Policy Compassionate Care Team Ltd adopts the position that behaviour that challenges has a purpose in that it meets a particular need for the individual. These needs may be demonstrated through a variety of emotions and behaviours. Therefore, it is important that staff can: • Develop an understanding of these needs • Anticipate the needs • Soothe situations before they occur • Provide the most appropriate responses to the emotions/behaviours displayed
When working with individuals with behaviour that challenges, staff will be expected to: • Recognise the individual’s rights to take risks • Ensure that the risk assessment places the Service User central to the purpose • Support the individual through difficulties • Preserve the dignity of the individual • Ensure that rights and choices are promoted • Create an environment in which individuals feel safe and secure • Try to ensure that reflection after an incident places it in the context of the individual’s life, and that this can be used to bring about positive outcomes for the individual
Service Users identified as being at risk of disturbed/violent incidents will be given the opportunity to have their views and wishes recorded, in the form of an Advance Statement.
A range of interventions, specifically based on the needs of Service Users, should be provided within the service to support the prevention and management of violent and aggressive behaviours.
The service will ensure that staff have the appropriate training and support in their role in managing behaviour that challenges.
Compassionate Care Team Ltd will ensure record-keeping is timely and effective in recording incidents and patterns of behaviour that challenges.
Procedure Service Users will be encouraged to identify, as clearly as possible, the interventions that they would and would not wish to be used. They must be encouraged to review their wishes with staff, and changes must be clearly documented within their Care Plans and other documentation. • If the professional to whom the wish is being expressed forms the opinion that the Service User lacks the capacity to understand the wish they are expressing, the professional must record their opinion, and their reasons for it, alongside the record of the Service User's wish. An advocate or carer should be invited to support a Service User who may lack the capacity to understand the wish they are expressing. (Mental Health Act 1983 Code of Practice 2015 Chapter 9.21)
Interventions will be provided based on the needs of Service Users. These will include the use of specific behaviour models adopting person-centred approaches in all areas of organisational activity to working with Service Users who challenge in a way that recognises the person behind the behaviours and takes a solution focused attitude. There should be interventions developed that are specific to Learning Disability, Children and Older People Services. Training for those service-specific interventions will be provided. In addition, there may be specialist interventions based on professional models, e.g. in clinical psychology. Training would be based within that professional group.
Compassionate Care Team Ltd will ensure, through safer recruitment and regular performance appraisal processes, that all employees have the necessary knowledge, skills and physical capability to manage thepotential level of violence and aggression in their employment role. Employees will need to be capable of participation in the level of training required for their role.
All employees who have been involved in an incident of violence or aggression will be offered timely support based on their individual needs or preferences. Support methods can include: • Practical help with transport or accessing medical help • Signposting to specific victim support or individual counselling • Critical incident analysis/guided reflection • Counselling or psychological therapies • Information and assistance in relation to criminal justice procedures • Access to Occupational Health Services • Training updates and additional training as required • Access to staff representation and buddy systems, where appropriate • Professional and line management supervision which must be documented
All employees must adhere to the relevant policies in order to ensure that all information that will promote the proactive prevention and management of behaviour that challenges is taken into account and acted upon. These include incident reporting, record-keeping and maintenance of simultaneous multi-professional progress recording and risk assessments.
All employees will adopt a proactive recovery-focused approach aimed at preventing the likelihood of incidents of behaviour that challenges occurring. The gathering of information from Service Users, their carers and families, colleagues and other agencies will lead to a formulation of the risk issues. That assessment will identify preventative strategies, both to promote a positive environment and to minimise the risks. Specific management guidelines will be based on individual Care Planning and risk assessments.
All incidents of behaviour that challenges, violence and aggression, (whether physical or non-physical) and near misses or incidents will be reported using the 'Record of Behaviour that Challenges Form' in this document. Employees should also refer to Compassionate Care Team Ltd's Accident and Incident Reporting Policy and Procedure. Employees will be supported in the incident reporting procedure and advised to complete requests as soon after the incident or near miss as possible.
A post-incident review will take place as soon as possible and within at least 72 hours of an incident ending. If possible, a person not directly involved in the incident will lead the review. The review will address: • What happened during the incident • Any trigger factors • Each person’s role in the incident • Their feelings at the time of the incident, at the review and how they may feel in the near future • What can be done to address their concern
A documented record of this must be drawn up, especially in relation to restraint. If a Service User is restrained, this must be discussed and the reasons why this was deemed necessary should be shared. Collaborative planning to prevent recurrence is essential. Restraint should only be used as part of an agreed plan of care and only by staff trained and assessed as competent to undertake the restraint in line with locally agreed procedures. Service Users and visitors who witness restraint must also be given an explanation of the need for forceful intervention to ensure understanding and allow any anxieties or fears to be voiced.
The purpose of a post-incident debrief is "to identify and address physical harm to Service Users or staff, ongoing risks and the emotional impact on Service Users and staff, including witnesses" and to "determine the factors that contributed to an incident that led to a restrictive intervention, identify any factors that can be addressed quickly to reduce the likelihood of a further incident and amend risk and care plans accordingly." (National Institute for Health and Care Excellence: NG10, Violence and Aggression: Short-termmanagement in Mental Health, Health and Community settings 2015) "The aim of a post-incident review will be to seek to learn lessons, support staff and service users and encourage the therapeutic relationship between staff, service users and their carers." (NICE 2005)
Many mental health and learning disability employees work as lone practitioners either in The Agency's premises or in community settings. The systems and procedures to be used to prevent, minimise and manage risk for lone workers are outlined in the Lone Working Policy and Procedure.
All employees are advised to contact the local police force, using the emergency 999 call number, if they are involved in an incident of behaviour that challenges or violent or aggressive situations that cannot be de escalated or managed by the range of procedures and interventions available to practitioners. This is particularly important if a violent incident is provoked or initiated by those who are not in receipt of clinical services and are not known to the clinical practitioner.
Engagement and observation are therapeutic risk management interventions that can be utilised to support the management of behaviour that challenges.
There is a range of interventions where medicines are used to assist in the prevention, reduction and management of violence and aggression. The specific use of prescribed medication to ensure rapid tranquilisation of Service Users who are becoming increasingly disturbed, violent or aggressive, or where their behaviour that challenges is escalating, may be used according to individual and pre-prescribed principles. Specific training is mandatory for employees to use these approaches.
When considering the use of medication as a prevention strategy, the following should be noted: • When used as a primary prevention, medication must only be used where a Service User has a mental health or co-morbid mental health problem that is alleviated by medication. A physical health and pharmacology assessment will be completed prior to the administration of 'as-required' medication, and before the use of a restrictive physical intervention • When considering the use of medication as a secondary prevention, or reactive strategy, the service advocates evidence-based approaches less dependent on medication and requires compliance with the guidance given in the 'Guidance for Restrictive Physical Interventions for People with Learning Disability and Autistic Spectrum Disorder in Health, Education and Social Care Settings (Department of Health, 2002, p18)'
NICE guidelines indicate that health and social care provider organisations should give staff training in de escalation that enables them to recognise the early signs of aggression and be able to respond appropriately.
These guidelines also stress the general principle that staff should establish a close working relationship with Service Users that will allow them to be aware of changes in mood. (National Institute for Health and Care Excellence: NG10, Violence and Aggression: Short-term management in Mental Health, Health and Community settings 2015) Staff working with Service Users with learning disabilities who may present behaviour that challenges should beaware of specific NICE guidelines titled 'Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges' NG11.
Compassionate Care Team Ltd supports the use of Breakaway Interventions that are taught in order to enable the staff to disengage from an attacker in a physical assault. Compassionate Care Team Ltd acknowledges that the use of reasonable force may also be necessary. Wherever possible, and from the formulation derived from the clinical risk assessment, a plan of Care prescribing the use of such interventions, or other preventative strategies, would be compiled.
There is no legal definition of 'reasonable force'. It is therefore not possible to comprehensively set out when it is reasonable to use force or the degree of force that may reasonably be used. It will always depend upon the circumstances of the case. There are three relevant considerations: • The use of force can be regarded as reasonable only if the circumstances of the particular incident warrant it. The use of any degree of force is unlawful if the particular circumstances do not warrant the use of physical force. Therefore, physical force could not be justified to prevent an individual from committing a trivial misdemeanour, or in a situation that clearly could be resolved without force • The degree of force employed must be in proportion to the circumstances of the incident and seriousness of the behaviour or the consequences it is intended to prevent • Any force used must always be the minimum needed to achieve the desired result
Reasonable force may be used for Service Users who are detained under the Mental Health Act, where it is "therapeutically necessary" to be medicated, restrained, fed or secluded. (See Section 63, part 4 of the Mental Health Act 1983 concerning medical treatment for mental disorder not requiring the consent of the patient.) For medical treatment for physical disorders, this cannot be administered without the consent of the person. For someone who lacks the mental capacity to consent, reasonable force may be used where the treatment is in the person's best interest. (Section 6 of the Mental Capacity Act 2005.)
When violence, aggression or behaviour that challenges cannot be de-escalated, and it is assessed that there are significant risks to the safety and security of the perpetrator and/or the potential victim(s), employees may need to use restrictive physical interventions (control and restraint). Those using these interventions must demonstrate competency through assessment. The training for the use of physical intervention is generic, but specific interventions for specialist needs can be identified for employees during training or from a requested consultation. For the purpose of this policy, physical intervention, as defined, does not involve the use of mechanical devices. Compassionate Care Team Ltd supports the use of restrictive physical intervention techniques that are taught to enable staff to respond to behaviour that challenges using direct physical contact to limit or restrict the movements of another, or disengage, as a last resort, when a Service User is presenting a high risk of harm to themselves or others.
Where restrictions or restraint on Service Users would constitute a deprivation of the person's liberty, this would be in contravention of the person's human rights, unless authorisation for the deprivation of liberty was sought. For further guidance on this, reference should be made to Compassionate Care Team Ltd's Policy and Procedure on Deprivation of Liberty.
Awareness of this policy will be disseminated to all employees through a line management briefing, cascaded through the operational and corporate service structures, supported by a standardised briefing. In addition, the implementation of this policy will be supported by the following actions: • The Registered Manager will designate a person to assess the environmental risks in premises within their areas of responsibility • An overall service specific risk assessment will be completed with the involvement of all staff in order to determine the level of risks posed, and the training requirements necessary to manage those risks • The outcome of the risk assessments will be assessed, reviewed and agreed through the service-specific governance systems • A register of environmental risks is to be maintained • Mandatory training will be provided in line with the organisational training needs analysis, with attendance monitored via human resources and reports sent to local managers to ensure mandatory training needs are met • For training that Compassionate Care Team Ltd has not classified as mandatory, managers should consider the necessary competencies for the specific work required and arrange for these needs to be met through the appraisal and personal development plan process. Access to support to meet these needs is outlined in the Training Policy and Procedure • Employees will be expected to complete a self-assessment of physical health in relation to undertaking training, rehearsal and practice in the delivery of breakaway and physical interventions. Any concerns regarding physical capability will be referred to the Registered Manager 5.19 Compassionate Care Team Ltd will ensure that the appropriate training and education is available to implement this policy. All employees will be expected to participate in the training and education programmes as determined by the organisational training needs analysis and identified as required by their role. Their competencies will be monitored through appraisal, supervision and Human Resources Systems. Appropriate recording will be maintained in staff's personnel files. Different forms of training are available: • Theory - Safety, Management and Security training to manage violent and aggressive behaviour, as well as promoting personal safety which follows the NHS Protect syllabus as best practice • De- -escalation and breakaway training - All of the content of the theory component, plus positive communication and the use of functional analysis in the prevention and management of violence and aggression, de-escalation interventions, preventative and breakaway physical interventions. Competency outcomes will be assessed during training • Bespoke breakaway training - All of the content of the theory component, plus positive communication and the use of functional analysis in the prevention and management of violence and aggression, de escalation interventions, preventative and breakaway physical interventions including a seated restraint technique. Competency outcomes are assessed during training • Physical intervention - All the content of the theory component and de-escalation and breakaway, plus physical interventions used in the management of violence and aggression and positional asphyxia.
Competency outcomes are assessed during training This protocol outlines specific practice underpinning the Care of those designated as having behaviour that challenges. For each Service User the following should be carried out: • An assessment of capacity to consent, and if capacity is present, permission must be gained for any assessment or intervention prior to it being carried out. If they are deemed to lack capacity to consent, or they are refusing treatment, professionals are to follow the 'best interest' rule • A comprehensive assessment and formulation must be completed, incorporating: Service User must not be approached and the police summoned to assist. If weapons are visible, then the Service User must be asked to put them down in a neutral area and not to hand them over.
For those staff involved in restraint, the following responsibilities will be understood and carried out: • The person controlling the individual's head will assume control of the intervention and will manage the situation. Other individuals, present at the situation, will take direction from the head person. Compliance with this procedure ensures minimisation of risk to staff and Service Users • There must be continual verbal de-escalation between the individual in control of the incident/situation, and the Service User. Communication between the rest of the team must be minimal • Staff will demonstrate at all times respect, dignity, and privacy and ensure that there is communication between the Service User and themselves • During any physical restraint intervention, the Service User's physical condition must be monitored in order to reduce physical risks, e.g. positional asphyxia. Where mechanical restraint is employed during and after physical intervention, guidance in the Mental Health Act Code of Practice says this should be regularly reviewed by a registered medical practitioner. This policy should be read in conjunction with Chapter 26 of the Code of Practice titled 'Safe and Therapeutic Responses to Disturbed Behaviour' • When possible, other Service Users and staff not involved with restraint must be relocated to another area • Restraint must be used as a last resort. At the earliest opportunity the Service User will be disengaged from the restrictive physical intervention when it is deemed safe and practicable to do so • Compassionate Care Team Ltd does not support the deliberate application of pain to Service Users to gain compliance. It is acknowledged "that there may, however, be high-risk situations where an element of pain - for both the individual and staff - may be unavoidable if the emergency is to be safely resolved”. (Guidance from the National Control and Restraint General Services Association at http://thegsa.co.uk) • The service's training needs analysis describes who must attend which form of Management of Violence and Aggression Training, and be deemed to be competent before engaging in these practices • Where physical restraint is used, staff must record the decision and the reasons for it. They must document and review every episode of physical restraint, providing a detailed account of the restraint as well as providing a record of the post-incident review • Staff must use debriefing and post-incident review following all episodes of restrictive physical interventions