Restrictive Physical Intervention

REGULATIONS AND STANDARDS

The Positive Relationships Standard
Regulation 11


Contents

  1. Therapeutic Crisis Intervention (TCI)
  2. Planning for Children
  3. Definition of Physical Interventions
  4. Who may use Physical Interventions
  5. Criteria for Using Physical Interventions
  6. Locking or Bolting of Doors
  7. Notifications
  8. Medical Assistance and Examination
  9. Recording and Management Review


1. Therapeutic Crisis Intervention (TCI)

Hull City Council, Children’s Social Care have adopted "Therapeutic Crisis Intervention" (T.C.I.) as the method of behaviour management within Children's Homes.

Therapeutic Crisis Intervention was developed by Cornell University in the United States of America. The University administers and oversees training and development of this model.

"Therapeutic Crisis Intervention" (T.C.I.) is a crisis prevention and intervention model for residential child care. It assists organisations in preventing crises from occurring, avoiding potential crises, managing acute physical behaviour, reducing potential and actual injury to young people and staff. T.C.I. can also help young people develop coping skills.

This model gives all carers a framework for implementing a crisis prevention and management system that reduces the need to rely on high-risk intervention.

All employees of Hull City Council who have operational responsibility for the "care" of children in Children's Homes will have undertaken and successfully completed:

  • Basic/Core Training of not less than 24 hours i.e. 3/4 days training;
  • Refreshers and updating as required by Cornell University.

Awareness Training will also be provided for employees and carers who have not completed core training or employees who do not have a primary function of caring for Children i.e. Housekeepers/Cooks/Administration staff of not less than one day's duration.

Children's Social Care will establish, develop and maintain a core group of Therapeutic Crisis Intervention trained trainers. This will be a minimum of one trainer per home. The group of trainees will establish a support network and be used to offer guidance on employee/carer competence.

Hull City Council and its employees/carers acknowledge that the very nature of the work brings with it contact with vulnerable and distressed young people. It is everyone's duty to support and protect children and young people. Staff and carers must work in a way which de-escalates situations by supporting children to control their behaviour.

The goal of physical intervention is safety. When young people place themselves and others at risk of harm, caring adults must take control however briefly, with the intent of keeping them safe in the moment of crisis and then ultimately, teaching them the skills necessary for self control.

All early and safety interventions should be promptly recorded using approved documentation. Responsible managers will ensure that within 24 hours of the use of measures of control including safety intervention a written record is made. Reports will be used to inform practice.

Occasions may arise when safety interventions cannot be fully or successfully applied. Staff and carers should inform the Home Manager or Senior Care Officer as soon as possible verbally and in a written format recording the events.

On admission each child will have formulated an Individual Crisis Management Plan which clearly records methods of dealing with challenging behaviour. The child's individual needs should be clearly emphasised and if certain circumstances prevent any forms of the technique it must be recorded. All individual plans should highlight any health needs, and particular attention should be given to conditions which may restrict the use of safety interventions.

Therapeutic Crisis Intervention requires employees to have a reasonable level of skill, aptitude, physical and emotional health. On occasions where the Managers professionally conclude that employees are unable to meet the requirements, they should be referred to Occupational Health for advice and support.

Children's Social Care will ensure that employees have the resources, training, supervision and support to enable them to reach the required standards. Where difficulties arise, consideration will be given to the appropriate Human Resources policies.


2. Planning for Children

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

If any risks exist, strategies should be agreed to prevent or reduce the risk. These strategies may include Physical Interventions. Staff in the children’s home should continually review any risk assessments.

Where physical intervention 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'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 be consulted regarding appropriate 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.

NOTE

The absence of a strategy in the 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 that it was not sufficient to prevent injury or damage to property.

Any deviation from an agreed plan or must be reported to the home’s manager and child's social worker without delay.


3. Definition of Physical Interventions

There are four broad categories of physical intervention.

  1. Restraint: is 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;
    • Restraint also includes restricting the child’s liberty of movement. This can include changes to the physical environment of the home, the removal of physical aides or the locking or bolting of a door in order to contain or prevent a child from leaving. These should all be recorded as restraint.

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;

  1. Holding: 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;
  2. Touching:  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;
  3. Presence: is 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.


4. Who may use Physical Interventions

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 genital areas;
  5. Avoid hyperextension, hyper flexion and pressure on or across the joints;
  6. Not employ potentially dangerous positions.


5. Criteria for Using Physical Interventions

There are different criteria for the use of restraint and other forms of physical intervention, such as holding, touching and physical presence:

  1. Restraint - Regulation 20 sets out the only purposes for which restraint can be used: • preventing injury to any person (including the child who is being restrained);
    • Preventing serious damage to the property of any person (including the child who is being restrained); or
    • Preventing a child who is accommodated in a secure children's home from absconding from the home.

When restraint 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.

  1. Other forms of physical intervention, such as holding, touching or physical presence, are less forceful and restrictive than restraint, and may be used to protect children or others from less serious injury or damage to property;
  2. Restraint may not be used to force compliance or as a punishment where Significant Harm or serious damage to property are not otherwise likely.

A child/young person can be prevented from the leaving the home if it is felt they are at risk of Significant Harm due to:

  • Child sexual exploitation;
  • Gang related activities;
  • Misuse of drugs.

This 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 any 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, a planning meeting should held with the placing authority to consider the appropriateness of the placement.

When strategies to manage behaviour are agreed in Placement Plans, they will be subject to a may be recognised that this is a process of ‘testing’, and as such the effectiveness of any strategies will need to be  reviewed in conjunction with the local authority. The review should be clearly documented, and any agreement must not conflict with regulations regarding 'Deprivation of Liberty'


6. 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.

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 5, Criteria for Using Physical Interventions) 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 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.

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.

There are some limited circumstances however, where doors may be and possibly should be locked:

  1. Where it is immediately necessary to prevent harm to any person or serious criminal damage. This action must be only for a reasonable and limited period of time e.g. until the risk has passed or alternate and more appropriate control measures have been organised. In such circumstances there must be a clear record of action taken and justification for those actions;
  2. To prevent access of any unauthorised persons wishing to gain access to young people or the premises for illicit or illegal purposes, for instance issues relating to child sexual exploitation or abuse, bullying, threatening behaviour etc. This action must be only for a reasonable and limited period of time e.g. until the risk has passed or alternate and more appropriate control measures have been organised, such as calling the police for assistance. In such circumstances there must be a clear record of action taken and justification for those actions;
  3. During the hours of dusk to dawn, as a reasonable security/safety measure. NOT in order to restrict the free movement of resident young people in or out of their unit/home, nor as a method of control. There may however, be significant risks in allowing young people to leave the unit/home at night without staff knowledge and therefore supervision. As such, young people wanting to leave at night will need to ask a member of the residential staff team or waking night care assistants to open the external door. These staff, having where necessary consulted the senior on duty, will then decide whether to let the young person leave or not based on the risk assessments on file or an impromptu additional risk assessment made owing to any presenting unforeseen circumstances. In such circumstances there must be a clear record of action taken and justification for those actions.

It is important that staff decisions to lock doors are in keeping with and guided by each young person’s Placement and Behaviour Management Plans, risk assessments and have line management approval. Prior approval should be sought where possible and where this is not possible, immediate retrospective approval for them to remain locked or a decision made to unlock them.

*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 give consideration to an application being made for a Secure Accommodation Order


7. Notifications

If physical intervention is used upon a child, the home’s manager and the child'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's parent(s) and, if so, who should do so.


8. Medical Assistance and Examination

Where Physical Intervention has been used, the child, staff and others involved must be able to call for 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.


9. 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 use, the restraint used must be recorded. Any other restraint used must always be recorded.

9.1 Recording

All forms of physical interventions should be recorded in the Restraint Log and an incident report must be completed.

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.

9.2 Management Review

The child's Placement 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.

Recording Steps

STEPS ACTION FORMS
1. On admission all children will have an individual crisis management plan put together. Children's Home Manager/Social Worker ICMP/RCC/02
2. All challenging behaviours will be dealt with using the principals contained within the Therapeutic Crisis Intervention (TCI) reference guide. By all residential child care employees T.C.I. Reference Guide
3a. All early and safety interventions will be recorded. By all residential child care staff within 24 hours of the event. Notification of serious events NSE/RCC/ 02
3b. On occasions where safety interventions cannot be fully or successfully applied. By all employees to notify the Children's Home Manager, verbally and in writing, of unsuccessful application. Children's Homes will use the notification of Serious Event Incident Form.
4. All notifications of the use of early and safety interventions will be endorsed by the Children's Home Manager. Notification of serious event forms and incident reports will be given to the Children's Home Manager. As above.
5. Managers, who have responsibility for the oversight of the behaviour management system, will be told of serious events and receive reports of all events. Children's Home Managers will prepare an analysis report each month for the Service Managers. Notification of serious events or incident report.
Any other reports as required.