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Part 4 - Appendices

Appendix 1- Devon County Council and Legal Context

Appendix 2 - Risk Management Process

Appendix 3 - Guidelines on Using Interventions

Appendix 4 - Prevention of Situations Needing an Intervention

Appendix 1 - Devon County Council and Legal Context

Staff deployment needs to ensure that appropriately-trained staff are available to respond to any incident requiring a Physical Intervention. This may include organising rotas to ensure sufficient trained staff. In the event of this being unfeasible due to reasons such as temporary staff injury, a further risk assessment on the viability of doing any physical interventions beyond a certain level needs to be undertaken, and possibly the use of certain interventions temporarily suspended.

The policy must be read and implemented within the context of the principles and practice guidelines set down in the following related documents (from various sources), legislation, and Devon County Council policies:

• A Differentiated Approach to Care Management; Policy and Guidance for Prioritisation and Eligibility.
• The Restriction of Liberty and Preventive Support for Adults in Residential Care, addendum to the Use of Physical Interventions Policy.
• Physical Interventions Training and Competency Procedure and Guidelines, addendum to the Use of Physical Interventions Policy.
• Dealing with Violence in a Caring Profession.
• Devon County Council policy Risk Assessment and Management of Individual Service User Situations (RAMISUS).
• Care Standards Act 2000 - Minimum Standards.
• Devon County Council Social Services policy - Safety from Violence and Aggression for Staff, Policy and Guidelines.
• Devon County Council Social Services Guidelines for Conflict Management.
• Multi-agency Code of Practice for the Protection of Vulnerable Adults from Abuse.
• Devon County Council's Residential Childcare Handbook - providing an overview of practice suggestions in relation to problematic situations.
• Children Act 1989 (especially Vol. 4 Residential Care Guidance and Regulations).
• Laming, Sir Herbert 1997 "The Control of Children in Public Care: Interpretation of the Children Act 1989".
• The Children (no 1 and 2) (Secure Accommodation) Regulations 1991.
• Children's Homes Regulations 2001 Part 3 (17).
• British Institute of Learning Disabilities, 1996 "Physical Interventions: A Policy Framework".
• British Institute of Learning Disabilities   "Code of Practice for Trainers in the Use of Physical Interventions".
• Education Act 1996 Section 550A; & DfEE Guidance in Circular 10/98 "The use of force to control or restrain pupils".

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Appendix 2 - Risk Management Process

Whenever it is foreseeable that a service user might require a physical intervention, a risk assessment needs to be carried out on using physical intervention with that person.  For each service user, there must be a written risk assessment and risk management plan (SS12/SS12(a)) which identifies the benefits and risks associated with different intervention strategies and ways of supporting the person concerned. The management plan must be developed from a risk assessment which balances the risk of using a physical intervention against the risk of not using a physical intervention. The RAMISUS policy, with associated forms, gives guidance on how to carry the risk assessment out, which needs to be followed.

The Risk Management Plan must include:

• A description of behaviour sequences and settings which may require a physical intervention response.
• Results from the assessment to determine any contra indications for use of physical interventions.
• A record of the views of carers and / or family members.
• Reference to the system of recording behaviours and the use of physical interventions.
• Previous methods which have been tried without success.
• A description of the specific physical intervention techniques which are sanctioned and a description of staff that are judged competent to use these methods with this person (see Section 16, Staff Training).
• The dates on which they will be reviewed.
• Steps that are most likely to work instead of physical intervention, or to minimise the level of intervention for this particular person.
• The ways in which this approach will be reviewed, the frequency of Review meetings and members of the review team.

An up-to-date copy of the risk management plan must be attached to the person's individual care plan, including the individual's handling plan.

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Appendix 3 - Guidelines on Using Interventions

The term physical intervention is used to describe both appropriate and inappropriate methods of restricting movement. Methods of physical intervention that might, under certain circumstances, be appropriate include:

• Two or more members of staff holding a service user to prevent them from assaulting somebody.
• Using a safe hold on a smaller child intent on hitting people or destroying everything in sight, until he or she calms down, while listening to the child.

Where possible, it is preferable to grasp clothes or hold arms and / or legs still. It may prove necessary to grasp other parts of the body, (avoiding genital areas) but this should be transferred to limbs or clothes as soon as it is safe to do so. While the grip should be firm, it should not inflict pain.

Methods of physical intervention that are potentially dangerous include:

• One or more members of staff sitting on a service user.
• The use of clothing or belts to restrict movement.
• Any procedure which involves pressure against the joints.
• Any procedure which restricts breathing or impacts upon the airways.

To the extent that seclusion involves restricting a person's freedom of movement, it is also a form of physical intervention. The use of seclusion for people detained under the Mental Health Act (1983) is set out in the Code of Practice in 1999.

Physical interventions are usually employed by staff or carers to gain control over behaviour that is likely to cause injury to people or animals, or serious damage to property. If the violence is solely directed at property, employees should only attempt to control it if there is no personal risk.  Property is expendable! Talking or careful listening, as appropriate, is a very effective way of helping a client to keep self control by expressing him or her self in other ways.

Physical interventions need to be introduced as part of a 'graduated response'. This seeks to establish a 'gradient of control'. That is, when staff respond to challenging behaviour, they follow a pre-determined sequence which begins with the application of the least restrictive options and gradually increases the level of restriction. The sequence is terminated as soon as control is established over a person's behaviour. Low levels of force and less intrusive measures are likely to be effective early on while physical management may become the only option if the situation escalates. The use of de-escalation needs to continue throughout. Except in extreme emergencies, physical interventions need only be used after less intrusive methods have been explored fully, and found to be inadequate.

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Appendix 4 - Prevention of Situations Needing an Intervention

The use of physical interventions should be at as low a level as possible along a continuum of control, discussed above, and should be minimised by the adoption of primary and secondary preventative strategies included within the risk assessment and management plan (SS12/SS12(a) - Adults, SS(C)12 - Children).

Primary prevention is achieved by proper management of environmental setting conditions as they interact with personal setting conditions.  Environmental setting conditions are the factors in a person's environment, such as providing enough activities.  Personal setting conditions are a person's physical and psychological make-up.  Personal setting conditions could be communication difficulties, history of trauma or abuse, or dementia.  A combination of wrong setting conditions, plus a trigger event, is likely to lead to an incident.

Primary prevention is achieved by:

• Changing aspects of a person's living and working environment to reduce the likelihood of challenging behaviour occurring.
• Helping service users and staff to avoid situations which are known to provoke violent or aggressive behaviour for example intrusion on personal space.
• Care plans that are responsive to individual needs.
• Creating opportunities for service users to engage in meaningful activities which include opportunities for choice and a sense of achievement.
• Developing staff expertise in working with service users who present challenging or problematic behaviours.
• Preventing a build-up by being aware of personal 'triggers'.
• Being aware of the person's boundaries, as he or she may need to feel some control over his or her physical environment for personal security.
• Developing Relationships between staff and service users based on honesty, mutual respect and good practice.

Control is more likely to be achieved where there is a structure to the service user's day, with the correct balance between free and controlled time. For this reason liaison with other agencies, for example, schools for statemented children in our homes, is essential, preferably in advance of the placement.

Secondary prevention involves recognising the early stages of a behavioural sequence that is likely to develop into violence or aggression and employing techniques to defuse / avert any further escalation. Secondary prevention procedures are designed to ensure the proper management of problematic episodes, using non-physical interventions aimed to reduce the likelihood of a person becoming violent and aggressive.

For secondary prevention techniques, staff can:

• Make options available so a person isn't boxed into a corner, including a person not being 'psychologically' boxed into winning a confrontation.
• Be aware of the physical proximity; will that person be reassured by contact or does he or she need space.
• Reduce demands on the person as much as possible.
• Change the people who are with the person.
• Talk to the person about their concerns and how these could be overcome.
• Verbally request a person to stop doing destructive behaviours.
• Use 'tangents' such as distraction, changing topics, changing setting.
• Remove any 'audience' so the person can back down.

All prevention strategies should be carefully selected and reviewed to ensure that they do not unnecessarily constrain opportunities or have an adverse effect on the service users welfare or quality of life.