September 17, 2019 Legal

CQC on restraint, seclusion and segregation and what this means for providers

This Ridout Report by Anna- Maria Lemmer considers CQC’s review of restraint, prolonged seclusion and segregation in services providing care for people with learning disabilities and or/autism and mental health problems.

Phase 1 of the review started in December 2018 and during this phase CQC considered whether and how restraint, prolonged seclusion and segregation are being used in child and adolescent mental health wards and wards for people of all ages with learning disabilities and or autism.
In May 2019, CQC published an interim report on its findings following phase 1 of the review, in a report titled ‘Review of restraint, prolonged seclusion and segregation for people with a mental health problem, a learning disability or autism’. In this report, CQC concluded that there was inappropriate use of seclusion and restraint, poor ward environments and poor quality of care which had a damaging impact on patients and staff.

Phase 2 of the review, will consider whether and how prolonged seclusion and segregation are being used in mental health rehabilitation and low secure wards. It will also explore whether and how restrictive interventions are used in the following settings:
• Residential care homes for people with learning disabilities and/or autism
• Children’s residential services (in partnership with Ofsted)
• 14 secure children’s homes in England (in partnership with Ofsted)
What does this mean for providers?
Whilst CQC’s review of restraint, prolonged seclusion and segregation is both welcome and necessary, there is a risk that CQC could be overly critical of providers, particularly when, on occasion restraint or seclusion is necessary in order to prevent the risk of harm to a person or a risk of harm to others. Providers should ensure that they have policies, systems and processes in place to ensure that these restrictive interventions are used appropriately.

The Department of Health Guidance, “Positive and Proactive Care: reducing the need for restrictive interventions” (2014) sets out the importance of using preventive approaches and de-escalation techniques for managing behaviour that services may find challenging. It also states that, restrictive interventions should be for the shortest time possible and the least restrictive means to meet the immediate need.

The segregation, seclusion and restraint of people with challenging behaviours in the care sector is a difficult and sensitive issue and use of these measures should always be in line with company policies and staff should be appropriately trained.

In all instances of restraint and seclusion, the person taking the action must reasonably believe that such an action is necessary to prevent harm to the person involved. They must also believe that the type of restraint or time period of seclusion, is proportionate to the likelihood and seriousness of potential harm.
What steps can providers take to ensure compliance?

Reasonable steps that providers may take to ensure that restraint, seclusion and segregation are used appropriately are set out (but are not limited to) below:
• Ensure that all service users have person centred, individualised care plans or behaviour support plans. They should follow the principles of positive behaviour support and that they have a focus on preventive strategies to manage challenging behaviour such as de-escalation techniques rather than using restraint or seclusion in the first instance.
• Staff should be adequately trained in restraint techniques and this training should be in line with best practice guidance on restraint. The key focus of the training should be on teaching person centred approaches to avoid situations where restraint is required. Staff should also receive regular refresher training.
• Ensure that all incidents of restraint or seclusion are appropriately recorded.
• Senior management should discuss incidents with staff to see if there are any opportunities to learn lessons from them.
Conclusion
Providers should be aware that restraint, seclusion and segregation is likely to be a ‘hot topic’ during future CQC inspections. CQC will assess the extent to which services follow best practice in minimising the need to use restrictive interventions and such interventions should only ever be used as a last resort and should always be proportionate to the risk of harm.
Once CQC has completed phase 2 of its review of restraint, seclusion and segregation, it will make recommendations to the Department of Health and Social Care and the wider system in its March 2020 report.

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