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Royal College of Nursing consultation: Draft guidance on the minimisation of and alternatives to restrictive practices in health and adult social care, and special schools

1. In 2012 the Department of Health published Transforming Care: A national response to Winterbourne View Hospital. This outlined key actions in response to the abuse and illegal practices witnessed at Winterbourne View Hospital as well as concerns that emerged from the subsequent Care Quality Commission (CQC) inspection of nearly 150 learning disability in-patient services. CQC inspections found evidence of uncertainty among providers regarding the use of restrictive physical interventions, with some services having an over-reliance on the use of ‘restraint’ rather than more proactive approaches such as positive behavioural support (PBS).

2. Failure of services to apply PBS, places people who present with challenging behaviours at heightened risk of detrimental responses such as:a. exclusion from local services

b. people being moved to ‘out of area placements’

c. restricted access to meaningful daytime activities, employment, education or home support

d. exposure to seclusion, restrictive physical interventions, locked environments and in some cases abuse

e. hazardous clinical approaches such as inappropriate prescribing of medication, punitive responses to behaviour and management regimes that are so restrictive as to significantly impair an individual’s quality of life; and

f. direct or indirect harm.

3. PBS is fundamentally about improving quality of life as well as meeting needs and reducing distress; it recognises that people engage in challenging behaviours because they have unmet needs, are exposed to environments and interactions which they find challenging and often have a generally impoverished quality of life. Much of the time, people’s behaviours represent a desperate attempt to meet their own otherwise unmet needs.

4. In response to growing concerns about physical interventions across all care sectors, the coalition Government committed the Department of Health (DH) to work with the CQC and external partners to review how providers record and monitor the use of restrictive interventions and to publish guidance on PBS with the aim of ensuring that physical interventions are only ever used as a last resort.

5. This new document replaces the 2002 DH and Department for Education and Skills guidance on the use of restrictive physical interventions in special schools, social and health care settings for people with learning disabilities and/or autistic spectrum conditions. It provides a road map by which to reduce

inappropriate reliance on unnecessary and restrictive reactive management approaches through the delivery of PBS and organisational Restrictive Practice Reduction Programmes. Its scope is broader than the document it replaces in that it applies to:

• all adult health and social care settings

• all health staff working with children and young people

• educational staff working in special schools;

and

• all service user groups regardless of health conditions and support needs.

The guidance is not intended to cover children’s social care settings or mainstream schools. It should be read in conjunction with Use of Reasonable Force. Advice for head teachers, staff and governing bodies which provides guidance for mainstream schools.