9.5.1 Sanctions and Physical Intervention in Units Caring for Young People

SCOPE OF THIS CHAPTER

This chapter has been amended in accordance with the Children's Homes (Amendment) Regulations 2011, Associated Guidance and National Minimum Standards. The changes are highlighted below.

Introduction
Develop and Maintain a Positive Culture
Taking a Child Centred Approach
General Principles Governing Interventions to Maintain Control
Understanding why Situations Turn from Day to Day Situations to Anger, Aggression and Violence
Sanctions
Permitted Disciplinary Measures
Prohibited Disciplinary Measures
Restriction of Liberty
The Care and Control of Children and Young People Outside the Unit
Risk Assessment and Care Planning
Physical Contact
Restrictive Physical Safety Intervention
Other Considerations
Ending a Restrictive Physical Safety Intervention
Areas of Danger and Concern
Learning from Events - Manager's Responsibility
Action Required following a Restrictive Physical Intervention - a Multi Level Post Crisis Response
Critical Incident Monitoring Panel
Cause for Concern Meeting
Methods of Care and Control which Fall Short of Restrictive Physical Intervention or the Restriction of Liberty
Training

Glossary

References and Further Reading Material

1. Introduction

Issues relating to control and discipline are included in the Children Act, 1989 Guidance and Regulations, Volumes 2 and 4, Children Act 2004, Children's Homes Regulation 2011 and the National Minimum Standards - Children's Homes, 2011 (Standard 3).

Further guidance is given by the Department of Health in Local Authority Circular LAC (93) 13 entitled: Guidance on the permissible Forms of Control in Children's Residential Care, and SSI (C1 (97) 6), The Control of Children in Public Care: Interpretation of the Children Act 1989.

The information contained in this section draws on guidance in these documents and other research found in reading list at the end of this document. Although this section focuses on physical intervention, it should not be seen in isolation. It fits in the whole context within which children and young people who are looked after in residential care are provided with care and control.

2. Develop and Maintain a Positive Culture

From: Barbara Kahan, Growing up in Groups, HMSO, 1994

"There can be no doubt that where children are cared for in establishments which have a clear purpose; where staff are clear about what is expected of them; and which are well managed, control is less likely to be a problem"

Each unit and each member of staff should reduce, as far as practicable, the need to restrain children, and keep to a minimum the risks to the child and others on those rare occasions when it is the only practicable means.

A positive culture starts with factors such as the environment - is the building safe, well maintained and pleasant to be in? Neither young people nor staff will feel safe or valued if there is graffiti on the walls and repairs don't get done or where there are dark, unsupervised corners. Space for children to get away from the group when they are feeling down or tensions are running high may also help to prevent high risk behaviour.

The ethos of the unit is more than the environment. Research into effective residential care has highlighted how important is a shared sense of purpose, where staff understand and support the aims of the establishment (Caring for Children away from home: Messages from Research, Department of Health 1998). The starting point for this shared sense of purpose is values.

The manager has an important role in talking about and developing these shared values and aims, which are reflected in the unit's "statement of purpose". The manager must also take responsibility for the culture within the unit, and take steps to deal with a negative culture so that staff can support children and young people.

Relationships between staff and children must be based on mutual respect and understanding and clear professional and personal boundaries which are effective for both the individuals and the group. Staff must convey a strong sense of wanting to form constructive relationships with children and young people, and of caring about them, even when the period of care is very short.

There is a need by the manager for leadership as well as management, not only setting out the principles on which the unit will operate but also living by them. Workers cannot expect young people to treat each other with respect if they see managers bullying staff or staff bickering among themselves. There should be a positive value of caring throughout the unit. If staff feel valued and cared for, have opportunities to sort out differences and to express their fears and frustrations safely, then this approach will be used more freely with the young people that are being cared for. As a result, the young people are less likely to lose control or threaten others. (See Counter Bullying and Harassment Policy and Procedure for Looked After Children Procedure).

"Staff need to hear the messages young people might sometimes be giving too strongly for their own liking. Someone may be aggressive because they are upset, and it takes skill to look beyond the aggression and not just dismiss the situation."

From: Children's views on restraint, Roger Morgan, 2004

If young people are restrained, this should be done within the context of a relationship. Relationships form the basis to all aspects of this policy. This means the relationships between staff and the manager, among the staff team, and most importantly between staff and young people. Each affects the others and all have an effect on the culture as it relates to the restraining of young people.

Staff may only use restraint techniques that are approved by the home. Managers must ensure that new staff are trained in the techniques approved by the home, before they start working with children.

The main task in residential childcare is to develop appropriate relationships with young people. This is because staff cannot do any of the other tasks effectively without these relationships. The tasks of developing and maintaining relationships, which help young people, cope with life's challenges; form the background for creating a childcare establishment that works well.

3. Taking a Child Centred Approach

Taking a child centred approach means consistently putting the needs of young people first, and always putting them before a member of staff's own convenience. It involves recognising the worth of each young person no matter what the behaviour. To be child centred, staff must do what is in the young person's best interests and aim to see things from that child's point of view. This can be particularly challenging in the face of violence and aggression.

To safeguard and promote the welfare of young people, staff must have a shared understanding of what young people need in order to thrive. The National Framework for change is based on the five outcomes, which young people have said are central to their well being in childhood (Every Child Matters: Change for Children, 2003). The important ones in respect of this policy are:

Stay safe - this means young people are safe from maltreatment, neglect, violence and sexual exploitation; safe from bullying and discrimination; secure, stable and are cared for
Enjoy and achieve - this means young people achieve personal and social development and enjoy recreation
Make a positive contribution - this means young people engage in law abiding and positive behaviour; develop positive relationships and choose not to bully and discriminate; develop self-confidence and successfully deal with significant life changes and challenges; develop enterprising behaviour

Young people cannot reach their potential unless they feel safe. This does not mean that young people are simply on the receiving end of care and protection by adults. When young people have been asked about their views they clearly want to be active partners in the process of keeping safe.

Expectations of behaviour for both staff and young people should be clearly understood and negotiated by those living and working at the home, including exercising appropriate control over young people in the best interests of their own welfare and the protection of others.

In day to day decision making, staff should demonstrate an appropriate balance between:

Each young person's wishes and preferences
The needs of individual young people arising from their personality, age, ethnic, religious or cultural background, stage of development, gender and history
The needs of the group of young people resident at the time
The protection of others (including the public) from harm

There are young people who sometimes might not be in control of actions, which may lead to the young person being restrained, others may be fully in control when being violent or committing other high risk behaviour. In either case, staff can help reduce occasions when young people have to be restrained by helping them learn the skills in order to take control themselves, and improve the quality of their lives.

To help young people learn skills to manage themselves, staff should:

Demonstrate control themselves
Control young people's behaviour in ways, which do not involve punishment
Interact in ways, which invites co-operation, rather than convey coercion
Show respect for the legitimate interests and property of others
Promote impulse control by encouraging discussion and considered choices rather than impulsive action

Staff should also offer young people opportunities to discuss and reflect on the difficulties, which led to their placement, and be helped to develop the strength and resources to make good choices. Giving young people opportunities for achievement also helps them feel good about themselves.

Child care workers and other adults responsible for young people have, generally speaking, the same rights and responsibilities as a parent to influence the young person in the interests of their welfare, to protect them from bad influences and where necessary, to protect others from harm. This applies regardless whether the young person is subject to a "care order" or is "accommodated".

The law protects all young people against the unreasonable use of force and limits deprivation of liberty to those properly placed in secure accommodation. Otherwise the law does not empower staff from utilising the rights and responsibilities as reasonable parents set out in paragraph above. The law does not oblige staff to agree to the young person's preferences or wishes, where doing so would be likely to prejudice the welfare of the young person.

Child centred practice does not mean that staff should be reluctant to take charge when they should be in charge. Staff need to be clear about what young people can decide, what is negotiable and what is non-negotiable.

Not intervening with young people in situations where they may need to be restrained or otherwise stopped can have the unfortunate consequence of confirming for them that intimidation and violence are acceptable ways to achieve what they want. (See Counter Bullying and Harassment Policy and Procedure for Looked After Children Procedure).

A strong adult presence, using authority appropriately, will reduce the need for restraint. Acting in this way, staff can give the young people and colleagues a sense of security. However, there must be a sense of fairness and a spirit of care underlying all interactions and decision-making.

"Something quite small - or something seen as unfair - can trigger a build-up that ends in restraint"

From: Children's views on restraint, Roger Morgan, 2004

4. General Principles Governing Interventions to Maintain Control

The following guiding principles provide a framework in which a residential worker can make judgements about possible interventions. It is imperative that staff exercise sound judgement and act with discretion in deciding how to react in a particular set of circumstances. Staff have a duty of care to intervene appropriately when a person is in danger of being harmed. This means that it would be unlawful to stand back and do nothing to protect them. There are defences in law to protect staff who act in the young person's best interests. At the same time the law is there to ensure that physical intervention does not become commonplace or abusive.

A distinction must be maintained between the use of "one off" intervention, which is appropriate in the particular circumstances, and in using it repeatedly as a regular feature of regime. Restrictive physical intervention can only be used to "protect" or "defend". In other words, it is not permissible just because it gets things done quicker, or for convenience
Staff must be able to show that the method of intervention was in keeping with the incident that gave rise to it. The least restrictive intervention should be used for the minimum amount of time that is safely possible. This is about using a "gradient" approach
The degree and duration of any force applied must be proportional to the circumstances
The potential for damage to person's or property in applying any form of restrictive physical intervention must always be kept in mind. A restrictive physical intervention must only be used until the young person is calm - no longer - so it is essential to monitor events all the time particularly where a restrictive intervention is used. Always looking for the first opportunity to enable a gradient release
The failure of a particular intervention to secure a young person's compliance should not automatically signal the immediate use of another more forceful form of intervention. Restraint may not be used to force compliance or as a punishment where Significant Harm or serious damage to property are not otherwise likely. Escalation should be avoided if possible, especially if it would make the overall situation more destructive and/or unmanageable. Staff need to be reminded that the sole purpose of reactive strategies, of which restrictive physical interventions are part, is to bring about rapid, safe control to a situation. This means there can be no justification for doing something that is more likely to make matters worse, rather than better
Restrictive physical intervention must only be used if "there is no alternative" (the TINA principle from Professor Christina Lyon). Even if staff only have a split second to judge, they need to be able to demonstrate that in the circumstances the only course of action left open to them to prevent harm or significant damage was to intervene physically. The ability to "demonstrate" will hinge on things like what was tried in the build up, the actual danger of the situation and what others thought the options were
Staff's intentions to bring a dangerous situation safely under control must be genuine. Even with the best training there may be rare occasions when, despite a person's best intentions, an injury results from the intervention. What is important to know is that the staff will be protected if it was obvious that their intention was genuinely to safeguard the young person, not to harm him/her. The staff member's track record of dealing with such incidents and the views of witnesses are crucial here
Another valuable principle here is to apply the "Substituted Judgement Test". In simple terms this means asking the question "If I were in the young person's position, exhibiting the same behaviour, (or if it were my child) would I (when calm and with the capacity to do so) come to the same conclusion that there is no alternative to using this physical intervention now
The age and understanding of the young person should be taken into account in deciding what degree of intervention is necessary
In developing individual daily living placement plans, consideration should be given to appropriate methods of control that would be suitable to that young person's individual needs. Therefore any interventions must form part of a planned and evaluated strategy

Using a restrictive physical intervention in appropriate circumstances can reassure young people that you care enough to keep them safe from harm. It also passes on the important message that actions have consequences and that there must be limits to how people can behave. Young people recognise this and can take part in setting these limits if given the opportunity. Staff may choose never to use a restrictive physical intervention because of the damaging effect on relationships with the young people may produce the opposite effect. Some young people in some circumstances may see staff as not bothered about their safety. The principles behind corporate parenting are important things to consider here. How would a reasonable parent respond to a young person displaying violent or very dangerous behaviour?

Restrictive physical intervention has a part to play in keeping young people safe and making sure they are ok. However people are often worried about its use, partly because of worries about things "going wrong".

"It is important that staff are trained properly in how to get restraint right without hurting you and without making you get even more out of control and making things worse"

From: Children's views on restraint, Roger Morgan, 2004

Some young people see being restrained as physically abusive and as a punishment - whatever the official justification. Young people also have a clear sense that there are right and wrong techniques and that they should be able to rely on staff to use the proper methods. Young people do not insist that they should never be restrained, but object to those situations where it is not justified. This is when they believe that there is no risk of harm to themselves or others or that all other measures have not been used.

These negative feelings can have a damaging effect on relationships within the unit. Young people may worry that staff don't like them or decide that they no longer like or trust the staff. They may be left feeling angry or powerless if they believe that they were restrained unfairly, incorrectly or with too much force. These feelings are particularly damaging if the young person cannot voice them. Young people must have the opportunity to discuss and make sense of the incident, to make a complaint if they want to and to have that complaint properly investigated.

As staff there are similar concerns about when it is necessary to use a restrictive physical intervention or what exact technique to use, of making a mistake, that someone will get injured. There may be questions about the way in which a situation was handled, of the relationship with the young person being damaged, or questions about others' practice. It is important to freely express and explore these anxieties, to help protect against abusive (or negligent) practice.

Managers have the responsibility for making sure that staff have the training, knowledge and skills to use a restrictive physical intervention properly on their own and as a team. Managers have a duty of care to staff and young people and must have ways to make sure everyone's well-being and safety is the best it can be. If all is not well, young people will not thrive and staff morale will suffer. All young people and their social workers should be given a copy of the policies and procedures and this discussed with them as part of the admission process. Staff may only use restraint techniques that are approved by the home.

It is unlikely to get to the point where staff feel comfortable with physically intervening. This is healthy. A culture where restrictive physical intervention is seen as "no big deal" is much more worrying than one where staff are concerned by restrictive physical intervention and want to discuss what happened. Staff must always take using power seriously and constantly question it. Staff must have the opportunity to explore any doubts and receive honest feedback. If restrictive physical intervention is used then it must be the only practicable means of securing the welfare of the young person, there must be exceptional circumstances and it must be reasonable and proportionate, using the minimum force for the shortest time needed to prevent harm. Not all staff will get it right at all times, but there should always be time for open reflection and discussion of practice. The voice of the young person must have a place within this discussion.

When considering whether or not to restrain a young person, staff are faced by two demands. First there is that young person's right to freedom of movement. Secondly there is the duty of care to the young person and others. Staff can only ethically justify infringing the young person's right to freedom of movement if the circumstances are exceptional and physically intervening is the only practicable way to secure the welfare of those present.

Although this policy provides advice on situations in which using restrictive physical intervention may be justified, it cannot address every situation. It is never a matter of simply following rules. Instead, staff are faced with circumstances which will raise difficult and sensitive issues. This needs to be based on ethical practice.

Ethical practice means staff must reach decisions taking account of all relevant factors - this is about real, vulnerable people. This has at its centre a process of moral thinking and deciding what matters, which is based on professional codes of conduct. Staff should create opportunities to discuss these issues with colleagues and supervisors to build a shared understanding

While professional codes of conduct are designed to help staff make ethical decisions they will not, by themselves, give the answers to the moral problems that can be related to an incident of restraining a young person. Restrictive physical intervention involves difficult ethical choices. Staff should create opportunities to discuss the ethical issues that physically intervening with young people raises with colleagues and supervisors.

All young people should be given the opportunity to discuss incidents and express their views individually or in a regular forum or young people's meeting where unsafe behaviour can be discussed by young people and adults. When disciplinary measures or restrictive physical intervention has taken place, young people must be encouraged to write or have their views recorded and sign their names against them if possible in the records kept by the home.

Unless the manager (the registered person) can demonstrate that this is not appropriate, the home must have procedures and guidance on police involvement in the home, which have been agreed with the local police and which staff are knowledgeable and clear about. (See Thresholds for Police Intervention where Incidents Occur in Residential Child Care Policy and Procedure - to follow).

The way in which an adult uses their superior power, status and possible strength to impose their will on children is a significant measure of society's approach to young people's rights. Young people are to be encouraged to develop a proper awareness of their rights and responsibilities in relation to those who live in the home, those who work there and people in the community.

From: UN Convention on the Rights of the Child.

Article 19: The right to protection from all forms of physical or mental violence

Article 25: The right to periodic review of treatment and placement

Article 37: No child shall be subjected to torture or other cruel, inhuman or degrading treatment or punishment

SSI guidance (LAC(93)13), is clear that staff can and must intervene immediately to try to prevent young people leaving the unit when there are grounds for believing that they are putting themselves at risk. In assessing whether harm is likely staff must take into account all the circumstances, including the young person's own background and the reasons why s/he came into care.

Residential childcare staff have the responsibility and the authority to interpret the definition of harm widely and to anticipate situations where harm is likely to occur.

For example, when the particular circumstances of the situation dictated otherwise, it would be reasonable to assume that a young person of 11 or 12 years, who persists in wanting to leave the home in the evening against the instructions of staff where these instructions are based on a considered and reasonable view of the young person's welfare, is likely to put him/herself at risk of harm.

The same would be true of a young teenager known to be involved with vice or criminal activity or otherwise likely to come under bad influence or be at risk of harm to themselves or others.

For most young people, decisions about the likelihood of harm can be thought through prior to a situation arising. This should be part of all care planning, risk assessment and reviewing processes and should be agreed between unit staff, parents or those with parental responsibility, the social worker and the young person, and such decisions should be clearly recorded as part of the Daily Living Placement Plan.

Staff should address issues of control in staff meetings, and develop methods of dealing with them as a team. This should include agreed approaches to defusing tension and diverting aggression. Staff will need to have a common understanding of how to detect early signs of mounting tension which could lead to disruption, and rehearse methods of communicating with each other when dealing with situations threatening the good order of the home.

Managers should ensure that their staff are familiar with the relevant histories of young people for whom they have responsibility. Staff should take this into account in deciding how they respond to a young person, and in making judgements about appropriate interventions. The history should be noted in care plans, which may include agreed approaches to the control of individual young people who present particular behavioural difficulties. (See Plan for Managing Behaviour: Individual Crisis Management Plans).

From: Caring for Children away from Home; Messages from research, Department of Health, 1998

Better outcomes will be achieved if information about children looked after is properly communicated to all those involved. Workers may benefit from being trained in the interpretation of this information, in terms of what it means for the supervision and day to day care of the child

It is expected that each unit will offer a positive reinforcement system that allows young people to achieve. The systems must be developed for individual young people and centred on their particular needs. Care must be taken to ensure that goals and targets that are set are attainable. Such systems must be based on positives, therefore no system set up should include elements of withdrawal.

Individual reinforcement systems should be recorded as part of the care plan and reconsidered at least at every Statutory Review.

5. Understanding why Situations Turn from Day to Day Situations to Anger, Aggression and Violence

Before we can consider appropriate sanctions and physical intervention it is important to understand how and why situations turn from day to day situations to anger and aggression. In order to do this we should consider the following psychological model: The William Davies Aggression Incident Model.

Professor William Davies was a founder member of the Institution for Psychological Therapy and through his work with probation and perpetrators of crimes he developed the following model:

The Aggression Incident Model

When you apply this model to the young people we can see why they may move their day-to-day situations into the areas of anger and aggression.

For example:

Situation

Most young people in our care will feel, that for some reason, all the adults in their life to date have let them down. This may be because of ill health or even death but is often as a result of challenges faced by themselves and their family. As a result some young people find themselves in care in a strange situation, with people they do not know or trust having responsibility for their care.

Appraisal

This situation is extremely frightening for them and their whole world at that time is strange.

The young person will appraise the situation based on previous life experiences where they feel they have no reason to trust that any adults will remain constant in their lives for them. They may have learned to go to extremes to get their needs met. They have used their "coping behaviour" in order to survive. Young people will test the situation by pushing at any boundaries set and by exhibiting challenging behaviour and towards staff. What they are doing is, in fact, testing to see how long it will be before this current group of adults finds that they can't cope and moves them on to another placement and another group of adult carers.

Anger

The appraisal, being negative will increase the level of challenging behaviour and will often present itself in the form of anger. The young person will be angry at staff, angry at other young people, angry at their situation, angry at the future and life itself.

Inhibitions

Whether the anger felt by the young person manifests itself into aggression is dependant upon their inhibitions. Having already stated that the young person is testing boundaries and why, their inhibitions are greatly reduced by this need to test and by their poor earlier life experiences with adults.

Aggression

As a result of poor or no inhibitions, the young person is likely to exhibit their anger through aggressive behaviour. There are many theories of different types of aggression, for the purposes of crisis management they can be reduced to two; reactive and proactive aggression. Reactive is the most common form of aggression and is when young people are so overwhelmed that they lash out from fear or uncontrolled rage. Proactive aggression includes what is called instrumental or operant aggression, it is planned and is used to obtain something, reason is dominant not emotion.

The Davies Model stops here but it could easily continue to another set of inhibitors to violence.

Young people in the care system, because of poor life experience, and with little or no coping strategies, may move through the model very quickly spending very little time on appraisal and inhibition, to the degree that it almost feels that they are leap frogging this part of the process.

In order to respond to a young person's behaviour, an understanding of the reasons behind the behaviour is helpful. All behaviour has meaning. What is the function of the behaviour? What needs are being met through the young person's actions? Once we recognise the dynamics of this type of behaviour this will help us to recognise what is going on for the young person and why they are behaving in the way that they are. From this knowledge staff have a responsibility to help young people develop new coping skills and find ways to meet their needs that are successful and within reach.

6. Sanctions

A major determinant in good behaviour is the quality of the relationship between staff and the children and young people. Good order is unlikely to be achieved unless there is an established framework of general routines and clearly stated individual boundaries. The aim must be to create an environment, which gives a firm structure and sense of order to the lives of young people, in which they can develop and be educated. If that and the associated control and discipline are lacking they are likely to experience further difficulties when they leave residential care.

"Too many rules lead to breaking them..."

From: Children's views on restraint, Roger Morgan, 2004

Staff must respond positively to acceptable behaviour, and where the behaviour of young people is regarded as unacceptable by staff, it is responded to by constructive, acceptable and known behaviour management techniques. The consequence of unacceptable behaviour must be made clear to staff and young people and any measures applied are relevant to the incident; reasonable and carried out as contemporaneously as possible.

Young people need to be aware of what is expected of them and how the arrangements for their care actually work. Consistency in care practice, based on the Aggression and Violence Audit of the workplace and risk assessment of the young person is a key feature in the maintenance of control. As well as the employers primary responsibility for ensuring that a self-audit has been undertaken as an employee staff have responsibilities too. (National Task Force Audit, DOH, 2000).

A young person's age and competence bear on her/his ability to recognise and understand danger to themselves, or others. As such they are factors to be considered when determining the appropriate response to a child or young person whom is in crisis.

Measures of control and disciplinary measures will be based on establishing positive relationships with young people, which are designed to help the child. Such measures must be fair and consistently applied. They will also encourage reparation and restitution and reduce the likelihood of negative behaviour becoming the focus of attention and subsequent disruption to the placement.

Young people of any age may have an impaired ability to recognise and understand danger. This may be, for example, because of a learning disability, autism, or severe emotional disorder. For such young people there may be a need to take action as in paragraph below. Brief periods of withdrawal away from the group into a calming environment may be more effective for the severely agitated young person than holding or physical intervention.

Sanctions must not be excessive or unreasonable.

Restrictive physical intervention must only be used to prevent immediate likely injury to the young person concerned or others. Restrictive physical intervention must not be used as a punishment, as a means to enforce compliance with instructions, or in response to challenging behaviour, which does not give rise to reasonable expectation of injury to someone.

In units which care for young people with special needs there will be a particular need to ensure that the young people do not have unsupervised access to unsafe areas including the outside of the building and grounds. The safety of the young person is paramount. Particular care should be taken to ensure that dangerous objects and materials are locked away. Homes should adopt normal domestic approaches to security, including for example, the locking of all external doors at night. The reasonable application of these practices would not constitute restriction of liberty. Fire safety issues must be considered.

The use of locked doors to restrict access to parts of the home should not be an easy means of saving staff time or to keep their number inappropriately low. Staff should be energetic in their efforts to find ways of keeping each young person safe, which minimises the need for physical control and restriction of liberty.

However effective staff are in creating the right conditions, problematic behaviour is bound to happen. Each unit needs to develop a strategy for managing this behaviour. (See Own Unit's Behaviour Management Policy - to follow). This is important so that:

Staff have a clear grasp of what they can and can't do when responding to problematic behaviour
The young person will be clear about what behaviour the unit can manage and what will follow if they try to harm themselves or others
Parents are helped to understand and talk with staff about how their young person's behaviour is being managed

A clear policy on managing behaviour may reduce the need for physical intervention, but is unlikely to make it completely redundant in all circumstances. A clear policy will make sure that the way young people are restrained is placed within a holistic and child-centred approach.

The successful conduct of any unit is dependant upon a combination of sound management, high standards of professional practice and care and upon caring relationships and the protection of the interests of young people. (See: The Pindown Experience and the protection of children, 1991).

Young people should be involved in decision making about their care, including when sanctions are being imposed. They should be encouraged to take responsibility for their own care, appropriate to age and understanding.

7. Permitted Disciplinary Measures

It is recognised that some form of sanction will be necessary where there are instances of behaviour which would in any family or group environment reasonably be regarded as unacceptable. Often such unacceptable behaviour can be prevented by the use of mild or severe reprimand. The imposition of formal disciplinary measures should be used sparingly and in most cases only after repeated use of informal measures.

Consistency of approach to discipline is a key feature in the maintenance of control. Failure to adopt a consistent approach could result in the young person not receiving adequate, appropriate level of care.

Young people in homes are likely, because of the system, to be confronted as to the consequences of their action by numerous adults; this often serves merely to compound misbehaviour and undermine the young person's self esteem. Staff should appreciate when a misdemeanour is finished and the subject should be dropped.

There should be a consistent system of rewards (commendations, extension of privileges etc.) as well as a system of sanctions. Such systems should be agreed within the team, be put in writing as part of the daily living placement plan for each young person, and each worker should be advised of the detail of the plan. The measures approved for use in the unit should be appropriate to the age and circumstances of the individual young person accommodated. Managers should monitor the use of privileges and sanctions at both the childcare review and at supervision sessions with all workers.

It is recognised that on occasions positive reinforcement systems alone may not be enough and that consequences of their actions need to be recognised by young people.

Appropriate measures could be:

Reparation - putting right the harm or damage a young person may have done, e.g. making an apology or doing something helpful
Restitution - compensation, e.g. paying for damages
Curtailment of leisure extras
Additional house chores
Increased supervision
Restrictions of contact with individuals, but only in accordance with the care plan for the young person or where there is urgent need to restrict access to individuals of doubtful influence
Refusal to go out as may occur as a normal domestic sanction, but only where this is an agreed sanction in the unit and is not seen as a restriction of liberty. (See Section 8, Prohibited Disciplinary Measures)
Withholding pocket money, but only where the young person is a perpetrator who is being made to pay for or make a contribution towards the cost of repair or replacement of misappropriated monies or goods. No more than a maximum of two thirds of a young person's pocket money should be withheld
Physical intervention, control by physical intervention is the last resort intervention where other interventions have failed, or would be insufficient to prevent the immediate risk of serious harm to the child or others. Workers must be appropriately trained. If staff are not trained, it is dangerous for the young person and themselves. (See Section 13, Restrictive Physical Safety Intervention)
Holding. When used to hold a young person in such a way as to encourage calming or to prevent them injuring another person

Managers and senior managers must ensure that all staff are aware of the measures which are acceptable, the extent of their discretion in administering them and the requirement to record full details of their use in a log book with numbered fixed pages and if a physical intervention has been used, in the appropriate restrictive physical intervention book.

Where young people lose control and become aggressive or violent restrictive physical intervention may need to be employed if all other interventions have been exhausted. (See Section 13, Restrictive Physical Safety Intervention).

Workers must be mindful of their own negative thoughts/responses in these situations and not respond to verbal abuse with inappropriate and often inflammatory phrases such as "Get lost", "calm down" and avoid having the last word.

Workers must be aware of their own body language and try to resist adopting aggressive stances.

"You need to be as good as possible at heading off an argument from leading to danger needing restraint"

From: Children's views on restraint, Roger Morgan, 2004

8. Prohibited Disciplinary Measures

Prohibited measures are listed below:

Techniques that Interfere with Breathing

Any restraint technique that may interfere with breathing is likely to present an unacceptable risk and should never be used. Holding a child by the neck carries a risk of suffocation or restricting blood flow to the brain, as well as a risk of spinal injury and on no account should neck holds be used as a way of restraining children or young people. So called "nose distraction" technique inflicts pain and is not proportionate, as it will involve unnecessary force. These techniques, therefore, are unacceptable and should never be used on children in any children's homes, including in secure children's homes.

Corporal Punishment

This covers any intentional application of force as punishment including slapping, throwing missiles and rough handling. It would include pushing or punching in the heat of the moment in response to violence from young people. Restrictive physical intervention or holding of the type incorporated in the Therapeutic Crisis Intervention programme is not included as corporal punishment.

Deprivation of Food and Drink

Meal times are an important social occasion in the life of a young person and it would be inappropriate for a young person to be refused meals. Deprivation of food should be taken to include the denial of access to the amounts and range of food normally available to every child or young person in the unit.

Deprivation of food would not include excess demands for treats e.g. chocolate, biscuits, ice cream nor instances where specific food or drinks have to be withheld from a child on medical advice.

Equally it would be inappropriate to force a young person to eat food, which was disliked. Encouragement to eat a range of foods however is appropriate.

Restriction/Refusal of Visits/Communications

The value of young people maintaining contact cannot be overstated. However, it is recognised that in some circumstances as part of the management and planning of care some restrictions may have to be placed on contact with certain individuals, for example the barring of friends from particular unit where they have been instrumental in the unacceptable behaviour or are linked to concerns regarding harm.

Any restriction on or delay in communications by telephone, post or in person with:

Their parents
Any person with parental responsibility
His/her relatives or friends
Any independent visitor
Their assigned social worker
Their CAFCASS officer (Children and Family Court Advisory and Support Service)
Any solicitor for the time being acting for the young person or whom the young person wishes to instruct

Requiring a Young Person to Wear Distinctive or Inappropriate Clothing

Some young people receiving our services already have a negative perception of themselves and requiring them to wear such clothing would only undermine their self-esteem and damage their self-confidence.

Wearing clothing connected with education or any uniformed organisation (such as Scouts or Guides) is of course not excluded.

Use of Withholding of Medication or Medical or Dental Treatment

This would be dangerous and unacceptable practice. The only time that it would be acceptable not to administer medication would be where there is reason to suspect that the young person is under the influence of drugs, alcohol, or other substances which may react adversely with the medication or treatment. In all such cases where medication or treatment is refused, the details including the reasons behind the decision must be fully recorded.

Intentional Deprivation of Sleep

This could inflict grave psychological damage and seriously affect the health of the young person.

Monitory Sanctions

It is not considered appropriate to simply fine young people as a punishment. However it would be perfectly proper to make a perpetrator pay for or at least make a contribution to the cost of repairs or replacement of misappropriated monies or goods.

Intimate Physical Searches

Intimate physical searches are totally unacceptable. Occasionally, and not as a punishment, a search of a young person's clothing may be necessary, e.g. for weapons, but where this does not allay anxieties about the young person's safety or the safety of others, s/he will have to be kept apart from the group and closely monitored by a member of staff. If it is suspected that a young person has secreted drugs on his/her person then the police should be notified. No physical search should involve a restraint. (See Thresholds for police intervention where incidents occur in residential child care policy - to follow).

9. Restriction of Liberty

The use of accommodation to restrict physically the liberty of any child is not permitted in a community home, other than secure accommodation approved by the Secretary of State. Total restriction of liberty is therefore prohibited in all Wakefield Family Services residential units for children and young people. When it is considered necessary to totally restrict liberty then a Secure Order must be sought in line with Departmental procedures. However the locking windows and doors at night, in line with normal domestic security is permitted. Refusing permission to go out, short of measures, which would constitute restriction of liberty, is not forbidden providing that it is an agreed sanction in the unit, however this sanction cannot be physically enforced.

Restriction of liberty should be restricted to circumstances where immediate action is necessary to prevent injury to any person.

In the ordinary course of maintaining control over a young person, an adult may tell them to do things, which they do not want to accept, including refusal of permission to leave the building. If a young person complies with reasonable instructions, the question of restricting liberty by use the use of accommodation does not normally arise.

For a young person, the potential danger in leaving a unit is real and obvious, and the case for action to prevent this is clear.

From: The Control of Children in Public Care: Interpretation of the Children Act 1989 (SSI C1 (97) 6)

Persuasion and the patient engagement of children in more structured and disciplined lives is the first line of resort in preventing a child or young person from leaving a residential unit which is not designed as secure. It has a good record of success and physical coercion should not become habitual. But if necessary staff have the authority to take immediate action to prevent harm occurring even if the harm is expected to happen some time in the predictable future.

Staff should recognise that there are practical limitations on their ability to prevent young people running away from an open children's home if they are determined to do so. External doors may be locked, as a temporary measure to prevent a young person leaving the building where a considered and reasonable decision has been taken that by leaving the unit the young person would be at serious risk of harm. The use of physical intervention in these circumstances cannot become a substitute for secure accommodation. Where there is concern for a child likely to run away and suffer significant harm, then consideration should be given to whether the criteria for placement in secure accommodation can be justified.

The criteria for placement in secure accommodation are that the young person:

Has a history of absconding and is likely to abscond from any other description of accommodation; and

If s/he absconds s/he is likely to suffer significant harm; or
That if s/he is kept in any other description of accommodation s/he is likely to injure him/herself or other persons

SSI guidance suggests that it is reasonable to bolt a door to temporarily restrict a young person's mobility or in order to win some time to call for help from other members of staff. The interpretation of temporarily must be defined as for no more than a few minutes with ten minutes being the absolute maximum.

No young person should be locked in a bedroom or other part of the building under any circumstances other than that the young person presents a serious risk to other people, and only then for the very shortest space of time required to summon help. Again, this should be for a few minutes and not more than ten minutes. Wherever possible, a young person should be locked in a room without a member of staff being present.

The practice of not allowing out ("gating" or "grounding", as it is sometimes called) is common and acceptable provided the young person is not prevented from leaving by being locked in or physically restrained and Children's' Homes Regulations (2011), 17(5) c (restrictions on visits or communications) is observed.

The practice of "grounding" (where a young person is not allowed to leave the home unless under staff supervision) is a restriction of liberty, even when the young person is not physically prevented from leaving. However, this is allowed but the following guidelines must be adhered to:-

No physical attempts are made to reinforce theses restrictions unless the young person is believed to be putting themselves others at risk
As with other sanctions and methods of control, it should be time limited, and not extend beyond twenty-four hours, relevant to circumstances that led to it being applied and the young person should not be set unreasonable targets to achieve before the sanction is lifted
"Grounding" should confine young people to the unit, but not deprive them of access to facilities, not limit their movements within the home and must conform to guidelines with regard to access and contact

Guidance on restriction of liberty must also be applied to oppressive supervision, where clear intention is to prevent the young person leaving the unit. Oppressive supervision could be defined as close, one to one supervision or shadowing a young person. Such supervision may only be considered for the following reasons:

Where a young person's age and/or competence requires the restriction of liberty in order to protect the young person.

In all other instances, in accordance with age and competence, young people should have their liberty. Residential staff have a general duty and responsibility, in line with their duties as a reasonable parent, to have knowledge of the whereabouts of young people in their care
Where a young person of age and competence requests limited restriction of liberty as part of their ongoing care programme, (i.e. to help prevent glue sniffing, absconding etc), this must be formally agreed in a review with clear parameters recorded
Where young people are known to be temporarily at risk due to emotional disturbances, under the influence of solvents, displaying suicidal behaviour or are known to be seriously threatening the safety of others, then their liberty may be restricted

Staff need to be aware of the authority implicit in their role and seek to strike a balance between supervision that is obtrusive and overbearing and that which is necessary to ensure general good order and discipline within the unit. Supervision which can be perceived as "over the top" by young people can breed resentment and lead to control issues, as can lack of adequate supervision. Staff need to convey to the young person that whatever level of supervision is being applied, it is based on care and concern for the young person and a general interest in their safety and well being.

10. The Care and Control of Children and Young People Outside the Unit

Staff in residential units must have regard for their care and control when they go outside. Plans, made in accordance with the Arrangements for Placement Regulations and subsequent reviews, should address all the relevant considerations, which staff will need to take into account when making individual judgements. Normally a young person of sufficient age and competence may be allowed out to the shops, to school and to visit friends etc. There may be young people for whom going out presents risks of harm to themselves or getting into trouble.

Those with parental responsibility should be party to this planning. When it is desirable for a young person to go out, even though this carries some risks, very firm requirements should be agreed with all parties concerned. When a young person is on a visit the responsibilities of those visited should be made clear. This may include a requirement for the friend to report the safe arrival, time of return or agreement that the young person should be escorted and by whom.

A young person who is living in a children's home may, with the knowledge and preferably the agreement of those with parental responsibility, may be refused permission to go out.

11. Risk Assessment and Care Planning

Care planning is central to the task of caring for a young person in residential care. It means that the young person, his or her parents and professional staff are clear about why the young person is accommodated and how their needs will be met. Care planning defines the aims of the placement and how everyone will meet the aims.

Although the term "placement plan" is referred to in the Regulations (Children's Homes Regulations, (2011) 12, 1 - 4), the term "care plan" is used here as a more common term. The care plan is the overall plan, which has to be produced under the regulations.

In addition to what the regulations say, a recommendation as best practice is that the care plan should:

Be clear about the aims of the local authority in looking after the child and how those aims are to be achieved
Be based on an assessment, which should include input from a range of professionals
Take account of the existing arrangements for looking after the at home include practical documents spelling out who will be doing what and when, where and how, to achieve clear aims

To guide staff's day-to-day work, it will be necessary to produce other, more detailed plans showing the ways in which staff will meet the aims of the care plan. These plans can vary in how complex they are and how often they are reviewed. (Daily Living Placement Plans) When necessary, some young people will also have detailed plans for managing behaviour (See Plan for Managing Behaviour - Individual Crisis Management Plans).

Staff in a residential establishment you should be clear about the part they will play day to day in putting the plan into action. If it is likely a particular young person will need to be restrained, arrangements for doing so must be written in the young person's care plan, and ICMP. The plan should anticipate but not assume the young person will be restrained, as it will always have to be the only practicable means to secure the welfare of the young person or another young person and only in exceptionable circumstances.

Managers of residential establishments are also responsible for the staff who look after the young people. In making plans for young people, the manager must also protect the safety of staff. (See Health and Safety circular No. 23: Personal Safety).

Staff working with troubled and angry young people on a daily basis, should keep a clear record of the risks, along with the measures put in place to reduce the risks. The measures may include the layout of the building and how it is used, staffing levels, ways of working with particular young people, routines and training. Individuals and employers are responsible for making sure that risks and control measures are taken seriously and are acted upon. (See Risk assessment and risk management practice guidance and residential care risk assessment format - to follow).

Each young person entering residential care has their own history and personality, which will result in different reactions to stress. Staff should reflect these individual differences in the way their risk is assessed and their behaviour is managed. Assessing risk must take account of both the specific risks posed by individual young people as well as the risk towards any individual young person if they are restrained. In either case, staff should carry out an individual assessment, including the steps to be taken to deal with the risks in the young person's day to day care arrangements.

Once young people are in the escalation phase of the crisis and have reached a state of high arousal, and they are on the verge of an outburst, ready to erupt, it is at this critical moment important, but difficult for the worker to avoid escalating the situation. Because of the combination of stress, arousal and anger, the young person is more likely to interpret any action from the worker as negative, and it will more than likely trigger an aggressive or violent response from the young person.

Choosing an approach in a potentially violent situation requires a quick assessment of the situation. The worker needs to look at the elements of the situation and make a decision as to how best to intervene in order to contain or de-escalate highly aroused individuals and bring the situation back under control.

Effective techniques to reduce the young person's anxiety and anger include:

Using any leverage gained from a positive relationship with the young person
Using active listening techniques to identify the young person's feelings
Remove any audience
Use non-confrontational limit setting (I ASSIST)

The immediate object in a potentially violent situation is to make the situation safe. This can be accomplished by reducing the level of arousal in order to promote compliance.

A priority is to isolate the young person before interacting, if at all possible. The easiest and least intrusive action at this point is to remove all others from the area. If the upset young person is responsive, the worker should suggest going for a walk or going to a quiet area
Actively listen to understand what the young person is trying to communicate. Even a young person who normally can share feelings appropriately, may have a limited ability to do so during periods of great stress. The worker must ignore any possible insults or arguments, as this is time to reflect the feelings
It is essential for the worker to stay in control and be respectful since this helps to reduce the level of arousal. This is particularly important if using a directive statement, to avoid using a raised tone of voice or blaming the young person. This takes practice and good self-awareness
It is important for workers to let young people know that they understand how young people are feeling before they request their co-operation. Any requests made of young people at this time should be to do something that will lower the level of arousal
To help young people calm down, the worker should invite them to consider positive outcomes rather than demanding that they change their behaviour. The impulse if stressed is to become increasingly coercive in an attempt to force compliance. This can often involve threats of consequences or punishments if the young person refuses to comply, and become counterproductive. To threaten the young person with negative consequences if the outburst continues will only inflame the situation and further challenge the young person. Another way to increase the chance that a young person will co-operate is to appeal to the young person's self interest and state the positive results of complying with the request. The strategy is for workers to draw on their relationship with the young person while directing the young person's behaviour
Giving the young person space will reduce the pressure and stress of the situation. If it is safe to do so, the worker can step away from the young person's sight for a short while. At the minimum, the worker should back off and not invade the young person's personal space. Silence can also be effective at this time
Time helps the young person to respond to requests, with space and time, the young person is more likely to consider the issue at hand, think about the choices and comply, rather than maintain opposition to the worker. If the worker stops the interaction, the young person no longer has anyone to argue with or resist

Plan for Managing Behaviour - Individual Crisis Management Plans

Every young person should have an individualised plan for how staff will manage a young person's behaviour, to which the young person, parents, social workers and carers have all had reasonable opportunity to contribute. With the aim that the plan will eliminate the need for external controls by helping the young person with more appropriate coping strategies. This will identify:

A strategy for intervening that includes specific physical interventions or alternative strategies, or if physical intervention is not an option, any medical conditions, medication, history of abuse, or anything that might contribute to decisions when making the decision to intervene
A range of questions that need to be asked - what are the likely triggers that cause the young person's distress; what function does the behaviour serve; what type of aggression does the young person display; what is the young person trying to communicate through the behaviour and what other factors can contribute to the behaviour

There should be ongoing reviews of the young person's day-to-day functioning and changes in behaviour. Intervention strategies should be reviewed frequently and every time there has been a physical intervention with the young person. Others should also be involved in the review such as family members, medical practitioners, social workers etc. The aim is to allow each young person to grow so that they do not need other people to control their behaviour.

"Fill in a form on their preferred way of calming down"... "each individual's plan could tell staff the best way to deal with that person if they lose control"

From: Children's views on restraint, Roger Morgan, 2004

Young people may lose control when something upsets them. The daily living placement plans should help staff tailor their approach, to help them manage the situations, people and behaviour, which causes them to lose control. When working with young people who have language and communication difficulties, staff should list the specialist communication approaches that can be used in their daily living placement plan.

The young person is the key stakeholder in all aspects of her/his care and under the Children Act 1989; staff must take proper account of the young person's views of their care. The young person's welfare is paramount.

12. Physical Contact

The use of physical contact, as opposed to restrictive physical intervention, is an acceptable and often effective method of preventing escalating behaviour.

By physical contact, we mean:

The use of touch that gently guides, e.g. a hand on the shoulder or arm
The use of holding that does NOT enforce compliance nor imply sexual connotations
The use of blocking passage, again no enforcing compliance

The above are only intended as part of an ongoing dialogue with the young person that conveys grave concerns about the behaviour/actions they are displaying and that staff are acting as reasonable parents. (See Section 21, Methods of Care and Control which Fall Short of Physical Intervention or the Restriction of Liberty).

13. Restrictive Physical Safety Intervention

Whilst this part of the guidance describes the use of restrictive physical intervention, it must be remembered that it only should be used as a "last resort".

Options to handling a violent situation:

Eliminate one of the elements of a violent situation
Make a directive statement that clearly communicates that the violence must stop
Use releases and maintain a safe distance
Leave the situation and get assistance
Employ restrictive physical intervention techniques (if indicated in the ICMP)

The proper use of restrictive physical intervention requires skill and judgement, as well as knowledge of non-harmful methods of intervention. The onus is on the care worker to determine the degree of intervention appropriate and when it should be used. The goal of physical intervention is that it is used to contain or control the behaviour to ensure safety and protection and when specified in the behaviour management plan. It shouldn't be seen as an end in itself, and should be used to help the young person develop better coping strategies. Staff must be careful not to overreact. If they are managed well, young people can be helped to move away from automatic and habitual responses, to a position where they can better control their choices.

Restrictive physical intervention may only be used where all other intervention techniques have failed to avert acute physical behaviour, (this is defined as behaviour that clearly indicates the intent to inflict physical injury upon oneself or others). Restrictive physical intervention should control the child safely with the best interests of the young person in mind and should only be used as a response to acute physical behaviour.

Staff may only physically restrain a young person when it is the only practicable means of securing the welfare of that child or another child and there are exceptional circumstances. Staff must reasonably believe that:

A young person will cause physical harm to themselves or another person.
A young person will run away and will put themselves or others at serious risk of harm, or
A young person will cause significant damage which is likely to have a serious emotional effect or create a physical danger, as in below:

Damage to property is not sufficient reason on its own for restraining a young person. However the damage done to the welfare of the young person or other young people by their damaging property may be sufficient reason. A young person destroying their history (all of their photographs for example) or destroying communal or private living space may cause significant harm to themselves or other young people - psychological in this case. It is harm to the young person, not property that is the issue. Damage being done to property does not necessarily mean that a young person or other young people are being significantly harmed.

"Staff should only use restraint if you were damaging something important or were likely to injure someone"

From: Children's views on restraint, Roger Morgan, 2004

Restrictive physical intervention should only be used if the staff member feels competent and capable of carrying out the intervention safely and has received appropriate training, and in such a way as to ensure no injury is caused to the young person or themselves. (See Section 22, Training).

As it is recognised that physical intervention may be required the agency/unit will have completed a behavioural audit. The aim of this audit is to compile information from the agency records, such as statistical and descriptive data about the general resident group that the unit cares for that will help determine the appropriate level of training in restrictive physical intervention that is required. (See Section 22, Training).

Any planned restrictive physical intervention:

Should be agreed in advance and agreed with the young person's social worker and those with parental responsibility
Recorded in writing as part of the daily living placement plan and ICMP for the young person so that the method of physical intervention and the circumstances when it is sanctioned for use are clearly understood. Any risks and limitations imposed by the young person's circumstances should be included

Any intervention should take place in the context on an ongoing relationship with the young person and be based on the principle of a maximum amount of caring with a minimum amount of force, minimum loss of dignity, therefore creating the possibility of making good progress when the crisis is over. The aim of the intervention is to de-escalate the situation by reducing stimulation, and should end as soon as the young person has regained control.

There are three important parts involved in the process of physically intervening with young people well:

What to think
How to act
What to do

How you should think - if you think about what you are doing this will dictate how you act. It is important for you to have the right frame of mind.

Set aside unhelpful thoughts; ask the question "How am I feeling right now?"
Think of the young people as unique individuals and each occasion as a unique occasion. (This helps you to use previous information without thinking that you are always bound to get the same outcome)
Be aware of your own emotional state and that restrictive physical intervention happens within the context of a relationship; ask yourself "how am I possibly contributing to this situation?"
Be aware of the young person's history and of anything that may increase or reduce the likelihood of things getting worse
Try and work out the young person's intention in behaving in this way; ask the question "What is this young person feeling, needs, wants?"
Think of violence and aggression as a form of strong communication and avoid becoming defensive
Consider how you speak to your co-workers. The way you do this can make your thinking clear to the young person, and help maintain a neutral viewpoint

How you should act - you can consider physically intervening with a young person as being a way of managing their behaviour on the surface. It can pave the way for other therapeutic action with them later. The way you act while restraining a child or young person contributes greatly to maintaining the relationship you need to do this further work.

Keep calm and controlled and act in a way that absorbs and responds to aggression without retaliating
Be sensitive about your choice of words, your tone of voice and your pace of speaking
Work with and don't compete with the young person
Don't rush the process, and let it take as long as it takes. However, you must be aware of the young person's level of discomfort and the dangers of restraining them for too long

What you should do - after assessing the risk in the situation, and as it becomes clearer that you need to physically intervene immediately, several things become particularly important. All workers must be aware of their own physical size, strength and height compared to that of the child. The child's background and experiences must be taken into account and gender issues must also be considered. Wherever possible male staff should avoid physical intervention with female residents.

You should:

Take steps in advance to avoid the need for physical intervention, e.g. through dialogue, diversion and non-confrontational techniques
Not use a restrictive physical safety intervention purely to force compliance with staff instructions when there is no immediate risk to people
Have good grounds for believing that immediate action is necessary to prevent a child from significantly injuring him/herself or others
Check where you are and the way this may affect the way you restrain them (for example type of flooring, space and so on)
Communicate with colleagues
Make sure that there are enough competent people to manage the situation safely
Make sure that someone takes the lead
Assess the possible reaction of the other young people present and make sure that they are not drawn in, and moved away where possible
Use only the techniques that you have been trained in
Choose the least restrictive way of physically intervening (such as the standing hold)
Use a restrictive physical intervention in an act of care and control, not punishment
Use as little force as reasonably practicable for the shortest time necessary

When practicable, you should assign someone the responsibility of monitoring the restraining process to check to make sure that the young person is not in unnecessary or life-threatening distress and that they are being restrained properly. (Signs to look for which indicate distress see Section 16, Areas of Danger and Concern).

If you see signs of life - threatening distress, stop restraining them immediately and seek medical help.

In carrying out techniques there are certain safety considerations. Staff should:

Minimise as far as practicable any pain or discomfort which may be involved
Avoid pressure on or across the joints
Make sure you carefully move to the floor in a controlled way (if this is involved in the type of restraint used)
Protect the young person's head, especially if techniques involved moving to the floor
Make sure that you use only holds you have been taught and are authorised to use in your unit
Constantly monitor the young person's breathing and wellbeing, taking account of factors that may affect the restraint (e.g. age, gender, obesity, medical difficulties, cultural issues, the child's history)
Continually review the need for the restraint and the safety of all concerned

What you must never do:

With safety still as an important consideration, there are things you should never do. You should never:

Deliberately inflict pain. You must always act reasonably, proportionately and without resort to excess
Put weight on the young person's neck, torso or hips, because of the dangers of affecting their breathing
Use "choke" or "strangle" neck holds
Use seated or kneeling holds if the person is bent forward at the waist (hyper flexion), or
Restrict airways, for example, by obstructing the nose or mouth

14. Other Considerations

Changing staff - it is appropriate for you to change the staff involved in restraining a young person when:

It is unlikely that the young person will calm down without changing the staff
You are no longer in enough control of your own feelings
You are injured in a way which makes continuing the restraint impractical
You are so tired you cannot continue
You believe that the young person is deliberately making you continue restraining them, for some form of gratification

Before deciding to change the workers involved in the restraint, you should think carefully about the ways in which the young person will understand the change. Avoid acting in ways, which undermine the authority of the worker who took the lead at first. For example some male workers may feel it necessary to take over from a female colleague, because they are uncomfortable with the situation as a result of her gender. Although well intentioned, these interventions can be unhelpful.

Ending a restraint before it's done - in rare circumstances you may need to stop restraining a young person before she /he has control of themselves and before you have completed a proper process of letting go. This can present you with particular difficulties, for example you may have made a wrong assessment of how appropriate it was to restrain the child in the first place. However, it is always better to admit your mistakes than to carry on with an ineffective and sometimes dangerous situation.

You will need to release a young person early when:

The young person has been injured, been sick or had breathing difficulties
You become aware of a threat to their well being as a result of other more long standing health concerns
You cannot continue safely because you have been injured and it is not possible for someone to take over

You and your colleagues need to make it clear to the young person why you are ending the restraint and should, if possible, go on engaging with the young person. If a member of staff is the target of a complaint, allegation, criminal charge or prosecution, civil claim or litigation and has acted within authority guidelines and training on restrictive physical intervention, they should reasonably expect to be supported by their employer. Control by restraint generally causes emotions to run high and can embarrass, disempower or otherwise upset a young person to the extent that they complain about their treatment.

Staff need to project confidence and assertiveness in their dealings with young people and to help them do this, managers need to make clear to their staff the support they will receive from them should their actions be called into question. This support should be offered in the context of the department having a duty to treat any complaint seriously, particularly those made by young people. In respect of any complaints or allegations arising out of the use of control by restraint or any other method of control referred to in this document, staff will be expected to demonstrate that the action they took was in keeping with this guidance and reasonable in the particular. It is important for staff to understand/recognize their role within these processes, and their rights of representation. (See Rights to Representation, Official Conduct/Appeals, Personnel Procedure - to follow).

Restraining a young person who has a disability, learning difficulty or other similar needs - in the lead up to and during a restrictive physical intervention, you should keep in mind any issues that might complicate the situation because of the young person's disability. Some examples are:

A young person may not understand your body language, tone of voice or facial expressions in the same way other children might
A young person may have great difficulty with changes to their routine and can be very sensitive to sounds or touch
While being restrained, young people whose hearing is impaired may not communicate in their accustomed way and will likely not be able to express their hurt, rage or fear. What is already a disempowering experience for a hearing/speaking young person could take away from this young person any feeling of control?
Young people with certain learning disabilities might not be able to understand what is happening to them before and while they are being held. The meaning they attach to what has happened may be very different from the adult's understanding

Whatever factors may complicate holding this young person, you must arrange things to minimise the chances of traumatising or re-traumatising them.

Situation in which restrictive physical intervention - while justified - should be avoided.

When it is judged that the worker cannot control the child safely through restrictive physical intervention techniques. That is, when it is believed that any attempt would hurt the worker or the young person. This may be because of size and strength differences or because the physical environment is unsafe, e.g. on the stairs, near a window etc.
When the worker cannot remain calm and in control; when they are so angry with the young person that harm might be inflicted as a result of a restrictive physical intervention
When workers find themselves in a situation where the young person is threatening them with bodily harm and appears capable of inflicting it
Where it is judged that sexual stimulation is the motivation of the young person
When the young person has a weapon, e.g. knife, broken glass, etc that would cause serious injury
When the young person's medical condition, e.g. heart problem, would be aggravated by a physical intervention
When the young person has been sexually abused and the physical intervention might result in emotional trauma for the young person

If restrictive physical intervention has been avoided, although justified, there are still steps that can be undertaken.

Send for assistance of other staff or, if warranted, the police. Know what help is available and how to obtain it quickly. (See Thresholds for Police Intervention where Incidents Occur in Residential childcare Policy and Procedure - to follow).

Isolate the young person from the other young people as quickly as possible.

Maintain a safe distance from the young person.

Remain engaged with the young person.

15. Ending a Restrictive Physical Safety Intervention

The way in which a restrictive physical intervention is ended, and the action taken immediately after it, will have a large influence on its overall effect

Letting go - the process through which you give back control to the young person and let go is important in terms of the effect it has on the young person and her/his relationships with the staff involved. Releasing too soon and having to immediately manage violent or otherwise high-risk behaviour all over again is obviously something to avoid. And holding a young person for longer than is needed is not only poor practice, but in some cases could be considered abuse, assault or negligence.

In between the extremes of much too soon and far too long lies a difficult area that involves skilled and knowledgeable practice.

Preparing to let go

Only one person should lead the process of letting go of the young person.

This is often the person who has been the lead in the restraint, but there can be exceptions to this if you believe that the young person cannot calm down when spoken to by the lead person
If the young person does not appear ready to start or continue the letting go process, don't start or continue.

While this may appear obvious, at the time it can be difficult to assess. So, tell the young person clearly, and often as needed, how they can let you know they are ready. Do not confuse the young person by starting to let them go, or continuing to let them go, if they have not let you know that they are ready
Use a firm, neutral and reassuring tone throughout the process.

Avoid statements that further provoke or stimulate the young person, including accusations and demands. At the same time, be firm; mean what you are saying. It may help the young person to be able to calm down when all other staff stay silent
Once you see that the young person has calmed down enough, let them know what you want them to do to show you that they are ready to begin the process of letting go.

Tensions are likely to still be high, and having to answer questions while still being held can often feel like a further humiliation. To avoid this, let the young person know what you are looking for in terms of an indication that he/she is ready.

Focus on what you are looking for so you know that the young person is ready to start the letting go (for example, asking him/her to take two deep breaths). You may want to tell the young person that what you are already seeing shows you that the young person is ready to start the process of letting go.

Once a young person is calm, slow deep breaths can be a good place to start. This offers a simple indication that the young person is ready and also helps to calm the body.

As the last step of the process, let the young person know what will happen after you release them, before you make the final release (for example, that the young person can take a few moments to get themselves together, and then will be brought something to drink and checked for injuries)
Letting go should be more of a process than an abrupt event. Take your time and assess throughout whether the young person is showing that they remain ready to regain control and be safe. A gradual release (either of the limbs or firmness of hold - depending on the hold used) will give you time to make this assessment

What to say

Keep your statements short and simple. Long and complicated messages can be difficult to follow
You should offer brief words of reassurance throughout the process
You need firm, neutral and reassuring tone. The process of letting go is also a good time to slow things down
Once the young person has shown that they are ready to start the process of letting go, let them know what your next step will be and what you will be look for from them to show they are ready to continue with the process
Deliver your messages in a child centred way

Practice example:

"I'll know you're ready for us to start letting go when you take two deep breaths. That will show me you are ready to take control of yourself in a safe way"

The young person will pick up on your intentions through the words you say and your tone of voice

What not to say

The process of letting go is not a time for negotiation. You are the person who must assess when it is appropriate to let go. Teaching young people to negotiate appropriately, so they can get what they want, is an important part of good practice. However, so is teaching them to deal with those situations, which are non-negotiable. The process of letting go is one of these situations.

This may seem to contradict some of the guidance you have been given. However, once you have decided that the young person's behaviour is serious enough to call for a restrictive physical intervention, you must then take full control. It would send an inappropriate message if the young person were in any position to negotiate. You need to be in control as an adult, in a way, which lets the young person, feel cared for, and not abused.

Don't think that this means that the young person doesn't deserve to be negotiated with in general. It is not about what the young person deserves in general. It is about securing her/his welfare. Because of the seriousness of the events that led to this point, it is your responsibility to keep control until you assess that the young person is ready to begin to be given that control back, with you supporting and helping all the way through.

Power and control

Usually the behaviour and events leading up to the restrictive physical intervention feel out of control to the young person, the staff or both, as can the physical intervention itself. The process of letting go can be affected by the young person's or the staff's reaction to losing control and the desire to get it back. So, it is essential that the letting go process does not become a "power play" in which you "show who is boss". Sometimes a young person may appear to be in control of him or herself but they are still not able to show you they are ready to act safely. In these circumstances they may still be looking to assert power in a dangerous way.

A desire to feel in control of what is happening natural, especially while being restrained, and in itself this is not the problem. Be clear about the appropriate boundaries of control (who really should be in control of what), and manage that desire to control. This helps to prevent it from becoming counterproductive.

Your influence at this time can be huge as the final stages of being restrained can make some young people drop their defences. Being careful about the messages you are delivering, and managing your own urges for a power/control will greatly influence how the young person makes sense of the intervention.

It is sometimes the case that the only thing the young person feels s/he has left is control over the point at which you let them go. This can be difficult when the young person decides to make a power play of this issue.

You should invite an attitude of partnership with the young person. When restrained, most young people feel stripped of all control. This may be necessary in circumstances in which there are no other ways to keep a situation safe. It is important to let the young person know, as soon as it is safe, your willingness to share control of the situation and help them through the restrictive physical intervention. This is not the same as negotiating and may be passed on as much through your overall attitude as the words you choose.

Restraining a young person for a long time

When a young person seems to be making a restraint last a long time, treat it as a type of communication. These types of situations can be extremely difficult to manage, partly because of the feelings they sometimes provoke in staff, and also because staff are rightly wary of restraining a young person any longer than is needed. While there is no simple solution, the following may be useful.

Resist any desire to deal with the situation with your own "power play". Acknowledge what you want (to be finished), but focus on the young person's needs
Try to see that their difficulty in calming down may not be a deliberate power play. Being restrained can bring up feelings that are extremely difficult to manage, which may also tap into unresolved rage, loss, grief, and sadness. For some young people, it can take a long time before they can once again control their emotions and be calm. In these situations, it may be best to give periods of silence, interrupted by brief messages of reassurance. You should also tell them how they could let you know when they are ready to begin thinking about the letting go process
Remember that the young person resisting our control over them, and trying to assert their own control can have a positive side, even though the way this is being expressed is not appropriate. This resistance might well represent a level of resilience that helped them survive previous abuse
Clearly say that you think the young person's behaviour is an indication that they still need you to hold them
Show that you are willing to wait with the young person and hold him, her as long as s/he needs you to. This can turn the power play on its head, as most young people in this situation do not want to see themselves as having needs that staff are meeting. (This is exactly what staff are doing by making sure that the young person is ready)
As in all challenging interactions avoid taking it personally. This can be hard to do, but it is vital in staying child-centred. Even if you sense the behaviour is an attempt to "get at" you, on a deeper level it is less about you, and more about that young person's history, beliefs and unresolved pain. The better you can understand this, the more effective you are likely to be

16. Areas of Danger and Concern

Physical action including restraint carries risks. These include the possibility of serious physical and psychological trauma and even death. Lack of supervision can have tragic results; young people have died while being restrained. The cause is very often asphyxia. The general circumstances surrounding some of these deaths appear to be that one or several workers perhaps inadvertently put their weight on the young person's back or chest, compressing the chest and causing serious breathing difficulty.

Therefore it is imperative to emphasise repeatedly during training, during practice, and during actual restraints that workers cannot, in any way, place their weight or pressure on the young person's back, stomach, or torso, or place the young person in a position that restricts their breathing.

Predisposing risk factors - several things that will put the young person at greater risk of experiencing serious injury during a physical intervention can be anticipated:

Obesity: if the young person is obese, it puts additional stress on the body. In a prone position, obesity inhibits the young person's ability to properly contract the diaphragm and raise the ribs to enlarge the chest and inhale
Influence of alcohol or drugs: drugs and alcohol can have a profound effect on the respiratory and cardiovascular system. If the young person is under the influence of substances, the physical intervention could be life threatening
Prolonged violent physical agitation: if the young person has been in a state of physical agitation and/or the restraint has caused further physical exertion, the young person is in a state of oxygen deficiency. In addition, the chest wall muscles, which help the process of breathing (the diaphragm), are fatigued
Underlying natural disease (i.e. enlarged heart, asthma, high blood pressure, diabetes) will also increase the risk of the young person sustaining serious injury during a physical intervention
Hot humid environment: if the air is hot and humid, breathing and physical exertion become more and more difficult and put extra stress on the body
Individual taking certain types of medication: as previously mentioned, certain medications or combinations of medications can put stress on the respiratory and cardiovascular system

Improper restrictive physical intervention methods that pose a risk of positional asphyxia - it is imperative that workers never use any techniques or initiate the restraint in any way that increases the risk of injury or death. The following are very important points to remember, and ways to reduce the risk of asphyxia:

It is exceedingly dangerous to apply any pressure to a young person's neck or place the young person in a position that compromises the neck
Intervention that limits the normal process of expansion and contraction of the chest also poses a risk of asphyxia. This would include sitting on or applying weight to a young person's chest, back or stomach while the young person is lying down. In the small child intervention be careful never to bend the child forward
Any technique that places the individual's arms behind his or her back while in a face down position poses a significant risk or asphyxia and may hurt the young person's shoulders
Placing anything near the young person's mouth or nose that might obstruct breathing must be avoided. Restraining a young person on a soft surface or mattress, or placing a pillow etc, under the person's head must be avoided
Any abnormal positioning of the body that limits the free movement of the chest, and thus restricts breathing, must be avoided
Never allow a young person to remain on the floor once there are no longer safety risk issues, and never allow a young person to continue lying or sleeping on the floor following from a physical intervention
Never ignore any of the warning signs of impending asphyxia, mentioned below. Do not fail to take immediate action if there is a need for emergency medical treatment
Make sure the position of the young person's body is appropriate to positions taught in training

"Some ways of restraining make you feel claustrophobic and panicky, leading you to struggle more so that staff hold you tighter. Staff should realise this"

From: Children's views on restraint, Roger Morgan, 2004

Warning signs - it important to monitor the young person during a restrictive physical intervention for signs of distress. It is important to terminate the physical intervention if there are any indications of significant physical distress or injury, difficulty breathing or seizure. The following are indicators of asphyxia and that a young person is in distress:

Asphyxia due to neck compression:

Goes limp and ceases to breath

Asphyxia due to respiratory interference:

States s/he can't breath
Respiration is laboured, rapid or abnormal
May make grunting noises
Vomiting or turning dusky purple colour, especially in the face
Goes limp and ceases to breath

Young people can die from staff limiting their breathing, even while they are still moving or while seeming to still be breathing. Moving does not mean the young person is getting enough air to live. Be aware of shouting or moving. This has been a factor in restraint related deaths, with "I can't breathe" being the young person's last words (Weiss et al, 1998).

17. Learning from Events - Manager's Responsibility

If you are a manager, you need to make sure that you have systems and procedures in place, which give the young people and staff the opportunities to reflect on and learn from the experience of restraining young people. Managers also need to provide evidence that information provided from young people and from staff is understood and acted upon by you and others who manage the service.

Most of the work related to supporting staff who are directly involved in restraining children and young people needs to be carried out by worker's immediate manager. However it is important that assistant managers are equally skilled as they are often on duty when managers are not.

Service managers must also become familiar with how young people are restrained within the authority, to consider how best they can support the staff and young people, and make sure that practice meets the highest standards.

To help staff to learn from each episode of restraint managers should make sure that:

They have enough understanding of the restrictive physical intervention of young people so that they can carry out the management role and offer support and guidance to staff
They are available and approachable for consultation, advice and appraisal
They have provided staffing levels and shift patterns, which take account of the need for regular supervision, staff meetings and informal staff discussion
They show genuine concern about the restraint of young people and don't just seek to blame
Young people know that they can approach managers directly if they do not feel safe
They respond to reports of assault, abuse or concerns and know who to report to, be they senior managers, regulators or the police

If managers and staff are actively involved in learning from events, it is more likely that the learning for the young people will be effective.

18. Action Required following a Restrictive Physical Intervention - a Multi Level Post Crisis Response

Immediate response (stage one): all young people and staff should receive immediate support following a crisis. Young people receive immediate support from the worker and/or any medical personnel. The support for the staff is best provided by the supervisor or a designated and trained staff member. The immediate goal at this stage is to ascertain if anyone involved needs medical attention and if staff members are able to continue with their job responsibilities. This is not a review of the incident, but a check to see if the worker needs some time or space before resuming regular duties or conducting the Life Space Interview (LSI) with the young person.

Where Physical Intervention has been used, the child, staff and others involved should be able to call on medical assistance. Children must always be given the opportunity to see a Registered Nurse or Medical Practitioner, even if there are no apparent injuries.

Some young people will want to be comforted in the period immediately after the restraint and as part of that will see the immediate opportunity to discuss the event as helpful. Some may welcome the period of calm, but will not be ready immediately to discuss events. Others may be angry, resentful and extremely resistant to any discussion. It is the worker's responsibility to find the right time to talk with the young person about how they can be helped to manage similar situations differently.

"It makes you feel like you are nothing. People holding you down brings bad memories, it's horrible. Makes you want to head butt them"

From: Children's views on restraint, Roger Morgan, 2004

The immediate response is a quick, supportive interaction between a staff member who has conducted a restraint or high-risk intervention and a supervisor who has not participated in the intervention. It provides a system to ensure that everyone is physically safe, emotionally calm and ready to return to "normal" functioning.

Life Space Interview for the young person (stage two): immediately after any incident irrespective of the perceived level of crisis a life space interview will be undertaken with the young person. The staff member involved in the crisis situation with the young person conducts the LSI as close to the event as possible. It must be remembered that no matter how effective the method of controlling young people in crisis, if young people do not understand and deal with the reason for their behaviour, then the crisis will repeat itself and a destructive cycle will be perpetuated.

As soon as the young person and intervening staff are ready, the LSI should take place. Whilst the intervening staff is responsible for this stage in the post crisis response, the supervisor may need to help the staff prepare for the LSI or provide additional coverage while the staff conducts the interview.

If for some reason the LSI has to be postponed, perhaps because of the young person's arrest or the need for medical attention, staff should let young people know that they will discuss the incident at a later stage. Only in exceptional circumstances should a LSI take place more than twenty-four hours after an event. Training on LSI's must be included within the TCI training programme offered.

The LSI uses the young people's reactions to difficult situations to help change their behaviour and expand their understanding and insight into their own and others' behaviour and feelings. It also gives the opportunity to restore the relationship between the worker and young person.

When working with young people who have language and communication difficulties, workers should be sure to use the specialist communication approaches which should be listed in the ICMP and/or daily living placement plan. For some young people with a learning disability who are in crisis, they may not understand the source of their emotional discomfort, but will feel it acutely. They may have trouble sequencing events and identifying the central issue. If the young person does not have the skills necessary to benefit from a regular LSI, there are some modifications that we can use to facilitate the process. The same seven steps are condensed into three general steps, the Shortened LSI.

There may be young people who cannot participate in even the shortened version of the LSI, but would still benefit from workers attempting to understand their frustrations and perspectives. The Advocate's LSI is designed to assist staff members to attempt to understand what a young person might be thinking or feeling.

The LSI (especially the plan) should be documented in the living file, within the individual key workers support to the young person.

Documentation (stage three): a separate book must be maintained by each unit for the recording of sanctions and a separate one for restrictive physical interventions. Entries should be made as soon as possible after the incident but at least prior to the end of the shift being worked.

The following must be received for each entry:

Name of child
Details of the child's behaviour leading to the use of the sanction / measure
Description of the sanction / measure
Date, time and location, of sanctions / measures used
The reason for using the sanction / measure
Name of the person using the measure, and of any other person/s present
the effectiveness and any consequences of the use of the measure
a description of any injury to the child concerned or any other person and any medical treatment administered
confirmation that the person authorised by the registered provider to make the record has spoken to the child concerned and the person using the measure about the use of the measure
To be signed by the person giving the sanction and a witness
The manager will sign all entries
The Service Manager to sign on monthly visits

Where a measure of restraint is used on a child the record must include:

the duration of the measure of restraint and
details of any methods used to avoid the need to use that measure.

All critical incidents must be documented on the HS3A and in the physical intervention book as close to the event as possible. This documentation is essential to the understanding of how the event unfolded, what intervention strategies were used and what outcomes were produced. Documentation is not just necessary to justify the use of restrictive physical intervention or high-risk intervention, but to see it as a tool to use in planning treatment and intervention strategies.

HS3As should be submitted within 24 hours. If it has not been possible to do all of the follow up work required at the time of submission, this should be noted on the HS3A.

It is required documentation for regulatory purposes and an essential tool in the supervisory process and in monitoring a young person's response to crisis situations.

The HS3A should include as much information as possible, it is important to describe what happened throughout the entire event. Minimally the following information should be included:

Who was involved?
Where did it take place?
When did it happen?
What were the antecedents?
What action did the staff take to de-escalate the situation? What worked? What was ineffective?
If physical contact was made, who did what (be specific)?
How long did the restraint last?
Were there any injuries? Was medical attention given to the young person or staff?
What plan was developed in the LSI?
Was any follow - up needed?
Were there any variances from the ICMP?
Comments from the young person about the event

The responsibility of documenting the event falls to the intervening staff member(s), but the manager/assistant manager must ensure there is time built into the shift for the completion of this task. In addition the supervisor must review and sign the report.

As well as properly recording the event after any physical intervention, workers must let the appropriate people know. Those likely to be included on any list are:

The young person's family and, where appropriate, carers
The young person's social worker
Managers within the residential unit
External managers
The police in cases where a crime may have been committed, including instances of assault by the young person or staff member

Critical Incident review with staff (stage four): if you have been involved in physically intervening with a young person, you must have the opportunity to reflect on what you did. The process for of providing learning opportunities for young people should be mirrored by opportunities for staff to learn from their experiences.

From: Martha Holden, Post Crisis Response workshop, 2002

"With the privilege of professional judgement comes the responsibility of reflective practice"

The supervisor should sit down with the intervening staff member(s) and analyse the crisis. Reflective principles are reinforced during this process debriefing, which has the following purposes:

It gives the worker an opportunity to express the difficult emotional pressures created by the physical intervention
It gives the worker and the manager an opportunity to reflect, in detail on what happened and set out the facts
It gives the worker an opportunity to reflect on what has been learned, to help in the future and to contribute to professional development

The review should be conducted in a supportive, forward looking and problem-solving atmosphere, without apportioning blame. It is the responsibility of the supervisor to ensure that the review follows the format as described on the post crisis response training. It is important that the worker has the opportunity to discuss the incident using the Stress Model of Crisis, analyse their interventions, to review strategies used in relation to the ICMP and to plan future strategies.

Managers/assistant managers need to have extensive knowledge of TCI in order to provide effective supervision and look at incidents objectively.

Critical incident review with the team (stage five): it is important to share the outcomes of the individual incident review with the team in order for all to learn from the crisis event. Wherever appropriate the manager/assistant manager should facilitate a review of the crisis event with the entire team, so that everyone can contribute observations and be involved in problem solving and planning for similar situations in the future.

The team review also needs to be conducted in a supportive, forward-looking, problem solving atmosphere, which reinforces reflective practice and not apportioning blame.

19. Critical Incident Monitoring Panel

Managers should monitor the restraint of young people in their care. This monitoring is essential to make sure young people are protected from any risk of physical abuse through using physical intervention improperly.

Monitoring for these purposes is entirely appropriate, but a good system of monitoring also provides benefits for everyone involved with residential care, including young people. To provide those benefits, the monitoring must be carried out in a way which emphasises its value as a tool for protecting staff and young people, for improving practice and not as a way of pinning blame on people.

A Service Manager will chair the monitoring group. It will comprise unit managers, TCI trainer and Staff Development Officer. Ideally there should also be a representative from Placement and Adoption service and LAC and/or social work teams. Periodic/occasional attendees might be Regulation 33 Visitor, Advocate, Social Workers, Health and Safety Representative, other Unit Manager / Staff.

The aim of the group will be to review all critical incidents in residential care, foster care and general placements in order to:

Assess the use of all interventions
Analyse data in order to measure the effects of efforts to reduce the number of physical safety interventions
Analyse the frequency and duration of restrictive physical safety interventions
Identify patterns of behaviour of individual young people and feed into the care management process where appropriate
Identify significant patterns of behaviour or responses by teams or individual staff members
Identify any significant resource implications for the unit
Identify training needs of teams or individual staff members
Analyse data to identify opportunities for improvement in the quality of care
Provide written evidence of action taken, in response to data analysis, to reduce the number of safety physical interventions used
Analyse young people's comments in order to collect data on their experiences in the use of safety interventions
Identify, shape, promote and praise good practice
Report the findings of the group as appropriate to Children in Need Service Managers, Group Placement Management Group and Performance Clinic

The group's terms of reference should be reviewed annually.

20. Cause for Concern Meeting

A planning meeting should be convened in the event of an incident, which, although serious, does not at this stage question the viability of the placement.

The meeting will also be convened if there has been a recorded accumulation of incidents of a repetitive nature or where a pattern can be identified and when Life Space Interviews have not resolved the problems.

The meeting should be convened by the Unit Manager who should chair the meeting. The meeting should be attended by the young person, the young person's key worker, Social worker, and any other significant person such as parents or other professionals who need to participate in an agreed strategy.

The meeting will ensure an exchange of information and will develop and agree a consistent strategy to be applied with the young person by direct carers and significant others. The meeting, outcomes and decisions will be minuted and circulated to those attending.

In the event of a serious incident, which it is felt puts staff or residents at serious risk of injury, or a placement disruption due to violence the safeguarding procedures need to be followed and a strategy/case conference convened. (See West Yorkshire Consortium Inter Agency Safeguarding Procedures). This meeting will address the question of whether the placement of the young person concerned is still viable, and whether strategies or resources are required. It is also the role of the field social worker that is crucial in establishing the safeguarding responsibility for the young person and make a professional judgement as to whether an incident warrants a Section 47 investigation.

In addition where a criminal offence is committed, consideration needs to be given to involving the police. (See Thresholds for police intervention where incidents occur in residential child care" policy and procedure - to follow).

21. Methods of Care and Control which Fall Short of Restrictive Physical Intervention or the Restriction of Liberty

From: Guidance on permissible forms of control in children's residential care (1993)

(1.2) The aim must be to create and environment, which gives a firm structure and sense of order to the lives of these children. In which they can develop and be educated. If that and the associated control and discipline are lacking they are likely to experience further difficulties when they leave residential care

The following has been taken from the above guidance:

Use of the worker's physical presence - this refers to actions, which reinforce a member of staff's authority or concern. It is an aspect of the staff member's role as a supervisor of young people. At its simplest level, staff member's presence in the room with young people should be deterrent to misbehaviour, or the young person feeling out of control. A look or gesture may send out signals to young people, which help to keep behaviour within acceptable limits. In any situation where a young person's behaviour provokes intervention, dialogue is an essential response. The guidance suggests acceptable limits can include standing in the way of a young person who is ignoring instructions or losing control, and may be reinforced further, for example by placing a hand on the young person's arm. This is acceptable only so long as the duration of this restriction does not extend for example into hours. This will be counterproductive if the young person's anger or distress increases. These are acceptable, provided that their use is persuasive rather than coercive.

The following principles apply to the use of an adult's physical presence. It:

Must be likely to be effective by virtue of the overall authority carried by the staff member, and not simply physical presence
Must be used in the context of trying to engage the young person in discussion about the significance and implications of their behaviour
Should not be persisted in if the child physically resists. In this case a decision will need to be made about whether another form of intervention is justified

Holding - small children may frequently be held for a number of reasons not directly concerned with control. There are also occasions when control can be maintained by holding a young person in a manner, which does not carry the force of restrictive physical restraint. For example, an adult may insist on holding a young person's hand when crossing the road. A young person may be successfully diverted from destructive or disruptive behaviour by being led away by the hand, arm or by means of an arm around the shoulder. Again, young people having an argument or fight, which in itself is not likely to cause serious harm, but is nonetheless disruptive and detrimental to the well-being of other young people, may be successfully separated by being held firmly and guided away, by using techniques taught on the training.

The main factor separating "holding" from "physical intervention" is the manner of intervention and degree of force applied. Physical intervention uses the degree of force necessary to prevent young people harming themselves. Holding would discourage but in itself would not prevent such action. It is more likely to find application in those homes caring for younger children, or those with a learning disability, particularly for those whose behaviour is unlikely to respond to verbal influence alone.

Workers should adopt the following principles when dealing with young people in this way:

Whenever possible, the worker involved should have an established relationship with the young person and should explain to the young person what s/he is doing and why
Holding should not arouse sexual expectations or feelings, and should cease if the young person gives any indication of this
Staff should be careful where they hold young people. For instance, staff should be careful not to hold a young person in such a way that involves contact with the breasts, buttocks or genitals
If on any occasion the young person forcibly resists or demonstrably objects, then "holding" should not longer be used as a method of restraint in that particular situation. Consideration should be given to other means of intervention, in consultation with other staff if circumstances at the time permit, and should be written in the young person's ICMP

Touching - it is not intended that the guidance should deter normal physical contact between care providing adults and young people. Although physical contact may on occasions be used to assert authority over a young person. It is more often an important element of care and parenting. Indeed, in the care of young people with learning, physical or sensory disabilities, physical contact might be the primary means of communication, and staff may have to undertake intimate activities such as bathing the young people. Staff should feel able to express "parental" affection towards young people in their care and to provide comfort to ease a young person's distress.

Given that a high proportion of young people in residential care have experienced sexual and physical abuse, residential staff need to ensure that any physical contact is not misinterpreted. The following guiding principles are suggested:

Before or on admission to the home, staff should ascertain, through discussion with the young person, other professionals and previous carers, the significance for the young person of physical contact with adults, particularly if previous abuse has occurred. If it is discovered that the young person is not comfortable with physical contact, this should be taken into account throughout the young person's period of residence in the home. Cultural factors will also be significant in determining unacceptable forms of physical contact
Physical contact should not be in response to or be intended to arouse sexual expectations of feelings
Age and gender are appropriate considerations in deciding proper physical contact
Where a member of staff feels that it would be inappropriate to respond to a young person seeking physical comfort, the reasons for denying this should be explained to the young person. The young person should be comforted verbally, as necessary
There should be no general expectations of privacy for the physical expression of affection or comfort, although this may be appropriate in some circumstances (e.g. bereavement)

22. Training

The whole approach to behaviour management must be underpinned by training when workers deal with challenging situations.

Training in Therapeutic Crisis Intervention (TCI) must be undertaken before a member of staff is involved in any restrictive physical intervention.

The training takes place within a background of common values and principles such as those mentioned in Section 2, Develop and Maintain a Positive Culture and Section 3, Taking a Child Centred Approach above.

In training new staff it is useful to have a period of time between their induction, which should address dealing with challenging behaviour to training in the actual techniques of restraining young people. Sometimes staff will only remember the physical part of the training, and this could have a negative effect on their work. New staff need time to develop relationships with the young people before they might have to restrain them. This must be balanced with having enough staff trained to restrain if necessary.

Members of staff (and students) who have not received appropriate, current and updated training should not physically intervene with young people. There are many ways of intervening that don't involve restraining a young person. This does not mean that staff who haven't been trained in methods for restraining young people should avoid intervening when it is absolutely necessary for the safety of the child or another person - there is a duty of care. The young person's needs must be considered first.

"All staff should be trained to do restraint right - not just some of them. Anyone might have to use restraint to prevent injury or serious damage and these situations; staff can't just say, "Pause while I get the right person."

From: Children's views on restraint, Roger Morgan, 2004

Managers of residential units should themselves receive training in the principles of restrictive physical intervention if they are to monitor services. At the very least they should know the principles, content and application of the training used. All managers and assistant managers should also receive training in TCI - Post Crisis Response. As managers have a role in:

Support and supervision
Mentoring
Monitoring
Making sure that workers always operate within the law
Making sure that the needs of the young people are appropriately met
Making sure that health and safety responsibilities are carried out
Making sure that there is a training strategy in place so that all workers receive enough training, including practice and refresher training

Training will take place in a number of different ways, the initial core TCI programme will take place away from the base and with workers from other units, and refresher training will take place within the work setting, or away from base. Staff members should also have access to accredited TCI trainers within the authority for consultation and advice. The training provided is recognised by BILD (British Institute of Learning Disability) and has to meet regulated guidance and all trainers follow the BILD code of practice.

Trainers delivering TCI will make reference to the following policy issues:

The values set out in the BILD/NAS Policy Framework
The legal framework, for example, duty of care and health and safety requirements, which apply to participants in the workplace
Organisational policies on the management of challenging behaviour, which apply to course participants in their workplace
Organisational policies on the use of physical interventions, which apply to course participants in their workplace
The principle of "least restrictive physical intervention" and minimum use of force
Good practice in developing individual crisis management plans and reviewing the support needs of the young people
The good practice of systematically monitoring the use of restrictive physical interventions and procedures to protect the best interests of young people
The rights of young people to be consulted on the use of strategies and interventions, which affect them
The influence of staff attitudes and service culture and the importance of addressing attitudes during training
The entitlement of staff to training in the use of restrictive physical interventions
Staff care and safety policies (especially around the area of child protection)
The importance of not sharing restrictive physical intervention skills informally

Training will be tailored to meet the needs and abilities of the young people who are likely to need restrictive physical interventions. After completing a behavioural audit for the unit, this will denote what level of training is required. As follows:

Level 0 - No physical interventions
Level 1 - Protective and restrictive physical interventions to the standing hold
Level 2 - All protective and restrictive physical interventions

Health and Safety - before training - those attending the TCI programme, will receive clear information, at least two weeks prior to the training, which will include the physical requirements for course participants. It will also include information on appropriate clothing required in order to undertake the training in physical interventions.

It is the responsibility of the organisation to assess all participants, to ensure that they are fit to participate in the training and to confirm this to the trainer. This is not always the case so the trainer will require participants to complete a health questionnaire as evidence that they can safely undertake training.

Employees are reminded that they have a legal obligation to report any factors that could increase the risk they face in the workplace. These include physical conditions (for example, pregnancy, brittle bones) and personal circumstances.

During training - trainers will remind participants of the existence of risk assessment procedures and their personal responsibilities in relation to:

Guarding against the risk of injury during training
Existing injuries and/or disabilities that pose related health and /or safety risks
Their responsibility for their own safety and welfare during training
Their responsibility for the safety and welfare of other course participants during training
Reporting any injuries sustained during training

The trainer will provide participants with information on the need to:

Participate only if physically and medically able
Remove objects that might cause injury
Be appropriately dressed
Offer no resistance in the role of the young person
Practice only the techniques demonstrated

The trainer has the right to exclude from the course anyone who the trainer believes to be unsuitable for training on the basis of health, physical status or attitude.

Training shall take place in a safe and suitable environment. There will be sufficient space (e.g. away from furniture) and, where appropriate, exercise mats of suitable quality and thickness.

Trainers will work in a minimum of pairs, (on the basis of one trainer to eight participants).

Trainers will ensure that they have up to date first aid training to enable them to respond to injuries that might arise during training. If trainers do not have an appropriate first aid qualification themselves, arrangements will be made for someone else with the appropriate first aid qualifications to be available during training sessions.

Monitoring performance - the performance of each participant on each part of the course shall be systematically evaluated and recorded. This will include:

The knowledge of each participant regarding the principles underpinning the Therapeutic Crisis Intervention and the safe use of physical interventions
The competence of each participant with respect to each appropriate safety intervention technique
The competence of each participant with respect to the Life Space interview

An assessment criterion has been established for each practical technique that is taught within the programme.

Participants who do not reach the required standard of the course will be referred, and given advice and support if necessary. They will be encouraged to undertake the training at a future date where possible.

The unit manager will be provided with feedback on the performance of each course participant, in respect of:

Their areas of weakness
Action, which can be taken to improve their performance
The implications of their current level of competence for working with young people who present challenging behaviour

The Staff Development Officer responsible for co-ordinating the TCI training, is required to maintain the following:

A record of all staff trained and updated in the core programme, their scores and status
A record of the status of all TCI trainers located in the department, when they were trained and updated (which has to be once a year)
A record of all training courses provided, the "level" of physical interventions taught, evaluation results and a record of any injuries

"Actions speak louder than words"

"By their example, staff can shape the behaviour and influence the growth of the young people in their care. At no time is this issue more important than during periods of crisis and upset. The skills, knowledge, and professional judgement of staff in reacting to crises are critical factors in helping young people learn constructive and adaptive ways to deal with frustration, failure, anger, rejection, hurt, and depression."

"The ability of the entire organisation to respond effectively to staff and young people in crisis situations is also critical in establishing not only a safe environment, but also one that promotes growth and development."

Therapeutic Crisis Intervention, 5th Edition, 2001

"Making our units as safe as possible and treating our young people with respect and dignity does not need to be legalised. It should be a value and belief we all share."

Glossary

Glossary of Terms
Advocate	A supporter
Acute Physical Behaviour	Behaviour likely to result in physical injury to young person or others
B.I.L.D.	British Institute of Learning Disabilities
C.A.F.C.A.S.S.	Children and Family Court Advisory and Support Service
Care Plan	A plan for children looked after. It sets out clearly the objectives for the care of the child or young person, and the steps by which the objectives will be reached
Child Centred Approach	Consistently putting the needs of the child first. Recognising the worth of a child no matter what the behaviour
I.C.M.P.	Individual Crisis Management Plan
I.A.S.S.I.S.T.	Acronym used for non confrontational technique: See training handbook
Justification	Something that justifies: something, e.g. a reason or circumstance, that justifies an action or attitude
LAC	Looked After Children
LSI	Life Space Interview - technique used in working with young people
NAS	National Autistic Society
Negligent	Failure to provide a proper or reasonable level of care
Ofsted	Body responsible for inspecting social care and residential care for young people (responsibility passed from Commission for Social Care Inspection April 2007)
Physical Intervention	The use of staff members to hold a young person in order to contain acute physical behaviour
Predisposing	Pre-existing conditions
Reparation	Putting right the harm or damage a young person may have done, e.g. an apology
Restitution	Compensation, e.g. paying for damages
Positional Asphyxia	Fatal respiratory arrest in which the ability to breathe is compromised by the positioning of the body in relationship to it's immediate surroundings
S.S.I.	Social Services Inspectorate. Functions now devolved to Ofsted
TCI	Therapeutic Crisis Intervention
Threshold	Starting point: the point at which something begins or changes

References and Further Reading Material

BILD (2001), BILD Code of Practice for Trainers in the use of Physical Intervention. BILD

Children's Workforce Development Council (2006), Common Induction standards for people working with children and young people

Davidson, J. McCullough, D. Steckley, L. Warren, T. (2005), Holding safely: a guide for residential childcare practitioners and managers about physically restraining children and young people. Scottish Institute for Residential Child Care

Davies, W. (1999), Preventing face-to-face violence: Dealing with anger and aggression at work, Association for Psychological Therapies

Department for Education (2011) National Minimum Standards for Children's Homes

Department for Education and Skills (2003), Every Child Matters: Change for children

Department of Health (1993 and 1997), Guidance on permissible forms of control in children's residential care

Department of Health (1998), Caring for children away from home: messages from research, Wiley and Sons

Department of Health (1991), The Children Act (1989); Guidance and Regulations, Volume 4, Residential Care. London, HMSO

Department of Health (2002), Children's Homes, National Minimum Standards. London: The Stationary Office

Department of Health (1997), The Control of children in the Public Care: Interpretation of the Children Act 1989

Department of Health (2001), The Care Standards Act 2000

Department of Health (2002), Children's Homes Regulations 2011. London: The Stationary Office

Department of Health (2000), National Task Force on Violence to Social Care Staff. Crown Property

Department of Health/Department of Education and Skills (2003), Guidance on the use of restrictive physical interventions for staff working with young people and adults who display extreme behaviour in association with learning disability and/or autistic spectrum disorders. London

Harris, J. Allen, D. Cornick, M. Jefferson, A. Mills, R (1996), Physical Interventions: A policy framework. Kidderminster, (BILD publication)

Hart, Di & Howell, S (2004), Report on the use of physical intervention across children's services. National Children's Bureau

Holden, M (2002), Post Crisis Response workshop

Holden, M. Holden, J. Kuhn, I. Mooney, A. Morgan, C. Pidgeon, N. Taylor, R. et al (2001), Therapeutic Crisis Intervention System, 5th Edition. Cornell University Family Life Development Centre, Ithaca

Kahan, B (1994), Growing up in groups London: NISW

Leadbetter, D (2003), The Debate on Prone Restraint. BILD Master Class

Levy, A and Kahan, B (1991) The Pindown Experience and the Protection of Children. The report of the Staffordshire child care Inquiry, Stafford; Staffordshire County Council

Lyon, C (1994), Legal issues arising form the Care, Control and Safety of Children with a learning disability who also present with severe challenging behaviour. London (Mental Health Foundation)

Morgan, R (2004), Children's views on Restraint: The views of children and young people in residential homes and residential special schools. Newcastle upon Tyne: Commission for Social Care Inspection

United Nations Convention on the Rights of the Child (UNCRC), (1989)

Weiss, E M et al (1989), Deadly Restraint: a Hartford Courant investigative Report. Hartford Courant, Oct 11 - 15

Welsh Assembly, 2005, Framework for restrictive physical intervention policy and practice

Willow, C. (1996) Children's Rights and Participation in Residential Care. National Children's Bureau

End

9.5.1 Sanctions and Physical Intervention in Units Caring for Young People

SCOPE OF THIS CHAPTER

Contents

1. Introduction

2. Develop and Maintain a Positive Culture

From: Barbara Kahan, Growing up in Groups, HMSO, 1994

3. Taking a Child Centred Approach

4. General Principles Governing Interventions to Maintain Control

From: UN Convention on the Rights of the Child.

From: Caring for Children away from Home; Messages from research, Department of Health, 1998

5. Understanding why Situations Turn from Day to Day Situations to Anger, Aggression and Violence

Situation

Appraisal

Anger

Inhibitions

Aggression

6. Sanctions

7. Permitted Disciplinary Measures

8. Prohibited Disciplinary Measures

Corporal Punishment

Deprivation of Food and Drink

Restriction/Refusal of Visits/Communications

Requiring a Young Person to Wear Distinctive or Inappropriate Clothing

Use of Withholding of Medication or Medical or Dental Treatment

Intentional Deprivation of Sleep

Monitory Sanctions

Intimate Physical Searches

9. Restriction of Liberty

From: The Control of Children in Public Care: Interpretation of the Children Act 1989 (SSI C1 (97) 6)

10. The Care and Control of Children and Young People Outside the Unit

11. Risk Assessment and Care Planning

Plan for Managing Behaviour - Individual Crisis Management Plans

12. Physical Contact

13. Restrictive Physical Safety Intervention

14. Other Considerations

15. Ending a Restrictive Physical Safety Intervention

Preparing to let go

What to say

Practice example:

What not to say

Power and control

Restraining a young person for a long time

16. Areas of Danger and Concern

17. Learning from Events - Manager's Responsibility

18. Action Required following a Restrictive Physical Intervention - a Multi Level Post Crisis Response

From: Martha Holden, Post Crisis Response workshop, 2002

19. Critical Incident Monitoring Panel

20. Cause for Concern Meeting

21. Methods of Care and Control which Fall Short of Restrictive Physical Intervention or the Restriction of Liberty

From: Guidance on permissible forms of control in children's residential care (1993)

22. Training

"Actions speak louder than words"

Glossary

References and Further Reading Material