Restrictive Physical Intervention

The use of any physical intervention with a child is considered as a last resort and only if there is no safer alternative. The use of de-escalation skills and techniques should be prominent at all times.

Restrictive interventions are defined by the Department of Health as: ‘deliberate acts on the part of other person(s) that restrict an individual’s movement, liberty and/or freedom to act independently in order to:

• Take immediate control of a dangerous situation where there is a real possibility of harm to the person or others if no action is undertaken; and
• End or reduce significant danger to the person or others; and
• Contain or limit the person’s freedom for no longer than is necessary.

Physical Intervention should only be used if it is both immediately necessary to prevent injury to self or others or significant damage to property and ­it is likely to succeed in resolving the situation without causing greater injury or damage.

Children and Family Community Services are committed to developing a therapeutic environment for children in care, where physical intervention is only ever used as last resort and when physical intervention is used, the least restrictive hold is applied.

Carers are committed to building positive relationships with children. The focus is on helping children to develop and benefit from relationships based on mutual respect and understanding, therefore reducing the risk of requiring physical intervention.

As part of the assessment and planning process for all children in care, consideration must be given to whether the child is likely to behave in ways which may place them or others at risk of injury or may cause damage to property.

Every child should have an Individual Behaviour Support Plan which will identify risks and set out stratiegies that will be adopted to prevent or reduce those risks. These strategies may include restrictive physical intervention and the Individual Behaviour Support Plans should be reviewed regularly.

In developing such a plan, consideration must be given to whether there are any medical conditions that might place the child at risk should particular techniques or methods of restraint be used and this needs to be identified and recorded clearly in the plan. 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 recorded accordingly. If in doubt, medical advice must be sought via the Children in Care Nurse.

Defining Restraint, Restrictive Physical Intervention (RPI) and the use of Reasonable Force Restraint refers to:
'The act of managing or exerting control by restraining someone or something.'
 (Compact Oxford English Dictionary).

Physical Intervention and Restrictive Physical Intervention have been jointly defined by the Department for Children, Schools and Families (formerly the DfES) and the Department of Health.

‘Restrictive physical interventions involve the use of force to control a person’s behaviour and can be employed using bodily contact, mechanical devices or changes to the person’s environment.’

In all cases the use of Restrictive Physical Interventions has to be justified by there being:

• The likelihood of injury to the child or young person; or
• The likelihood of injury to others; or
• The likelihood of serious damage to property;
• In social care settings, Restrictive Physical Intervention may be justified to prevent the running away of any child ‘lawfully detained’ (usually a child remanded to local authority accommodation).

Restrictive Physical Interventions should only be used when a situation warrants immediate action. De-escalation techniques should always be used to avoid the need to employ a Restrictive Physical Intervention, unless the risk is so exceptional that it precludes the use of de-escalation.

The de-escalation techniques should be appropriate to the child, acknowledging that the member of staff may not speak the child’s first language or that the child may not have sufficiently developed language skills to be able to respond to verbal de-escalations.

The use of Restrictive Physical Interventions is also governed by the principles of ethical practice. The intervention should take into full account the following:

• To be in the best interests of the child or young person;
• To be reasonable and proportionate to the circumstances;
• To use the minimum force necessary for the minimum time necessary;
• To be based on a comprehensive risk assessment;
• To have regard for other children or adults present;
• To respect the safety and dignity of all concerned.

Children and Family Community Services will seek to reduce the need for Restrictive Physical Interventions as far as is practicable. Several steps have been identified to achieve this:

• To maintain a positive culture;
• To promote ethical practice;
• To maintain a child-centred approach;
• To understand high risk behaviour or violent behaviour;
• To promote an awareness in staff of their own reactions to aggressive or violent behaviour and the effect of their mood on others;
• To promote self-control in children;
• To use authority appropriately;
• To implement therapeutic techniques and approaches which fully acknowledges and supports therapeutic parenting techniques;
• To fully acknowledge and understand the impact of trauma and behaviour.

To promote positive relationships.

The behaviour of a small number of children may give rise to concern before they come into care. Additionally, some children may develop such behaviours following admission. In these cases, a written plan to manage the child’s behaviour must be developed which must include intervention strategies.

Individual Positive Behaviour Support Plans are integrated which reflect a trauma informed approach including the strategies to assist.  The strategies incorporated into the plan are drawn from a number of trauma-informed frameworks and trauma theory and research including Therapeutic Parenting, Attachment, Dyadic Developmental Psychotherapy, Emotion Coaching and the Neurosequential Model of Therapeutics.

The plan will be developed and agreed by the Residential Home Manager, Child in Care Nurse, Social Worker (where applicable) Reparative Care Team and or CAMHS. Ideally, the child and those with parental responsibility will be involved in discussing and agreeing the plan.

Unplanned Restrictive Physical Intervention may become necessary when a child behaves in an unexpected way. The child may not have a behaviour support plan and trained staff may not be on hand. Unless the situation is urgent, staff should seek assistance from appropriately trained staff.

Even if such assistance is not available, the duty of care still remains and any response must be reasonable, proportionate and use the minimum force necessary to prevent injury and maintain safety, consistent with the circumstances and with any training the staff may have received.

Restrictive Physical Interventions should only be carried out by identified members of staff who have been appropriately PRICE trained.

In the event staff are unable to safely manage the de-escalation of a situation using restrictive physical interventions then the Police will be called to assist and either the on call Residential Manager or Emergency Duty Service Social Worker will be notified if this takes place out of hours.

All incidents of Restrictive Physical Intervention will be recorded as quickly as possible and in any event within 24 hours of the incident. An Incident Risk Alert will be recorded as part of the Ulysses incident reporting system and a child’s parent or other person(s) with parental responsibility will be contacted as soon as practicable.

As a minimum the written record will include the following:

• The names of the staff and child/ren or young involved;
• The date, time and duration of the intervention;
• The reason for using a physical intervention, rather than using an alternative strategy;
• The nature of any de-escalation used, seeking to prevent the need to intervene physically;
• The type of physical intervention used;
• Whether or not anyone was hurt, if so the action taken;
• Whether or not anyone was distressed, if so the action taken;
• The views of the child or young person.

Recording Restrictive Physical Interventions serves several purposes, including:

• Compliance with statutory requirements;
• Monitoring the welfare of children;
• Monitoring staff performance;
• Identifying training needs;
• Contributing to service audits and evaluations;
• Details of how and when the incident was reported to parents/carers.

As soon as possible after the incident the member of staff should be de-briefed by an appropriate manager or where deemed necessary by an appropriate Reparative Care Team member of staff.

The de-brief should allow for reflection and the relevant manager/Reparative Care Team member should be prepared to deal with the emotions raised by the incident. The de-brief enables learning to take place and contributes towards professional development.

The response of the child should be sought, and they will also be allowed to reflect on the incident via a de-brief and this will ideally take place within 24 hours. The child involved in the restraint should be able to express their feelings about this experience and will be encouraged to record their views to the record of restraint.

The risk assessment documentation must also be reviewed alongside the Individual Positive Behaviour Support Plan.

The residential home manager will monitor episodes of Restrictive Physical Intervention alongside the Safeguarding & Quality Assurance Service.

If a child continually requires a level of restrictive physical interventions to help them to remain safe, a planning meeting will take place to review the strategies in place.

The use of restrictive physical intervention is also monitored and reviewed through the independent residential inspection framework.

Children & Family Community Services recognise the importance of appropriate training for staff in order to be able to use Restrictive Physical Interventions safely. All staff working within residential care will receive appropriate training in methods of behaviour support, including the use of restrictive physical intervention and restraint.

Children & Family Community Services use PRICE Training (Protecting Rights In the Caring Environment). This training is certified by the Restraint Reduction Netork (RRN) and the British Institute of Learning Disabilities (BILD) and includes both proactive (i.e. preventative) and reactive strategies.

An up-to-date record of training received by staff will be maintained by all residential home managers and used to ensure that training remains appropriate to the needs of the children accommodated by Children & Family Community Services.

Children & Family Community Services are committed to ensure staff ideally should be given time to develop relationships with a child before they might have to use Restrictive Physical Interventions.

Trained staff may only use techniques that are approved PRICE and such techniques should comply with the following principles:

• Not impede the process of breathing - the use of 'prone face down' techniques must never be used;
• Not be used in a way that may be interpreted as sexual;
• Not intentionally inflict pain or injury or threaten to do so;
• Avoid vulnerable parts of the body, e.g. the neck, chest and sexual areas;
• Avoid hyperextension, hyperflexion and pressure on or across the joints;
• Not employ potentially dangerous positions.

If a child suffers from a serious pre-existing medical condition, then a medical assessment/examination should be completed by a health care professional co-ordinated or completed by the Child in Care Nurse and this will need to be recorded as part of the healthcare. If a child suffers from a serious pre-existing medical condition (including but not limited to the following):

• Heart defects;
• Epilepsy;
• Asthma;
• Obesity;
• Cystic fibrosis.

There are different criteria for the use of Restraint and Holding, Touching and Physical Presence/proximity.

1. Restraint may only be used where there is likely significant injury or serious damage to property;
2. Holding, Positive Touching or Presence are less forceful and less restrictive and may be 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. Before any other form of Physical Intervention is used, all of the following principles must be applied:
   1. For the intervention to be justified there must be a belief that injury or damage is likely in the predictable future;
   2. The intervention must be immediately necessary;
   3. The actions or interventions taken must be a last resort;
   4. Any force or intervention used must be the minimum necessary to achieve the objective.

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

• Sexual Exploitation;
• Gang Related Activities;
• Use of drugs or other illicit substances.

This restriction of a young person’s liberty should be for the minimum amount of time possible and in response to immediate danger. Carers 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 team around the child 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 and, this will need to be clearly documented and any agreement must not conflict with regulations regarding ‘Deprivation of Liberty’.

It is acceptable to use mechanisms or modifications to a children’s home or foster home 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 it is safe for them to do so.

It is also acceptable to lock office or storage areas to which children are not normally expected to gain access.

If such mechanisms are used they must be outlined as follows:

In children’s homes, if any such mechanisms or modifications are used, they must be set out in the home’s Statement of Purpose and the arrangements for their use set out in the home’s Staff Handbook.

In foster homes, if any such mechanisms or modifications are used, they must be agreed by the manager of the Family Placement Service and set out in the Foster Care Agreement.

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.

Where the following measures are used in children’s homes or foster homes, they must be approved and set out in writing.

• In children’s homes, they must be set out in the home’s Statement of Purpose or in Behaviour Management Plans (as part of the Placement Information Record) for individual children;
• In foster homes, they must be set out in the Foster Care Agreement or in the Behaviour Management Plans (as part of the Placement Information Record) for an individual child.

Time out involves restricting the child’s access to all reinforcements as part of a behavioural programme.

Withdrawal involves removing a child from a situation, which places the child or another person at risk of injury or to prevent damage to property, to a location where they can be continuously observed or supervised until ready to resume usual activities.

In children’s homes where Physical Intervention has been used, the child, staff/carers and others involved must be given the opportunity to see a medical practitioner, even if there are no apparent injuries.

In other settings, where physical intervention is used, the child, staff/carers and others involved should be given the opportunity to see a medical practitioner if there are any apparent or reported injuries.

The medical practitioner, if seen, 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 medical practitioner must be recorded, together with the outcome.