Regulator calls summit to address issue of restraint in the care of older people
17 December 2007
Key stakeholders in social care recently discussed ways of
addressing the use of various forms of ‘restraint’, which, while
often intended to keep people safe, can compromise their rights to
take risks and their freedom. The discussion was centred on a paper
published today by the Commission for Social Care Inspection
(CSCI).
Rights, risks and restraints explores the use of restraint in
the care of older people and says that clear guidelines and well
resourced services are needed to ensure dignity of care for people
who use services.
The study examines the issues and dilemmas around restraint,
particularly the tensions between respecting people’s rights to
freedom and to make choices, while at the same time ensuring
people’s safety. Although there is policy and legislation to
respect people’s human rights, CSCI’s report suggests that in
practice care workers and ordinary families caring for relatives
have been left largely unsupported to deal with these tensions and
to know what is best to do.
Dame Denise Platt, CSCI Chair, said: “Our paper highlights some
examples of poor practice that are clearly not acceptable. Wherever
we find these, we will not hesitate to deal with them.
“Our paper also argues that people should be able to make
choices about their lives and to take risks, whether they are in
their own homes or in a care home. While they should also be able
to expect that the care they receive will support their dignity,
some people have told us they have found security in some types of
restraint.
“So there are no simple solutions. That’s why our study has
explored this sensitive issue and attempts to raise questions and
prompt debate about the balance that needs to be found. To what
extent is restraint in the care of older people ever acceptable?
What responsibilities do others have to stop the improper use of
restraint?”
Rights, risks and restraints is not a prevalence study but gives
details of unacceptable examples of the use of restraint, and sets
outs evidence that restraint does not always make people’s lives
safer. Some people believe, for example, that electronic tagging
can be employed as a careful part of a care regime, but the report
suggests that this should not be a substitute for inadequate
staffing.
CSCI’s study also suggests that different forms of restraint,
including chemical and physical restraint and how they are used
should be made more transparent and clear. A panel of interested
parties, care providers, commissioners, regulators and Government,
discussed this report last week. Everyone present agreed that there
was a shared responsibility for supporting care staff and sharing
best practice.
Julie Jones, Chief Executive of Social Care Institute for
Excellence (SCIE), said: “This report raises some serious and
difficult issues and it is right that they should be highlighted.
Staff and carers should be able to expect better advice and support
to ensure that practice improves in all settings. SCIE will be
responsible for working with the sector to develop materials which
help people make the best possible decisions in these difficult and
distressing circumstances.”
Martin Green, Chief Executive of the English Community Care
Association, said: “The CSCI report highlights the complexity of
the issues of restraint, and I am pleased that CSCI brought
together a range of stakeholders to debate the report and to think
about how the sector responds in ways that both ensure people’s
safety but also respect their dignity and autonomy”.
Help the Aged’s Director of Policy and External Relations, Paul
Cann, added: "This is a difficult and sensitive subject - but one
that requires discussion and guidance. This report is therefore
very welcome.
"Greater clarity and guidance must be given to care staff - many
of whom work in very challenging and exceptional circumstances.
This report sets out clearly just how urgent the need for this
guidance is.
"While restraint exists within care settings, it is imperative
that the dignity of older people is maintained at all times - it is
simply non-negotiable. Policies and practices must be shaped to
preserve the dignity of those being cared for - that calls for
planning in advance. Many situations where restraint is currently
used can be avoided altogether by anticipating behaviour that may
cause difficulties. Advanced planning should involve all parties
concerned, including relevant staff, families and the older person
themselves. Any decisions taken must be consultative and avoid the
imposition of blanket 'one size fits all' policies. The
individual's own circumstances are paramount."
Ends
Notes for editors
1. The study fully involved older people, aiming to understand
their experiences and views, as well as family carers. We also
involved care providers, care staff and the voluntary sector both
in the research and in consultations about the findings.
Responsibility for the discussion paper rests with the CSCI.
2. The event organised by CSCI was also attended by the Social
Care Institute for Excellence; English Community Care Association;
Age Concern; Counsel and Care; Kings College; Alzheimers Society;
Registered Nursing Homes Association; National Care Association;
General Social Care Council; and the Department of Health.
3. The following examples illustrate some of the issues and
dilemmas highlighted in the discussion paper about keeping people
safe and ensuring people’s right to take risks:
There are situations when restraint was seen as the right thing
to do:
- “I was becoming violent towards another person and went to
physically attack them. The restraint made me feel more calm as if
someone else had taken control” (older person).
There are situations where there can be disagreement about the
use of restraint:
- “Currently a daughter is insisting that her mother is
restrained by the use of a small table to prevent her from falling
from a chair. Her mother has dementia and does not speak English.
She often kicks the table away, causing bruising to her legs, which
the daughter claims is caused by poor care. The daughter does not
appear to be aware that the table is a form of restraint” (social
services care manager).
There are circumstances where staff are faced with difficult
decisions:
- “She became very distressed and aggressive (shouting, kicking,
spitting, scratching and lashing out), for example when undressing
for bed or using the toilet, so they sometimes needed to restrain
her to prevent injury to herself or to her staff” (complaint
received by CSCI).
There are examples of unacceptable practice where CSCI has taken
action:
- “The manager gave night-time medication at tea time so
residents could be put to bed at 6.30” (complaint about a service
received by CSCI).
There are examples of good sensitive care:
- “A staff member whispered to a resident who was agitated; the
resident responded by whispering back and became calm.”
- “A CSCI inspector observed two residents raise their voices to
each other, with one raising a fist. The staff member watched what
was going on quietly, then led on of the residents away and helped
them to sit elsewhere. A few minutes later this resident went and
sat back next to the first resident and talked to them about the
weather”.
4. CSCI is the single inspectorate for adult social care in
England, responsible for regulating and inspecting social care
providers – whether in the public or independent sector – and for
assessing the performance of local councils in delivering their
personal social services functions.
5. The Commission’s primary aim is to improve social care by
putting the needs of people who use care services first.
6. The Commission is chaired by Dame Denise Platt DBE and has
five Commissioners. The Chief Inspector is Paul Snell. CSCI staff
work across seven regions in England.
7. Social care services for children are regulated and inspected
by the Office for Standards in Education, Children's Services and
Skills (Ofsted).