Reducing restrictive interventions (RRI) policy (formerly prevention and management of violence and aggression (PMVA) policy)

1 Introduction

1.1 Restriction intervention statement

The trust is committed to providing high-quality, person-centred care that maintains the dignity of, and respect for our patients. This means that staff focus on the use primary and secondary non-restrictive strategies in order to prevent and reduce the use of force and support patients in a proactive way in order to reduce and manage the risk of aggression, violence, and crisis behaviours.

The trust recognises there may be times when staff may need to adopt tertiary strategies in the form of restrictive interventions (including the use of physical interventions). The trust therefore promotes and encourages the use of a human rights-based approach, working with individuals in a trauma informed and person-centred manner, developing therapeutic environments which aim to ensure that any restrictions and use of force is proportionate and only ever used as a last resort.

The policy is developed using the following frameworks of current legislation including:

Human Rights Act (1998)
Mental Health Act, Code of Practice (2015)
Health and Safety at Work Act (1974)
Criminal Law Act 1967, 3 (1)
Common Law: “Cases of Necessity”
Mental Capacity Act (2005)
Deprivation of Liberty Safeguards (DOLS)
Mental Capacity Act Code of Practice (2007)
Mental Health Units (Use of Force) Act (2018)
Restraint Reduction Network (RRN) Training Standards

The following documents have also been considered in production of this policy:

The Department of Health, Positive and Proactive Care: Reducing the need for restrictive interventions (April 2014)
NICE Guideline 10 Violence and aggression, the short-term management in mental health, health, and community settings (2015)
Metric Definitions – Restrictive Practice Tier 4 Child and Adolescent Mental Health Services (CAMHs) (General Adolescent Services including Specialist Eating Disorders Services) Quality Dashboard (2021/22)
Restrictive interventions in inpatient intellectual disability services: How to record, monitor and regulate (2018)
Care and Treatment of Children under the age of 18 on Adult Acute Mental Health Inpatient Areas Policy (2022)
Rapid Tranquillisation Policy and Guidelines (Pharmacological Management of Violence) (2022)

2 Purpose

The purpose of this policy is to set out the arrangements for managing the risks associated with the reduction, prevention, and management of work-related violence and aggression, both in clinical and non-clinical settings ensuring that the risk of its reoccurrence is minimised.

3 Scope

This policy applies to all staff, patients, and visitors. It covers both physical and non-physical violence and aggression, including:

physical violence and assault
self-harm
antisocial, offensive, or disruptive behaviour
verbal abuse
threatening language or behaviour
harassment
damage to personal or trust property

A significant proportion of this policy applies particularly to staff working in the trust’s mental health and learning disability in-patient services, where specific legal and practice requirements must be implemented as set out in documents such as NG10 on Violence and Aggression 2015, The Mental Health Act Code of Practice 1983 (amended 2015). The detail of some of these requirements is further set out in a number of associated trust polices listed in section 12, with which staff must be familiar.

4 Responsibilities, accountabilities and duties

4.1 Trust responsibilities

The trust board recognises its duties in regard to reducing restrictive interventions and the prevention and management of violence and aggression by safe and proper means demonstrating the least restrictive option, in order to safeguard staff, patients and others as far as is reasonably practicable.
The board of directors delegates to the chief executive overall responsibility for the effective implementation of this policy, which in turn is delegated to the executive directors of the trust.
The role of director responsible for RRI is the director of nursing and quality.

4.2 Security management director (SMD)

The role of the executive director of finance in this trust is also the SMD, whose role is to promote security management work from the non-executive function at board level, to support the local security management specialist (LSMS) in their role, challenge, scrutinise and ensure accountability in respect of security management work and facilitate access to competent legal advice when required.

4.3 Local security management specialist (LSMS)

The LSMS will:

develop a strong interface with clinical services to help promote a culture that focuses on early recognition, prevention, and de-escalation of potential aggression with the focus on reducing the risk of its recurrence
promote awareness and support implementation of evidence based best practice, from an overall security management perspective
take forward security management work locally according to statutory requirements and Health and Safety at work Act (1974)
provide advice and support to managers and staff following a serious assault
monitor incident reports of violence and aggression, promoting the use of sanctions, notification to the police and prosecutions as appropriate
work with the RRI team and managers to promote continuous improvement with regard to security management and organisational learning
work collaboratively with the police to facilitate any required investigation processes
Provide the health and safety forum with an annual report and forward work plan to tackle security management issues with an emphasis on the prevention and management of workplace violence

4.4 Directors

Through their managers the directors will:

make arrangements for the effective implementation and monitoring of the policy
promote a culture which focuses on RRI by early recognition, prevention, and de-escalation of potential aggression, using techniques that minimise the risk of its recurrence
support the use and implementation of individual positive behavioural support plans where necessary
promote a positive reporting and learning culture to facilitate continuous improvement with regard to violence and aggression
influence the design of buildings via the head of estates and facilities so that full account can be taken of known environmental factors associated with positive risk management
assess their areas of responsibility and produce risk assessments as required under the Management of Health and Safety at Work Regulations 1992, where violence is identified as a hazard, the risk assessment must be produced in liaison with the health and safety lead, there are a range of issues associated with violence and violence can be not just from patients but could include visitors or staff not being able to respond to violence as a result of their own health limitations
following the risk assessment, agree local procedures as required and communicate these to the associated staff
advise and instruct staff on the policy requirements via local induction arrangements and ongoing communication mechanisms, such as staff meetings, supervision, post-incident reviews etc
facilitate and monitor the attendance of staff on mandatory RRI training

4.5 Head of learning and development

The head of learning and development is responsible for the implementation of the mandatory and statutory training policy and associated training needs analysis, providing reports on compliance to the individual care groups. The responsibility also includes the management of the RRI team and the training programme and the RRN standards accreditation.

4.6 Reducing restrictive interventions (RRI) team

The RRI team will:

promote awareness and a culture using evidence based best practice, which focuses on RRI by early recognition, prevention, and de-escalation of potential aggression, promoting the use of primary and secondary strategies and pro-active approaches
ongoing education must aim to facilitate a shift from the use of restrictive tertiary strategies to a focus on prevention through organisational learning
oversee, coordinate, and take responsibility for, the planning and provision of training according to national guidance and local risk assessments, any training in RRI within the trust must only be provided in consultation and agreement with the RRI team
maintain comprehensive training records of all training delivered, the records will be kept in line with current CQC or GDPR requirements
provide advice and support to managers on risk assessments and positive behaviour support plans, in order to identify and plan for training, which is fit for purpose, appropriate to role, evaluated from lessons learnt
work with managers to facilitate effective implementation and monitoring of this policy
where needed or appropriate work with staff and patients to review incidents and where possible be available for de-brief
support and advise areas on individual patient needs providing bespoke training where this is an identified need, in line with the Use of Force Act
where the need for an intervention has been identified, the team will work with areas where required to provide advice on the management of the intervention using the least restrictive option
work with the head of estates and facilities on design of buildings so that full account can be taken of known environmental factors associated with positive risk management

4.7 The resuscitation service

The resuscitation service will:

support and advise areas to plan physical healthcare of patients during and after restrictive interventions
provide advice and support to both patient areas and the RRI team around the physical healthcare of patients during and post restrictive interventions

4.8 Managers

Managers will:

advise and instruct staff on the policy requirements via local induction arrangements and ongoing communication mechanisms
facilitate an understanding of the legal and practice requirements which must be implemented as set out in this policy and associated polices
facilitate and monitor the attendance of staff on mandatory RRI training
maintain accurate staff training records
promote an environment where all staff demonstrate and encourage respect for equality and diversity and recognise the need for privacy and dignity
promote a culture which focuses on RRI by early recognition, prevention and de-escalation of potential aggression, using techniques that minimise the risk of its recurrence (promoting the use of primary and secondary strategies)
promote a positive reporting and learning culture to facilitate continuous improvement with regard to the provision of safer and therapeutic services
ensure all incidents of violence and aggression are reported via the electronic incident form (IR1)
any incidents requiring physical intervention must have a Restraint or physical intervention monitoring form and body restraint chart completed via SystmOne
facilitate timely post-incident patient debrief which will not only provide support and understanding but will enable the team and patient to work in partnership to create or evaluate positive behavioural support plans, by working in partnership with patients, teams will be able to minimise the risk of reoccurrence of violence or implement the least restrictive interventions by learning from previous incidents, post-incident support, involving the attention to physical and emotional wellbeing of the individuals involved
facilitate timely post-incident reflection and learning review, both aspects of this post incident review should involve staff, patients or service users, carers and any others involved

4.9 All staff

All staff are required to:

promote a culture which focuses on reducing restrictive interventions by early recognition, prevention, and de-escalation of potential aggression, by focussing on the use of primary and secondary techniques that minimise the risk of its recurrence
ensure the implementation of positive behavioural support plans
implement the policy and agreed measures to manage risks
demonstrate and encourage respect for equality and diversity and recognise the need for privacy and dignity
participate in the identification of both environmental and clinical violence and aggression hazards and the production of risk assessments, we promote that staff are involved in the writing of patient plans and encourage staff on training to find out what these plans look like in areas in which they work
take reasonable steps to protect themselves and others from harm
attend mandatory training on RRI, and only use the techniques that have been taught in order to support patients, unless bespoke plans have been agreed, as per the mental health units (use of force) policy
report all incidents and participate in post-incident reviews
seek advice and support as required in a timely manner

5 Procedure or implementation

All those involved in the management of disturbed, or violent behaviour should be familiar with:

the relevant sections of the Mental Health Act (1983) (amended by the Mental Health Act 2007) and its Code of Practice 2015
the Mental Health Act Code of Practice, chapter 26, Safe and Therapeutic Responses to Disturbed Behaviour which outlines Primary, Secondary and Tertiary Strategies
the principles underlying the common law doctrine of ‘necessity.’
the requirements of the relevant articles of the European Convention on Human Rights (opens in new window), including Article 2 (right to life) and Article 3 (the right to be free from torture or inhuman or degrading treatment or punishment). Article 5 (the right to liberty and security) and Article 8 (the right to respect for private and family life) and the principle of ‘proportionality.’
the Health and Safety at Work Act (1974), which places duties on both employers and employees, and applies to the risk of violence from patients and the public
the Management of Health and Safety at Work Regulations (1992), which places specific duties on the employer to ensure suitable arrangements for the effective planning, organisation, control, maintenance and review of health and safety (these duties include ensuring that risk assessments are undertaken and implemented).
the Mental Capacity Act (2005) Deprivation of Liberty Safeguards, Code of Practice (MOJ 2008)
receive regular training on the above
ensure that a comprehensive record is made of any intervention necessary to manage an individual’s disturbed or violent behaviour, including full documentation of the reason for any clinical decision
ensure or contribute to ensuring that all aspects of the management of disturbed or violent behaviour are monitored on a regular basis, and that any consequential remedial action is drawn to the attention of those responsible for implementing it
be aware of the obligations owed to a patient while their disturbed or violent behaviour is being managed, and of parallel obligations to other patients affected by the disturbed or violent behaviour, to members of staff, and to any visitors
ensure or contribute to ensuring that any patient who has exhibited disturbed, or violent behaviour should not be the subject of punitive action by those charged with providing them with care and treatment, and that where the disturbed or violent behaviour is thought to warrant criminal sanction, it is drawn to the attention of the proper authority

5.1 The duty of care

By law, staff have a duty of care to patients, themselves and others. This will be provided by ensuring suitable treatment and care that is in the patients’ best interests. Treatment must be necessary to preserve or improve health and be in accordance with practice accepted at the time by a responsible body of opinion appropriate to the staff involved. Staff must be skilled in the particular form of treatment being utilised.

5.2 The duty Of candour

Duty of candour refers to the “volunteering of all relevant information to persons who have or may have been harmed by the provision of services, whether the information has been requested and whether a complaint or a report about that provision has been made”. Refer to being open policy (incorporating the duty of candour).

5.3 Risk assessments

Risk assessments are a crucial component in preventing and minimising aggressive and violent behaviour. The completion of an appropriate patient FACE risk assessment based upon accurate and relevant information offers a framework for assessing and managing risks associated with violence and aggression.
Environmental risk assessments, all work areas must have a risk assessment protocol pertinent and applicable to their respective situation or speciality that allows the assessment and management of risk in relation to violence and aggression. Risk assessments will be subject to a timely review. Please see the trust’s health and safety policy, fire safety policy and ligature risk reduction policy.
Patient risk assessments, patient risk assessments, where violence and, or aggression are indicated, must include a focus on physical presentation, early warning signs, situational and environmental triggers and those protective factors, that reduce the risk of violence. Patient risk assessments are the responsibility of the nursing teams and multi-disciplinary teams (MDT). A restraint reduction plan should be established to minimise and prevent the risk of violence and aggression.
Lone working, where staff are working alone or in remote locations, they should follow the guidance and instruction within the lone working policy.

Workplace stress, should staff indicate that violence and aggression has caused them stress, in line with the healthy workplaces staff support and stress at work policy they should complete the stress questionnaire and discuss with their supervisor or line manager to agree strategies to support them.

5.4 On admission to a mental health ward or learning disabilities service

The trust promotes the use of positive behaviour support plans (or equivalent care planning structures) for all patients admitted into its services. These plans should focus on the use of pro-active person-centred care, utilising primarily primary and secondary strategies, and always working in the least restrictive manner. Service users and, where appropriate their families and, or carers, must be involved in the care planning process.

5.4.1 Primary strategies and prevention

Primary strategies are those that should be used to improve the quality of life and reduce the likelihood of behaviours of concern. They should be used as part of everyday working practice and should be person-centred.

Plans should include any identified or known triggers, actions to be taken should any of these occur.

5.4.2 Secondary intervention

Secondary interventions are those which alleviate the situation and prevent distressed behaviours from escalating. These strategies are to be used when there are early warning signs, and the trust promotes person centred de-escalation strategies.

5.4.3 Non-restrictive tertiary strategies

Non-restrictive tertiary strategies are those used when an actual behaviour of concern is occurring. They are used to bringing about rapid safe control of a situation and should be in the form of person-centred de-escalation strategies.

5.4.4 Restrictive tertiary strategies

Restrictive tertiary strategies are those used when an actual behaviour of concern is occurring. They are used to bringing about rapid safe control of a situation, in order to prevent harm from occurring. They may include measures such as physical restraint, chemical restraint, seclusion, enhanced observations. These measures should only be used when de-escalation and all other strategies have failed to calm the patient.

It is vital therefore that when any restrictive procedures are used, deploying staff are fully aware of the risks involved. These risks and associated precautions must be addressed in training syllabi which places them within legal, ethical, and professional context.

These interventions are management strategies and are not regarded as primary treatment techniques. They should always be used in conjunction with further efforts at de-escalation and must never be used as punishment or in a punitive manner.

5.5 On admission to other services

During the admission process, all patients should be observed for any behaviour which may indicate that there is a heightened risk of violence, aggression, or abuse. If so, individual positive behavioural support plans should be developed, and advice sought from the RRI team if required.

5.6 Advance statements and advance decisions

Patients identified to be at risk of disturbed or violent behaviour should be given the opportunity to have their views and wishes recorded in the form of an advance statement.
They should be encouraged to identify as clearly as possible what interventions they would and would not wish to be used. This should be subject to periodic review. See advance statements and advance decisions to refuse treatment policy.
When determining which interventions to employ, clinical need, safety of patients and others, and, where possible, PBS and statements made by patients who are subject to compulsory powers under the Mental Health Act 1983 (MHA) about their preferences for what they would or would not like to happen if a particular situation arises in future, should be taken into account. This includes legally binding advance decisions to refuse treatment. See chapter 9, Code of Practice Mental Health Act (1983) (amended by the Mental Health Act 2007)

5.7 Physical interventions

Managing aggressive behaviour by physical intervention using the least restrictive approach should be undertaken only as a last resort in an emergency when there is a real possibility that harm would occur if no intervention were carried out. RDaSH is classed as a prone restraint trust, this is due to the prone decent. However, we must log roll the patient into the supine “T” position as soon as possible to minimise the risk of positional asphyxia.

The most common reasons for needing to consider such interventions are:

physical assault
dangerous, threatening, or destructive behaviour
extreme and prolonged over-activity that is likely to lead to physical exhaustion and risk to health
attempts to abscond (where the patient is detained under the MHA)
searching of a patient, please see searching of a person or their property policy.

The purposes of intervention where de-escalation has failed are to:

take immediate control of a dangerous situation
end or significantly reduce the danger to the patient or others around them
contain or limit the patient’s freedom for no longer than is necessary

Any physical intervention used must be:

reasonable, justifiable, and proportionate to the risk posed by the patient
using the least restrictive approach at that moment in time, which should be reduced as the patient de-escalates
used for only as long as is absolutely necessary
involve a recognised technique that does not depend on the deliberate application of pain
be carried out by staff who are appropriately trained and compliant with the training

A single member of staff should lead and control the situation and the patient should be approached where possible and agreement sought to stop the behaviour. Where possible an explanation should be given to the patient of the consequences of refusing the request from staff to desist. The special needs of patients with sensory impairments should be considered, approaches to deaf or hearing-impaired people should be made within their visual field.

During physical intervention one team member should be responsible for protecting and supporting the head and neck, where required. They should take responsibility for leading the team through the physical intervention process, and for ensuring that the airway and breathing are not compromised and that vital signs are monitored.

The Safety Pods should be utilised wherever possible and used as a primary strategy to reduce distress and behaviours that challenge

RRI physical interventions comprehensive (high Level) techniques (staff access only) (opens in new window) may require the use of head protection to reduce the risk of injury to the patient and, or staff. This role is given to number one (please see 3-person team set up in physical interventions, core techniques (staff access only) (opens in new window) and physical interventions, comprehensive (high Level) techniques (staff access only) (opens in new window) techniques both can be found on the RDaSH intranet). They should take responsibility for leading the team through the physical intervention process, and for ensuring that the airway and breathing are not compromised and that vital signs are monitored.

A number of physical skills may be used in the management of a disturbed or violent incident. Every effort should be made to utilise skills and techniques that do not use the deliberate application of pain, which has no therapeutic value and could only be justified for the immediate rescue of staff, patients and, or others. Under no circumstances should there be more staff than required for a physical intervention than is necessary, this is outlined in the risk assessments for each technique. If it is a prolonged restraint, there may be times when staff need to change such as qualified staff needing to go for medication, staff injuries, tiredness, clashes of personality. Please see the table below for reference:

Intervention	Classification	Number of staff required
Passive hold	Standing, escorting	3 people (including number one at the front)
Figure of four	Seated, standing, escorting	3 people (including number one at the front, knelt at eye level in seated)
Back-to-back	De-escalation only	3 people (including number one at the front)
Reverse passive to the pod	Supporting, de-escalating	3 people (including number one at the front knelt at eye level)
Sit Back in Passive with head protection	Supporting, floor	3 people (number one protecting the patients head on the floor)
Double wrist hold with head protection	Standing, escorting	3 people, (number one on head protection)
Finger and thumb hold with head protection	Standing, escorting	3 people, (number one on head protection)
Sit back in finger and thumb with head protection	Supporting, floor	3 people (number one protecting the patients head on the floor)
Prone decent to supine ‘T’ via log roll	Supporting, floor	3 people (number one protecting the patients during the prone decent and protecting the head on the floor)
Prone decent to supine ‘T’ via log roll with leg management	Supporting, floor	4 people (number one protecting the patients during the prone decent and protecting the head on the floor number 4 on leg management)
Assisting to stand from supine ‘T’	Supporting, floor	3 people (number one protecting the patients head on the floor and head protection throughout assistance to stand)
Assisting to stand from supine ‘T’ with leg management	Supporting, floor	4 people (number one protecting the patients head on the floor and head protection throughout assistance to stand)
Seclusion exit with head protection	Supporting, kneeling	3 people, (number one on head protection)

It is important that restraint through the use of physical intervention is seen within the overall spectrum of approaches for dealing with violence and aggression. Disengagement from a violent or potentially violent situation is preferable. Occasions may occur when the safety of self or others may supersede this.

Staff will develop a clear understanding of factors that may contribute to disturbed behaviour and dealing with violence and aggression through local induction procedures, advice, and instruction from managers on the policy and through their attendance on mandatory RRI training.

Staff likely to be involved in restraint through the use of physical interventions must be suitable trained by attending the relevant course as set out in section 9 of this policy.

Violence that occurs very suddenly and without time to de-escalate or summon help may require immediate physical intervention. The use of such intervention is acceptable in law providing the amount of force is reasonable to stop the attacker, and, or stop injury to the person being attacked or injury to the attacker.

5.7.1 Clinical holding

A definition of clinical holding as taken from the Mental Capacity Act is “the use of restrictive physical interventions that enable staff to effectively assess or deliver clinical care and treatment to individuals who are unable to comply”.

Clinical holding may be defined as the proactive holding of part of the body to allow a procedure to be carried out, for example, holding an arm while blood is being taken in order to prevent reflex withdrawal and consequent unnecessary pain, distress or injury to the patient, staff or accompanying persons.

Clinical holding interventions are planned interventions and therefore must be care planned accordingly.

Clinical holding interventions should not routinely be incident reported (IR1) unless something untoward occurs (for example, an injury to patient or staff).

Clinical Holding should not routinely require a full early warning score (EWS) to be completed unless there is a clinical need.

5.8 Physical care and observation of the patient or national early warning score (NEWS2), observations during or following restraint or physical interventions

Physical monitoring should commence during any restraint, however, is of particular importance:

during and following a prolonged or violent struggle
if the patient has been subject to rapid tranquillisation
if the patient is suspected to be under the influence of alcohol or illicit substances
if the patient is clinically obese
if the patient has a known condition which may inhibit cardiopulmonary function, for example, Asthma

At the point of restraint and every 5 minutes during the restraint the following observations should be recorded:

respiratory rate
central nervous system (CNS) (alert newly confused voice pain unconsciousness) (ACVPU) level
oxygen saturations (O2 saturations)
pulse

If it is not possible to monitor o2 saturations and pulse, respiratory rate, and CNS (ACVPU) must be recorded as a minimum and rationale documented as to why o2 saturations and pulse could not be recorded, this must be done in the patient notes.

These observations must be recorded on the NEWS 2 physical observation chart NEWS calculated and recorded.

It is also important to monitor for any verbal or non-verbal signs of pain or discomfort.

If after release from restraint observations do not improve further medical assistance should be sought via the ambulance service particularly if:

the patient is struggling to breathe
there is noted flushing and redness to the face and neck
there is marked expansion of the veins in the neck
changes in behaviour
reducing level of consciousness

Once the restraint has been released the following observations must be recorded every 15 minutes for the first hour and every 30 minutes for the next three hours:

respiratory rate
CNS (ACVPU)

These observations must be documented on the NEWS2 physical observations chart, and a NEWS calculated. Since they can be taken without cooperation from the patient, and therefore must be taken in every event.

The following observations should be taken only if there is clinical indication of deterioration or change in the patient’s physical condition and only then, if it is safe to do so:

O2 saturations
blood pressure
pulse
temperature

These observations must be documented on the NEWS 2 physical observations chart and a NEWS calculated.

If at any time, there is cause for concern for the patient’s physical health a doctor must be contacted.

Rationale for the level of physical observations taken should be recorded in the nursing notes, not on the chart.

See also section 7.5 patients brought in by the police who may have been restrained.

For more information on the national early warning score (NEWS2) please see the resuscitation manual.

5.9 Seclusion

Seclusion is the supervised confinement of a patient in a specifically designed and approved room, which may be locked. Its sole aim is to contain severely disturbed behaviour which is likely to cause harm to others. It has a place to play in the spectrum of least restrictive interventions available to support the management of violence and aggression. See secluded or segregated policy management of a secluded or segregated patient.

5.10 Rapid tranquillisation

Rapid tranquillisation should only be considered once de-escalation and other strategies have failed to calm the patient and should be considered as a management strategy and not a primary treatment technique. See rapid tranquillisation policy and guidelines (pharmacological management of violence).

Physical intervention may be used in order to administer medication to an unwilling patient where there is legal authority, whether under the Mental Health Act 1983 (amended by the Mental Health Act 2007) Mental Capacity Act 2005 or otherwise, to treat the patient without consent.

5.11 Observation

Increased levels of observation may be used both for the short-term management of disturbed behaviour and to prevent suicide or serious self-harm. See supportive therapeutic observation policy.

5.12 Mechanical restraint

The use of mechanical restraint is not permitted.

This might include strapping or tying a patient to an object, fastening trays to chairs to prevent patients getting out, placing chairs facing walls to prevent movement, hooking clothes over chairs, commodes, or other objects to prevent movement. The trust does not support any of these forms of approach.

5.13 Incidents where weapons are present

Staff should not attempt to physically disarm any person who is acting in a hostile manner with any kind of dangerous weapon or item that can be used as such. Urgent police assistance should always be requested when the safety of patients and staff are compromised.

5.14 Debriefing or post-incident reviews

In line with the RRN standards, the trust recognises the need for thorough post incident review procedures to ensure:

attention is given to the physical and emotionally wellbeing of those involved
post-incident reflection and learning

Post incident review must therefore:

evaluate the physical and emotional impact on all involved including witnesses
identify if there is a need, and if so, provide counselling or support for any trauma that might have resulted
help patients and staff to identify what led to the incident and what could have been done differently to ensure lessons are learnt from each incident
determine whether alternatives including less restrictive interventions were considered
determine whether service barriers or constraints make it difficult to avoid the same course of action in future
where appropriate recommend changes to the service philosophy, policy, care environment, treatment approaches, staff education and training
patients should not be compelled to take part in debrief, they should be offered the right to talk about the incident independently

If required, the RRI team can be available to assist in the debrief process.

5.15 Staff considerations

A review of whether staff require medical treatment, sick leave or temporary relief from duty must be carried out by the manager and appropriate arrangements made. Staff may wish to be referred for counselling via the relevant occupational health department or alternatively could choose to access the staff counselling service.
A review and assessment of working practices and security measures must be carried out, and appropriate changes made where required. Where changes are required, but cannot be implemented, these must be reported to the director or senior manager immediately.
The manager should discuss the issue of pursuing a prosecution against the assailant and offer to accompany the member of staff to the police if necessary. Advice and support can be provided by the LSMS.
If the member of staff requires sick leave, then please refer to the sickness absence policy. Advice and support can be sought from the human resources department as appropriate.

5.16 Visiting

Trust staff are responsible for the health and safety of any visitors who are on trust premises. In the event that visitors are in the vicinity when an incident occurs, they should be removed to a safe area immediately.
Witnessing a violent incident can be distressing. Staff should offer support and reassurance, and explain why the visitors are being removed, and when it is safe for them to return to the area from which they have been removed.
See visiting patients on inpatient areas policy, and children visiting inpatient and residential units within the trust policy.

5.17 Incident reporting and recording

Staff must report all incidents of restrictive interventions as soon as possible after the incident by completing and submitting an electronic incident form (IR1) via the electronic safeguard incident reporting system. See incident management policy.

For reporting of incidents in ward settings, the mental health units (use of force) policy must also be followed (section 5.5.3, data collection requirements).

These incident reports are reviewed by the local security management specialist (LSMS), RRI team and resuscitation service and reviewed with the relevant Manager as appropriate.

It is a requirement that all incidents of physical and non-physical assault are reported, whether intentional or not.

5.18 Responding to complaints

Any complaint made against staff as a result of a violent incident will be dealt with quickly and fairly and investigated as per the listening and responding to concerns and complaints policy (formally complaints handling policy). Staff are also encouraged to consult their own professional association or trade union for advice.

5.19 Pursing criminal proceedings

Following a serious assault, the process set out in appendix A must be followed. The LSMS will provide advice and support to managers and staff as required.

5.20 Gender or sexuality

There may be occasions where the staff team, confronted with an aggressive patient, face the potential problem of gender or sexual issues, such as an all-male team needing to manage a female patient or an all-female team having to manage a male patient.

On these occasions an attempt should be made to ensure there is a staff member of the same sex as the patient at the scene to observe the management of the situation.

There should be no attempt to change the responding nurse team into one of mixed gender unless it is safe to do so and the person stepping in is trained in physical interventions.

5.21 Patients with disabilities

Where it is known that a patient has disabilities, including physical or sensory impairments and communication difficulties, they should have specific instructions in their PBS plan concerning the preferred method of dealing with incidents, which may require specific interventions. The PBS plan should set out the responsibilities that each member of staff has in relation to the actions required.

5.22 Pregnant patients

Where it is known that a patient is pregnant, advice should be sought from the RRI team, resuscitation service, obstetrics and gynaecology, and special provisions made where interventions may be required. The agreed interventions must be documented in the patient’s care plan.

5.23 Managing patients with HIV or other communicable diseases

If staff are aware that a patient has a potentially infectious condition, the advice of the infection prevention and control team should be sought. Upon their guidance, protective clothing and equipment will be made available. Any special provisions to be implemented with patients should be clearly written up in their care plan.

If a member of staff or a patient is involved in an incident which involves a risk of infection, where the skin is broken, blood is spilt, or there has been direct contact with body fluids, then the policy for spillages of blood and other bodily fluids should be followed.

5.24 Patients brought in by the police who may have been restrained or searched

Where patients are brought in by the police, staff must establish if the police have physically or mechanically restrained the patient, and if so, or if staff are unsure a physical observation should commence as per section 5.7 of this policy. The discussion with the police should be recorded in the patient’s clinical record and body map completed. Staff must establish if the patient has been searched prior to arrival at the unit, if not or staff are unsure, they should follow the direction in the trust’s searching of a person or their property policy.

5.25 Staff who undertake domiciliary visits or work alone

There are some staff within the trust, who are due to the nature of their work, will have to visit patients in their own homes or who may find themselves working alone. It is recognised that any staff who do work alone are particularly vulnerable, and the trust has in place a lone working policy to which all managers and staff must adhere in all these circumstances. See lone working policy.

5.26 Persons under 18 years of age on adult wards

In the exceptional circumstance that a person under 18 years of age is admitted to an adult ward, due consideration should be given to the involvement of parents or carers in the planning of care and treatment to maintain the therapeutic relationship

6 Training implications

In line with the RRN standards an annual review of the training needs analysis and training offer is carried out in relation to this policy. These documents are formulated based on data from across the trust to ensure that training remains relevant to staff and patient groups. The training needs analysis (TNA) for this policy can be found in the trust’s mandatory and statutory training policy.

6.1 Training

6.1.1 All inpatient adult mental health wards or older persons mental health or forensic service, bank staff

How often should this be undertaken: Annually.
Length of training: 3 days.
Delivery method: Face to Face.
Training delivered by whom: 3 Day comprehensive update, ILS, manual handling, learning and development.
Where are the records of attendance held: Staff ESR record.

6.1.2 Physical health wards, community staff who are patient facing, support service assistants, estates, catering

How often should this be undertaken: Annually.
Length of training: 3 hours.
Delivery method: Face to face.
Training delivered by whom: Disengagement update.
Where are the records of attendance held: Staff ESR record.

6.1.3 All new starters at the following, inpatient adult mental health wards or older persons mental health or forensic services, bank staff

How often should this be undertaken: Once.
Length of training: 4 days.
Delivery method: Face to face.
Training delivered by whom: 4 Day induction comprehensive RRI.
Where are the records of attendance held: Staff ESR record.

6.1.4 All new starters at the following, physical health wards, community staff who are patient facing, support service assistants, estates, catering

How often should this be undertaken: Once.
Length of training: 1 day.
Delivery method: Face to face.
Training delivered by whom: 1 day induction disengagements RRI.
Where are the records of attendance held: Staff ESR record.

6.1.5 All staff

How often should this be undertaken: 3 yearly.
Length of training: 1 hour.
Delivery method: eLearning.
Training delivered by whom: Conflict resolution.
Where are the records of attendance held: Staff ESR record.

6.2 Reducing restrictive interventions (RRI) team

All staff must have a comprehensive understanding of reducing restrictive interventions (RRI).

The trust provides the following training in relation to this:

conflict resolution, e-learning
RRI, disengagement (annual)
RRI, comprehensive (annual)
bespoke training, delivered to specific staff teams in relation to a specific patient referral

An individual’s training matrix will identify at which level training should take place.

Staff working in any in-patient settings (ward based), must only use the applicable physical intervention techniques taught on training, specific to a given ward area, in line with the mental health units (use of force) policy.

If staff have concerns about supporting individual patients and feel the taught physical interventions will not adequately support that patient, then they must make a request for bespoke training and, or bespoke physical intervention training to the RRI team.

The RRI team will then, working in conjunction with nursing teams and the MDT, gather additional information and formulate a bespoke package of training. Any bespoke person-centred physical interventions will be fully risk assessed and signed off by the delegated responsible person for the use of force, prior to implementation.

In line with the RRN training standards, upon attendance to either of the RRI courses, facilitators can ask staff to re-attend on the basis of language and attitude displayed on the course this can be either towards other staff or facilitators, they can also be asked to re-attend if they have not been deemed competent by the end of the training. A letter will be sent out to the manager to inform them of re-attendance.

6.2 Resuscitation, life support

All clinical staff involved in restraint or the administering and prescribing of rapid tranquilisation, or monitoring patients who have received rapid tranquilisation or restraint must receive training in immediate life support (ILS) to a level equivalent to the resuscitation council ILS course. See the trust’s resuscitation manual.

With regard to persons under 18 years of age (see 6.7 above), from puberty a child is considered to be an adult in a life support situation.

6.3 Rapid tranquilisation

All staff involved in rapid tranquilisation must be trained to the level of ILS prescribers and those who administer medicines must receive training in rapid tranquilisation including the properties, risks and titration of medications used in rapid tranquilisation. See the trust’s rapid tranquillisation policy and guidelines (pharmacological management of violence)

7 Monitoring arrangements

7.1 How the trust carries out risk assessments for the prevention and management of violence and aggression

How: LSMS work plan and security report.
Who by: Head of health, safety and security.
Reported to: Quality assurance sub committee.
Frequency: Annual report and half yearly update report.

7.2 Timescales for review of risk assessments

How: LSMS work plan and security report.
Who by: Head of health, safety and security.
Reported to: Quality assurance sub committee.
Frequency: Annual report and half yearly update report.

7.3 How action plans are developed as a result of risk assessments

How: LSMS work plan and security report.
Who by: Head of health, safety and security.
Reported to: Quality assurance sub committee.
Frequency: Annual report and half yearly update report.

7.4 How action plans are followed up

How: LSMS work plan and security report.
Who by: Head of health, safety and security.
Reported to: Quality assurance sub committee.
Frequency: Annual report and half yearly update report.

7.5 Arrangement for making sure lone workers are safe

How: LSMS work plan and security report.
Who by: Head of health, safety and security.
Reported to: Quality assurance sub committee.
Frequency: Annual report and half yearly update report.

7.6 How the trust trains staff, in line with the training needs analysis

How: Report.
Who by: Head of learning and development.
Reported to: Individual care groups.
Frequency: Monthly.

7.7 Audit of positive behavioural support plans

How: Report.
Reported to: Environmental risks in clinical areas steering group.
Frequency: Annually.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

There are no effects on the provision of privacy and dignity or respect within this policy.

8.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

9 Links to any other associated documents

10 References

11 Appendices

11.1 Appendix A Definitions or explanations of terms used

Definitions
Term	Definition
Clinical Holding	A definition of clinical holding as taken from the Mental Capacity Act is “The use of restrictive physical interventions that enable staff to effectively assess or deliver clinical care and treatment to individuals who are unable to comply”
Clinical holding	As the proactive holding of part of the body to allow a procedure to be carried out, for example, holding an arm while blood is being taken in order to prevent reflex withdrawal and consequent unnecessary pain, distress or injury to the patient, staff or accompanying persons
De-escalation	The use of techniques (including verbal and non-verbal communication skills) aimed at defusing anger and averting aggression (NICE)
Duty of candour	Refers to the ‘volunteering of all relevant information to persons who have or may have been harmed by the provision of services, whether the information has been requested and whether a complaint or a report about that provision has been made’
Non-physical assault	The use of inappropriate words or behaviour causing distress and, or constituting harassment
Physical assault	The intentional application of force to the person of another without lawful justification resulting in physical injury or personal discomfort
Positive behavioural support plan (PBS, HEE)	“PBS is a person-centred framework for providing long term support to people with a learning disability, and, or autism, including mental health conditions, who have, or may be at risk of developing, behaviours that challenge. It is a blend of person-centred values and behavioural science and uses evidence to inform decision-making.’’
Restrictive intervention	Interventions that may infringe a person’s human rights and freedom of movement, including physical restraint, chemical restraint, rapid tranquillisation, psychological restraint, seclusion, clinical holding, mechanical restraint (RDASH does not use mechanical restraint)
Restrictive practices	Restraint reduction network (RRN) defines restrictive practices as ‘’making someone do something they don’t want to do or stopping someone doing something they want to do. In service settings this can be linked to the use of blanket rules which apply to everyone regardless but may have a tenuous for application or are only necessary because of a specific individual risk.’’
Using restraint	Mental Capacity Act Code of Practice, section 6(4) states that someone is using restraint if they: “Use force or threaten to use force to make someone do something that they are resisting or restrict a person’s freedom of movement whether they are resisting or not.”
Violence and aggression	Refer to a range of behaviours or actions that can result in harm, hurt or injury to another person, regardless of whether violence or aggression is physically or verbally expressed, physical harm is sustained, or the intention is clear
Work-related violence	The health and safety executive (HSE) defines it as any incident in which a person is abused, threatened, or assaulted in circumstances relating to their work. This can include verbal abuse or threats as well as physical attacks

11.2 Appendix B Action following a serious assault

Serious assault on a:

member of staff
service user
visitor

Senior member of staff to:

contact service matron or senior manager on-call
contact clinical director (if medic assaulted)
ensure the member of staff that has been assaulted has reported it to the police (with support if needed)
inform local security management specialist (LSMS)

For any serious assault against a medic, the medics decision-making responsibility will be immediately suspended, and responsibility temporarily handed to the duty consultant, who will make any immediate decisions required for the service user’s care.

Arrangements will then be made for the service user’s long-term care to be allocated to another consultant via the pre-agreed rota.

11.2.1 Report to police

Anyone can report the assault the person assaulted my not be able to, regardless of section, police can arrest and remove, at this point we would discharge, once they are charged or not, they will be reassessed in the custody suite by our staff and re-sectioned if required.

11.2.1 Arrested by police

Criminal justice system procedure to take its course.
Return to service only after full risk assessment by consultant psychiatrist (new consultant for service user if appropriate)

11.2.3 Not arrested

Remain in service.
Clinical review.
Risk assessment by consultant and victim informed of risk management process by the consultant managing the situation.
Movement of staff if required.
Change of medic if appropriate.
Senior manager to raise the incident with police at senior level if felt to be required.

11.3 Appendix C Safety pod guidance and information

The utilisation of the Safety Pods on our Inpatient areas form part of the trust’s commitment to enhancing patient and staff safety.
It resembles an over-sized “bean bag” and meets safety standards and infection control compliance and is designed to provide ergonomic support to both staff and the patient concerned when physical interventions are required. Please see reverse passive to the pod and seated in physical interventions, core techniques (staff access only) (opens in new window) and physical interventions, comprehensive (high Level) techniques (staff access only) (opens in new window), both of these can be found on the RDaSH intranet.

RDaSH promote the use of the Safety Pods for primary and secondary preventions and is to be used as therapeutic de-escalation tool. Should a situation continue to escalate, the Safety Pod can be utilised as a tertiary strategy. The Safety Pod does not require a change in staffing levels to realise its benefits.

The Safety Pod training is an integral part of the RRI training which all staff must attend. The UK Pods, Safety Pod, manual of guidance, which is provided in this appendix also sets out training in regard to safety pods, in line with Pods UK guidelines for use. Safety pod training is part of the RRI course not a standalone training session, and safe use of the pod forms part of the competency’s framework. Further information on Safety Pods including maintenance can be found on the UK pods website (opens in new window) and in the medical devices management policy.

11.3.1 UK Pods LTD

A global brand that’s clinically proven to reduce the need for restraint even in some of the most challenging of situations.

Our service’s aim to provide our client’s with a safer alternative to ground restraint when presented with situations that may appear challenging.

“I believe the Safety Pod is likely to enhance the safety, reduce injury and render restraint a less unpleasant experience for the subject and staffing teams.”, Dr Anthony Bleetman.
“The purpose of this guidance is to provide a universal framework to support the development and understanding of the safety pod in professional practice. This manual demonstrates the use of nationally recognised methods of delivering person centred care alongside Safety Pods, which better meet the needs of people and enhance their quality of life”, Palkesh D Crawford.

11.3.2 Medical review

The award-winning Safety Pod is the only device of its kind to have medical backing and endorsement for use during physical interventions. Annual reviews are carried out by some of the UK’s leading industry experts, such as Dr Anthony Bleetman.

If you would like a copy of our latest medical review please contact

Email: info@ukpodsltd.co.uk

We recommend that the Safety Pod is implemented as an essential agent in creating person-centred care alongside a recognised spectrum of positive approaches aimed at reducing the need for restraint, therefore it is essential where Safety Pods are provided that all people responsible for and working where people who are known to be at risk of being exposed to restrictive interventions review this guidance and formally integrate it into their services. This requires that you clearly delineate how this equipment will be used within the context of primary, secondary and tertiary interventions as well as how the Safety Pod will be integrated into restrictive intervention reduction (restraint reduction) activities.

11.3.3 Training

We recommend that all staff expected to use the Safety Pod receive training which covers approved physical Intervention techniques, approaches and procedures as well as covering the potential risks. This training should be provided as part of a credible and competent system of physical intervention or PMVA and should follow their respective company policy on the use of physical intervention.

This training is likely to be RRN certificated.

The use of the Safety Pod should be fully recorded for review and planning purposes.

All staff using the Safety Pod should be in-date for their training.

It is best practice that the planned use of the Safety Pod be fully documented in an individual’s support or crisis plan where its use can be carefully reviewed and approved by an MDT.

It is always good practice to include clients in any such consultation.

11.3.4 Guidance

The Safety Pod, offers many opportunities for positive and proactive working, to mitigate rising distress and avoid the use of restrictive interventions altogether. It may also be used to keep people safe from harm in the event action needs to be taken to limit harm.

The following shows examples of ways in which the Safety Pod has been used by clients, and represents some recommended uses. Primary uses:

adjunct in therapy based sessions
as object of comfort
to facilitate relaxation
also to support general supervised activities

Secondary uses:

de-escalation aid
as object of comfort and, or to facilitate relaxation within context of co-regulation and self-regulation
deep pressure therapy support tool.

Tertiary uses:

physical intervention aid
enhance safety and support as well as restraint reduction or minimisation efforts

Restrictive interventions, physical intervention holds in particular, may be used in the context of secondary and tertiary measures. The additional scope for reduction in the use of restrictive interventions may include, but are not limited to, the following:

fewer staff involved in responses to challenging behaviour
less Likelihood of injury to client or staff
shorter periods of physical intervention
less restrictive holds
less likelihood of undignified and unsafe interventions, for example,
takedowns to ground level
reduced time spent in potentially unsafe positions, for example, on the floor

Where integrated into a personal support plan, or crisis plan, the rationale for use should be explicit and how it is to be used should be recorded and must be clear. It is recommended that the Safety Pod is used in conjunction with all current legislation and guidance on the use of force specific to your industry sector. Furthermore, all uses should be supported by appropriate risk assessment.

11.3.5 How to set up the Safety Pod

Take hold of the hood next to the logo and shake the Safety Pod until the hood is empty of inner contents.

Place the hood of the Safety Pod and rest it onto the body of the Safety Pod as shown below.

11.3.5.1 Moving and handling

The Safety Pod weighs approximately 15kg. It is advised that the Safety Pod is set up for use and placed upright on its side when moving.

PI Training team support is recommended before using the Safety Pod, for more information please contact info@ukpodsltd.co.uk.

Ensure the Safety Pod is set up before each use (see set up instructions).

It is recommended that the Safety Pod should be placed in supervised areas at all times.

It is advised you check the Safety Pod on a regular basis to check for damage (see maintenance guide).

We advise a refill, if the Safety Pod appears flat or low to the ground. A refill service is available nationally please contact:

Email: info@ukpodsltd.co.uk

To achieve the best results, it is advised your Safety Pod is checked and maintained on a regular basis. Please refer to maintenance log provided.

It is recommended the Safety Pod is not to be used on wet or slippery.

11.3.5 Health and safety

11.3.5.1 Advised use of the Safety Pod position

The person should be sitting upright with head on hood support:

We recommended you do not:

Don't

do not place a person face down in the Safety Pod or any surface
do not place the Safety Pod on top of a person

11.3.6 Contact information

UK Pods LTD
6 Wallis Road
Skippers Lane Industrial Estate
Middlesbrough
TS6 6JB

Phone: 01642 453777
Email: info@ukpodsltd.co.uk
Website: www.ukpodsltd.co.uk (opens in new window)
Company number: 10414909

11.3.7 Safety Pod refill guide

We recommended that your Safety Pod maintains an even level from front to back and across to each side as shown below in the Safety Pod position.

In the hood of your Safety Pod passes the half way seam as seen below, or if you do not have an even surface when the Safety Pod is in the set-up position your Safety Pod may require a refill or service.

Please contact a member of our team if you require any further information regarding a service and refill:

Email: info@ukpodslitd.co.uk

Your Safety Pod will reduce in volume over time, to maintain good performance, it is advised your Safety Pod is checked on a weekly basis. Please find overleaf a maintenance log for your reference. If you require further information on this please contact manufacturers:

Email: info@ukpodslitd.co.uk

It is advised your Safety Pod is serviced annually.

We advise if any damage appears or if you have any questions about your Safety Pod condition please contact:

Email: info@ukpodslitd.co.uk

For guidance on cleaning your Safety Pod please refer to cleaning guidance.

It is advised that risk assessments are carried out regarding the safe use of the Safety Pod and that this is done on an individualised basis.

UK Pods Ltd accepts no responsibility for damage or faults to a Safety Pod that does not carry a clear record of consistent maintenance

We highly recommend that your Safety Pod is regularly maintained. It is the user’s responsibility to ensure regular maintenance is carried out and evidenced.

A maintenance log is provided with every Safety Pod as a guide.

It is recommended that you check your Safety Pod after each use and once a week for damage or faults.

We advise that you do not attempt to remove or add any filler to your Safety Pod, if you have any queries regarding the fullness of your Safety Pod please contact a member of our team.

11.3.7.1 Maintenance log

Maintenance log
Date checked	Check by	Safety Pod location	Check by	Further action required

11.3.8 Cleaning

We have engineered our products with material which offer the ultimate in stain resistance and clean-ability. All of our products have been rested with a wide range of cleaning products and are able to withstand the most rigorous cleaning regime.

Our Safety Pod’s can be cleaned using all current NHS approved cleaning solutions such as Chlor-Clean, Haz-tab, Milton and Tristel.

Document control

Version: 6.1.
Unique reference number: 311.
Approved by: Corporate policy approval group.
Date approved: 25 January 2024.
Name of originator or author: Lead facilitator MAST or prevention and management of violence and aggression (RRI) team.
Name of responsible individual: Executive director of people and organisational development.
Date issued: 26 January 2024.
Review date: 31 January 2026.
Target audience: All clinical staff working in all service areas including the community. All staff working in areas where patients are present.

Page last reviewed: November 18, 2024
Next review due: November 18, 2025

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