put to bed at unwanted times, or having meals at a time to suit the staff. It could also be seclusion in bedrooms because of their behaviour resulting in deprivation of activities and other stimulation Medical restraint is the fixing of medical interventions such as catheters to deliberately restrict movement or being positioned to prevent their removal. Who gets restrained? : Who gets restrained? Three groups of people were identified as the most likely to be restrained; those people: perceived as difficult or threatening who cannot be persuaded in other ways to do what others (eg care workers) wish them to, or not conforming, thereby causing a management problem who are less physically or mentally able. Who gets restrained? : Who gets restrained? “He was having his evening meal in his bedroom not the communal dining area. I asked why and the nurse in charge said she thought it was because he had shouted at the carers that morning. I found this very distressing. His care plan clearly states his cognitive ability is impaired.” Who gets restrained? : Who gets restrained? ”Usually only residents with reasonable mobility get an opportunity to go outside and then often only after a struggle and interrogation as to where they are going and for how long.” Who gets restrained? : Who gets restrained? “A resident in a wheelchair had been moving around the corridor during the night and staff had assisted him back to bed. The staff had removed the wheelchair from the room.” Who gets restrained? : Who gets restrained? ” All of the residents were up and dressed by 7.30 am. In order to supervise the 13 service users the staff members endeavoured to ensure that they were all seated in the lounge. A female resident who had dementia insisted on going downstairs to the lower ground floor. A member of night staff attempted to persuade her to go upstairs to the lounge. The situation rapidly became a confrontation with the member of staff becoming more frustrated and the resident becoming increasingly angry.” Who gets restrained? : Who gets restrained? ” A resident was shouting out and disturbing other residents; she was taken into her room and the door was closed. It was an elderly woman in a wheelchair so she was unable to leave the room. ” Main Points : Main Points Respecting people’s rights to dignity, freedom and respect underpin good quality social care. People may need support in managing their care and making decisions but they have the right to make choices about their lives and to take risks. People using care services are free to do what they want, and go where they want unless limited by law. Restraint is illegal unless it can be demonstrated that for an individual in particular circumstances not being restrained would conflict with the duty of care of the service. And that the outcome for the individual would be harm to themselves or for others. Main Points : Main Points Enabling people in care services to take risks, make choices and keeping them safe is a difficult balance. Restraint can take many different forms. It is not limited to a physical intervention by another person stopping someone doing something. It can include amongst other things the use of drugs, the environment or surveillance to restrict people’s actions. Where people in care services have capacity restraint may only take place with their consent or in an emergency to prevent harm to themselves or others or to prevent a crime being committed. Main Points : Main Points In all cases restraint should very much be seen as the ‘last resort’, with other techniques and strategies always being employed before restraint is considered as an option. Any restraint should be in the best interests of the person. Based upon the level of risk present, taking account of the person’s size, gender, age and medical conditions. It should be used for the minimum amount of time and with the least amount of intervention. Any restraint should always follow agreed policies and procedures that focus on best practice and improved outcomes for the individual. Main Points : Main Points The misuse of physical restraint has resulted in many injuries, and in the most serious case, deaths. If restraint is seen to be necessary to maintain an individual’s safety, or the safety of others, the agreed methods of how and when it should be used must be clearly detailed, and those involved in the intervention must have received the appropriate training. Duty of Care : Duty of Care ‘ Independence, choice and risk a guide to best practice in supported decision making’ (DH 2007) defines duty of care as ‘ obligation placed on an individual requiring that they exercise a reasonable standard of care while doing something (or possibly omitting to do something) that could forseeably harm others’. This means that when people using services voluntarily choose to live with a level of risk (and have mental capacity to make these decisions) there can be no breach of duty of care. Duty of Care : Duty of Care Historically duty of care has been seen as a way of limiting risk, reducing choice and imposing restrictions on how people live their lives. The principle of duty of care should inform the risk assessment process, but not be used as an excuse to artificially create limits on peoples’ rights and choices to live the lives they choose Mental Capacity Act 2005 : Mental Capacity Act 2005 5 key principles: A person is assumed to have capacity. People must be helped to make decisions. Unwise decisions do not necessarily mean lack of capacity. Decisions must be taken in the person’s best interests. Decisions must entail the least possible restriction of freedom. Mental Capacity Act 2005 : Mental Capacity Act 2005 The Act defines restraint and gives criteria that need to be met for restraint to legally occur, they are: The person lacks capacity and it will be in the person’s best interests and It is reasonable to believe that it is necessary to restrain the person to prevent harm to them and Any restraint is a proportionate response to the likelihood of the person suffering harm and the seriousness of that harm Preventing Need for Restraint : Preventing Need for Restraint Primary prevention is based on: Putting systems and process in place to limit the possibility of the need for restraint Having an awareness of the person’s needs and methods of communication. Working in a person centred way. Having sufficient staff numbers available. Having a staff team that is skilled, experienced and used to supporting the person. Helping people using services to avoid difficult situations that might escalate. Understanding potential triggers of behaviour that might result in the need for restraint. Using person centred plans. Preventing Need for Restraint : Preventing Need for Restraint Secondary prevention is more immediate action that needs to be taken if the primary prevention has not been successful, and is based on: Diffusion and de-escalation of behaviour. Recognising and acting upon the early stages of when behaviour could escalate into violence or aggression. Preventing Need for Restraint : Preventing Need for Restraint Use person centred planning, and a person centred approach when providing care to a person. Recognise the particular needs of people regarding their race, gender including gender identity, sexual orientation, disability, age, religion or belief. Joint working approaches to care: extended multi- professional team e.g. Speech and language therapist, psychologist, occupational therapist. Use risk assessments to provide governance to actions that might be seen as restraint. Be using therapeutic alternatives to restraint and understanding that restraint must only be used as a ‘last resort’. Be aware that the buildings and the environment may constitute a form of restraint, and be proactive in how they enable people to make choices. Preventing Need for Restraint : Preventing Need for Restraint Provide a range of person centred activities and programmes for people using the service to increase stimulation. Ensure that people who use services are enabled to communicate their needs. Provide chairs and beds that do not limit movement. Ensure that there are continence programmes in place for people that need them. Ensure that there is clarity provided to staff about what is acceptable practice. Constantly monitoring and managing staff attitudes and behaviours. Monitor the effect of medication and arrange regular medication reviews. Monitor and clearly record of the use of ‘as required’ (PRN) medication. Preventing Need for Restraint : Preventing Need for Restraint Be aware that when a person is happy, contended and ‘free from fear’ they are less likely to demonstrate behaviours that could necessitate restraint. Be proactive in the assessing and predicting triggers for behaviour that could result in restraint. Monitor behaviour and regularly review care plans. Train staff appropriately and raise awareness of restraint. Have good policies and procedures – which have input from people using services. Ensure that people using services are kept as mobile as possible, and use innovative methods to achieve this. Ensure that people who use services have regular contact with their legally appointed representative or mental capacity advocates, and that these people are routinely consulted when restraint is an issue. Restraint : Restraint Appropriately trained staff That it is only being used as a final option when there is no less restrictive alternative. It should be used for the shortest possible time and as safely as possible. Clear policies and procedures about restraint that: Reflect current legislation and best practice. Have been developed with the input of people that use services and professionals. Clearly explain what is meant by restraint and its scope. When restraint can be used and the procedures to follow Are widely known by staff and explained to people that use services. Are regularly reviewed. Restraint : Restraint Risk assessments that: Are relevant for the risk assessment of identified behaviour Are individualised. Are relevant for specific situations, and not generic. Use information included within the person’s care plan. Balance the activity with potential for the risk of harm. Involve the person using services and / or others people important to the person using services. Recognise the wider scope of restraint including possible environmental, chemical and cultural restraint. Use a multi disciplinary approach. Explore alternatives to restraint Focus on prevention Restraint : Restraint Record when restraint has taken place. This recording should be: Clear, consistent and individualised. Completed as soon after the event as possible. Used to identify why restraint took place. Used to detail what actually happened, including: When?, Who was involved? How long the restraint lasted?, What form did the restraint take?, Were there any injuries?, Was there any impact of the restraint on other people using the service?, Have the relevant people been informed that restraint took place? Restraint : Restraint Recording continued Used to record what has been learnt, including: What did not work well?, What did work well?, What could be done differently, and was the least restrictive form of restraint used?, Are there any training needs identified for staff?, Discussing the event with the person using services and seeking and recording their views., Does the person’s care plan need updating?, Are risk assessments still valid?, What are the implications for debriefing people that use services, staff or other witnesses Restraint : Restraint Any planned restraints should be monitored and regularly reviewed to ensure that they are still appropriate to meet the need and are part of a more proactive approach to reducing the impact of the person’s behaviour. Recording should show evidence of consultation with any legally appointed representatives, or mental capacity advocates. Staff Training : Staff Training Staff should receive training in the wider implications of restraint (including legal issues) and the different types of restraint. Training should be provided in the area of equality and diversity to help recognise particular issues regarding a persons race, gender including gender identity, sexual orientation, disability, age, religion or belief. Training should be based on an audit of the specific needs of the people being supported, and tailored to address these identified needs. Staff should not receive training in unacceptable restraint methods as this could legitimise restraint that should not be used in any circumstances. Any staff using planned physical intervention must have had appropriate training in its use. Physical interventions training delivered to staff who work with people with learning disabilities should be from a source accredited by BILD (British Institute of Learning Disabilities). Legislation and Guidance : Legislation and Guidance Care Standards Act 2000 and it’s associated regulations (e.g. Care Homes Regulations 2001, Domiciliary Care Agencies Regulations 2002 [Regulation 13 (7) (a), 13 (7)(b), 13(8), 12(1)(a), 12(3), 13(6)] The Human Rights Act 1998 Mental Capacity Act (MCA) 2005 Department of Health (DH) ' Guidance for restrictive physical interventions. ‘ Independence, choice and risk a guide to best practice in supported decision making’ (DH 2007) Information and Advice : Information and Advice CSCI guidance on: Mental Capacity Act 2005 Equipment and restrictive practice Legal briefing on Mental Capacity Act 2005 CSCI study on restraint (released December 2007) CSCI learning and resource centre Mental Capacity Act code of practice British institute for Learning Disabilities (BILD) Counsel and Care Nursing and Midwifery Council (NMC) Royal College of Nursing (RCN) Department of Health (DH) guidance on restrictive practices National Institute on Mental Health Excellence (NIMHE) Health and Safety Executive (HSE) Tensions : Tensions Balancing people's rights to make their own decisions and responsibilities to protect from harm Dilemmas and ambiguities Complexity of job of caring Resolving these in day-to-day care practice What do you do? How do you get help? Tensions : Tensions At the core of positive practice lies recognition of the authority of the older person to determine how they want to live. Nevertheless, asserting these rights does not resolve each situation for staff. Tensions remain: does the lifestyle within the home, what staff say and do, help people to live as they want or prevent them from doing so? How do staff respond to relatives’ concerns, but also assert the authority of older people to determine how they want to live? And in the minutiae of daily life, when does the comfort of a reclining chair turn to restraint, or the convenience of a table beside a chair or the safety of a lap belt turn into a means of immobilising? Staff need every support in dealing with these tensions . Deprivation of Liberty Safeguards: Deprivation of Liberty Safeguards From Mental Capacity Act 2005 and European Court of Human Rights ruling (Bournewood case) specifically through Mental Health Act 2007 MCA DOLS exist to protect people who cannot make decisions about their care and treatment when they need to be cared for in a particularly restrictive way. Standard process that hospitals and care homes should follow if they think it will be necessary to deprive a person of their liberty to deliver a particular care plan that is in the person’s best interests. Deprivation of Liberty Safeguards: Deprivation of Liberty Safeguards no single definition or a standard checklist ECtHR has said deprivation of liberty depends on the specific circumstances of each individual case Case Law, EctHR and UK courts: restraint was used to admit a person to a hospital or care home when the person is resisting admission medication was given forcibly, against a patient’s will staff exercised complete control over the care and movements of a person for a long period of time staff took all decisions on a person’s behalf, including choices relating to assessments, treatments, visitors and where they can live hospital or care home staff took responsibility for deciding if a person can be released into the care of others or allowed to live elsewhere Deprivation of Liberty Safeguards: Deprivation of Liberty Safeguards when carers requested that a person be discharged to their care, hospital or care home staff refused the person was prevented from seeing friends or family because the hospital or care home has restricted access to them the person was unable to make choices about what they wanted to do and how they wanted to live, because hospital or care home staff exercised continuous supervision and control over them. The court’s decision recognises a distinction between restriction and deprivation of liberty, said to be one of 'degree or intensity'. Deprivation of Liberty Safeguards: Deprivation of Liberty Safeguards From these cases you can see two strands of what Deprivation of Liberty means: Takig away rights to decide where their treatment or care is given Liberty to decide taken away to protect them from harm, often for prolonged period Deprivation of Liberty Safeguards: Deprivation of Liberty Safeguards Who is covered by the MCA DOLS? The MCA DOLS apply to people in hospitals and care homes who meet all of the following criteria. A person must: be aged 18 or over suffer from a disorder or disability of mind; and lack the capacity to give consent to the arrangements made for their care or treatment; and for whom such care (in circumstances that amount to a deprivation of liberty within the meaning of Article 5 of the ECHR) is considered, after an independent assessment, to be a necessary and proportionate response in their best interests to protect them from harm. When should MCA DOLS be used?: When should MCA DOLS be used? should be used for all people in hospitals or care homes who lack the capacity to make their own decisions and where personal freedoms need to be restricted in the patient’s best interests, to the extent that they amount to a deprivation of liberty. The MCA DOLS should not, however, be used if a person meets the criteria for detention under the Mental Health Act 1983 and either is, or should be, detained under the terms of that Act. When should MCA DOLS be used?: When should MCA DOLS be used? The managing authority (the hospital or care home) must apply to the supervisory body (the PCT in the case of hospitals or local authority in the case of care homes) for authorisation of deprivation of liberty if a person who lacks capacity is: about to be admitted to the hospital or care home and the managing authority believes the person risks being deprived of their liberty already in the hospital or care home and is being cared for or treated in a way which deprives them of their liberty. Managing Challenging Behaviour: Managing Challenging Behaviour Planning and managing situations and behaviours  Primary Prevention, minimising the factors that contribute to situations and behaviours. Prevents violence or abusive/harmful behaviour so that restraint as a reaction to such behaviour is not necessary  Secondary Prevention, recognising the early stages of a behavioural sequence that is likely to develop into challenging behaviour and employing 'defusion' techniques to avert any further escalation  Non-restrictive interventions when reacting to violent, abusive/harmful behaviour  Restraint, restrictive interventions Factors which contribute to a violent situation: Factors which contribute to a violent situation Factors which contribute to a violent situation: Factors which contribute to a violent situation Individual factors: Physical States Disability, Illness, Pain, Maturity, Sexuality, Fatigue, Sleep disturbance, Medication side effects Mental States Learning disabilities, Mental illness, Perceptions, Expectations, Self-image Emotional States Anxiety, fear, confusion, loss, dependency, temperament, frustration Personality Communication abilities Knowledge and insight Training Factors which contribute to a violent situation: Factors which contribute to a violent situation Interaction factors: Communication Verbal, Non-verbal (tone of voice, facial expression, body posture, body movement, space, pace), Subject, Clarity, understanding, Listening, Written Actions Behaviour Relationships Patterns of interaction over time – patterns of behaviour, Expectations, Cultural norms in relationships, Learned helplessness and dependencies, Past experiences, Groups and group behaviours Factors which contribute to a violent situation: Factors which contribute to a violent situation Situational (and environmental) Physical Room design and layout, Objects, Stimulating/boring, Noise, light, temperature, ventilation, Crowded Social Territory, Privacy, Rules, Culture, gender, age, ethnicity Time (specific times, experience of time e.g. waiting) Situation (working alone, cash, drugs) Effect of Care Setting (institutionalisation) Primary Prevention: Primary Prevention Ensuring numbers of staff and their level of competence corresponds to needs of service users. Staff should not be left in vulnerable positions Care plans which are responsive to individual needs and include current information on risk assessment, person centred Creating opportunities for service users to engage in meaningful activities which include opportunities for choice and a sense of achievement Developing staff expertise Talking to service users, their families and advocates about the way they prefer to be managed when they pose a significant risk to themselves and others Helping service users to avoid situations which are known to provoke challenging behaviour (e.g. settings where there are few options for individualised activities) – avoidance strategies Primary Prevention: Primary Prevention Active Support to help individuals manage challenging behaviour you work with individuals, key people and others within and outside your organisation to examine the reasons why individuals behave in particular ways identify situations, events, environments, actions, people, and the behaviour of others that might cause the behaviour you support individuals to: explore and communicate their feelings about their behaviour you work with individuals to find alternative ways to deal with and avoid situations, events, environments, actions, people and the behaviour of others that lead to the behaviour recognise and understand the consequences of their behaviour understand the affects of their behaviour on others understand why the behaviour is unacceptable to others Primary Prevention: Primary Prevention Active Support to help individuals manage challenging behaviour you support individuals to understand what might happen and the actions that would have to be taken, if they behave in ways that are: unacceptable to your organisation’s policies and procedures outside the law you support individuals to seek and acquire specialist support to help them understand and deal with their behaviour and the reasons for it. you support and respond to individuals in a manner which values and respects them as individuals you ensure that your own behaviour and actions do not lead to situations that cause the behaviour in individuals Secondary Prevention: Secondary Prevention Recognising the early stages of a behavioural sequence that is likely to develop into challenging behaviour and employing 'defusion' techniques to avert any further escalation Secondary Prevention: Secondary Prevention De-escalation Techniques: Diversion strategies – diverting into other activities Use of space – finding alternative spaces Use of people – finding alternative people Removal of triggers – objects, situations, people Providing face-saving alternatives from which a person can choose Enable individual to find alternative ways to express their feelings Secondary Prevention: Secondary Prevention Therapeutic Techniques: Relaxation techniques Refocusing – providing time and space to calm down and talk through the problem, getting the individual to describe the problem, think about it and refocus about it, rather than acting out anger etc. General: Protect potential victims at whom the behaviour may be directed Informing the team, getting help Non-restrictive Reactions: Non-restrictive Reactions Defusing Techniques (to take the steam out of a situation) Defusing yourself – relaxation techniques Physical - breathing, releasing rigidity in body Defusing your mind – visualisation techniques, positive thoughts, care values/principles, it's not personal Defusing others – communication techniques Non-verbal: eye-cheek contact, facial exressions, tone of voice, posture, positioning Verbal: personalise, clear and concise, assertive, non-confrontational Active listening Diversion techniques (as in Secondary) Restrictive Interventions: Restrictive Interventions Principles: respect for the dignity of older people, respect for autonomy, promoting overall well-being, promoting self-reliance From the Mental Capacity Act: 1. A person must be assumed to have capacity unless it is established that they lack capacity. 2. All practicable steps to help him to make decisions have been taken 3. A person can make an unwise decision. 4. An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests. 5. Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action . Restrictive Interventions: Restrictive Interventions Where there is judged to be an immediate risk of harm to the individual or others, restraint would be legitimate if: consideration is given to the best interests of the individual and others there is a serious risk of harm to older people or others the intervention is proportionate to the risk of harm other methods to control the situation, such as de-escalation, have been tried, found to be unsuitable or failed the least practicable amount of force is used for the shortest time used according to agreed guidelines (that are regularly audited and revised) and where a risk assessment has been conducted and decisions fully recorded it is a last resort, as an urgent action only to be used in exceptional circumstances.