Policy on Physical Intervention

• Background

• The Policy

• The Procedure

• Appendix

Background

The production of a policy on Physical Intervention within Hayfield is part of an on-going process which seeks to continually review and improve service delivery within the organisation.

This document is to be seen as part of a wider framework of policies and procedures which serve to inform, monitor and direct the provision of such services as the organisation seeks to deliver.

The Policy is developed in conjunction with and taking account of:

• The stated Aims, Objectives and Values of Hayfield in relation to the organisation’s role in providing services for deaf people with other difficulties.

• The legal obligations and responsibilities laid down for service providers in the Care Sector, with particular reference to:-         

Community Care (Scotland) Act 1990

Mental Health (Scotland) Act 1984

Adults with Incapacity (Scotland) Act 2000

• The principles and guidelines of recognised good practice, as outlined in the Care Commission (“National Standards”) and the Mental Welfare Commission for Scotland (“Rights, Risks and Limits to Freedom”).

• The operation of accredited Physical Intervention techniques as stipulated by CALM Training services.

Policy

Introduction

Service users have a right to make choices, including the right to take risks. Therefore the avoidance of risk should not automatically be seen as a reason for limiting behaviour or resulting activity.

Within the care setting of Hayfield, professional judgement must involve making assessments of when and if any intervention can and should take place.

The organisation recognises that it has a responsibility to provide all care staff with adequate and appropriate training in how to deal with challenging behaviour and in the assessment of the need for and use of physical intervention.

Hayfield staff who have not had access to training or who have not obtained accreditation in the use of appropriate physical intervention techniques, shall not attempt to use such techniques, and shall follow the requirements of the associated  Hayfield Policy on “Challenging Negative Behaviour”. 

Any physical intervention undertaken by Hayfield staff must be consistent with the legal obligations and responsibilities of both the organisation and the individual staff member, as outlined in this Policy and the corresponding staff training.

Hayfield will work within the existing legal framework to seek to ensure that all provision of care, including the use of physical intervention, will be in the best interest of service users .

Hayfield will undertake an annual review of the policy and procedures governing the use of physical intervention, including an updating of legal obligations or requirements. This review will take place in conjunction with annual staff retraining or re-accreditation.

The existence of this Policy will be made known to all service users, their representatives and, where appropriate, their families and carers.

This Policy should be regarded as part of Hayfield’s wider policy framework, and should take account of associated policy statements on “Challenging Negative Behaviour”, “The Complaints Procedure”, “Records and Communication”, etc.

Values

 Hayfield values individuals on the basis of their differences as well as their similarities and recognises that service users should be treated fairly and with courtesy and respect.

Hayfield will encourage and assist service users to make decisions and choices in matters which affect their lives.

Hayfield will present experiences and opportunities for learning which are appropriate to each service user’s interests and abilities.

Hayfield recognises that these approaches will involve service users taking risks and possibly making inappropriate choice and that this should be acknowledged as part of their personal development.

It is therefore accepted as essential that any physical intervention should only be used in the best interests of the service user.

Training

Hayfield will use the approach known as “Crisis and Aggression Limitation Management” (CALM) for the training of staff and the recording and monitoring of all incidents of physical intervention.

Hayfield will ensure that care staff and managers who may be required to use physical intervention will receive the appropriate training in CALM techniques and approaches.  This will include training in knowledge, skills and values as well as the practicalities of actual physical intervention.

The training will highlight the importance of factors which may help to avoid or de-escalate crisis situation and emphasise the fact that physical intervention should only be used as a last resort.

Training will stress the importance of individual risk assessments and of the need for adequate and consistent incident reporting.

CALM training will be provided by instructors who have appropriate experience and qualifications

Hayfield will provide opportunities for trained staff to practice accredited techniques on a regular basis and will inform staff of any changes in the operation of these techniques.

All trained staff will be required to submit themselves for annual re-accreditation.

Hayfield staff will only use the physical intervention techniques that they have been trained and accredited to use.

Prevention of Challenging Behaviour

Hayfield is committed to non-aversive approaches to care and to positive programming to prevent or minimise the occurrence of crisis situations.

Hayfield recognises that challenging behaviours can be prevented or minimised by effective organisational arrangements and by the professional approach of trained staff to assist service users to maintain self-control.

Prevention of crisis development must be the focus of this approach and is best achieved through proactive care planning, in which triggers for crisis are identified and strategies adopted to minimise risk.

Primary prevention:  Service users may be affected or influenced by their surroundings and environment (“setting conditions”). These setting conditions will be assessed for each service user and recorded in their individual Risk Assessment and where possible the conditions will be modified to reduce the likelihood of challenging behaviour occurring.

Secondary prevention:  Staff will use procedures highlighted in their training and outlined in Hayfield Policy to ensure that problematic episodes may be dealt with using non-physical interventions whenever possible.

For each service user the focus of secondary prevention will be governed by the knowledge and experience of that individual, as recorded in their Risk Assessment and Incident Reports.

Each service user who presents challenging behaviour will have individualised strategies and procedures for staff response to such behaviour.  Such procedures should be designed to enable staff to respond effectively to potentially violent behaviours while ensuring the safety of all concerned.

Where appropriate, the strategies will include directions for the possible use of physical interventions, but will also identify individuals or situations which must not involve physical interventions.

These strategies and procedures will be recorded in the service user’s Care Plan and should be known and understood by all staff involved with that service user.

Each service user’s Care Plan will be reviewed at least twice yearly and any changes in preventative strategies will be recorded and made known to the appropriate care staff.

Promoting The Best Interests Of Service Users

Hayfield is committed to preventing the physical, sexual and emotional abuse of all service users within its care.

Hayfield staff will reflect the Values of the organisation in all their work with service users.

Service users and their representatives will be informed about Hayfield’s Policy on Physical Intervention and the fact that this process will be used solely for crisis management.  Where appropriate service users will have a demonstration of any planned techniques which staff may be required to use with them.

Hayfield recognises the prime importance of practice being led by training and professionalism, backed by knowledge and experience of individual service users.

Hayfield staff should only use physical intervention in conjunction with other strategies which might help the service user to learn alternative, non-challenging behaviours.

Staff undertaking any action involving planned physical intervention must be able to justify it in respect of the following criteria:-

Previous knowledge of the service user involved, as recorded in the Risk Assessment and Care Planning process.

Knowledge of any alternative approaches that can be used with that service user.

An evaluation of the potential risks involved in physical intervention at that time.

Acknowledgement that attempts at prevention or de-escalation had been unsuccessful.

Appropriate training and accreditation to use the interventions required.

The potential use of physical intervention with any individual service user will be reviewed at least twice yearly, in conjunction with the Risk Assessment and Care Planning process.

Risk Assessment & The Protection Of Service Users

This section should be read in conjunction with the Hayfield Policies on “Risk Assessment” and “Assessment & Care Planning”.

Hayfield recognises that service users have a right to make choices in matters which affect their lives and that this should also allow them to take risks.  The Risk Assessment process should not be used solely as a means of limiting behaviour but rather as a means of protecting the health and well being of the individual.

Hayfield recognises that there are potential hazards associated with any situation in which physical intervention is used.  Wherever possible these hazards should be systematically investigated and recorded, using the Risk Assessment process.

By using the CALM techniques of physical intervention, Hayfield recognises that such interventions should not involve unreasonable risk.

Service users who have been subject to physical intervention will be given an opportunity to discuss the circumstances with representatives or carers, who will also have access to records of any such incidents.

Hayfield staff who are trained and accredited to use physical intervention will be aware that:-

Physical intervention should be employed using the minimum reasonable force.

Physical intervention should be employed for the minimum duration of time.

Each service user should be individually assessed to identify any physical or emotional reasons why physical interventions might not be sanctioned in their case.

Physical intervention should only be sanctioned for use with any individual service user if this can be seen to be in their best interest and should be regularly reviewed.

Physical interventions should not be used if they cause pain or distress.

Service users who are subject to physical intervention will be assessed for signs of injury or psychological distress.

Organisational Responsibilities.

Hayfield’s Management Team will be responsible for implementing the Policy on Physical Intervention and for ensuring that this Policy is reviewed annually.

Service Managers will ensure that all care staff are aware of and have access to this policy and all associated procedural documents.

Service Managers will be responsible for ensuring that all incidents which involve physical intervention are clearly, comprehensively and promptly recorded.

Hayfield will ensure that service users and their representatives have ready access to the  organisation’s Complaints Procedure.

Management Responsibilities to Staff

Hayfield recognises that managers are responsible for the safety and well-being of staff as well as service users.

Hayfield staff will be encouraged to monitor all incidents of challenging behaviour and physical intervention, even when not directly involved and to report any incidents which give cause for concern.

Hayfield’s Management Team will take account of the impact on resource management with regards to the implementation of the use of physical intervention.  Staff deployment will be organised to ensure that sufficient appropriately trained staff are available to respond to any incidents which may require the use of physical intervention.

Service Managers have a responsibility to ensure that staff who have been involved in an incident, in which they have had to deal with challenging behaviour or had to use physical intervention, are offered opportunities for effective de-briefing.

Managers will have responsibility for monitoring the physical and emotional well-being of staff who have been involved in crisis situations or who have had to use physical intervention and to ensure that they have access to adequate support services, including external counselling.

The Procedure

Hayfield operates a framework of Policies and Procedures covering all aspects of service delivery.  This document should be seen as part of this framework and should be read in association with related documents as identified in the text.

Managers will be responsible for ensuring that all Hayfield care staff are aware of, and acquainted with, these Policies and Procedures.

Managers will ensure that master copies of these documents and the CALM Manual are located in each work location, and that they are accessible to staff.  Any missing documents should be replaced immediately.

This Policy and Procedure document will be reviewed annually, in conjunction with staff re-training / re-accreditation.  It will be the responsibility of the Director to ensure that this review is undertaken.

Information

Hayfield will be responsible for ensuring that the introduction of this Policy on Physical Intervention is relayed to all appropriate individuals and agencies.  This information will explain that staff have been trained in CALM techniques and that they are operating a system of crisis management which focuses on prevention and de-escalation of challenging behaviour, but which may involve the use of physical intervention as a last resort.

Details of this Policy will be available to service users, families, carers and referring authorities and representatives.

All new service users and their representatives will be made aware of this Policy at the time of referral.

Service users who may present challenging behaviour and who may be subject to physical restraint as part of an agreed Care Plan will be informed of this possibility.

Care Planning &  Risk Assessment

All Hayfield service users will have the benefit of initial and on-going assessments of their individual needs and abilities, as outlined in the “Assessment & Care Planning” and “Risk Assessment” policy documents.

Hayfield staff will use the application and initial assessment process to collect information about any history of challenging behaviour or need for physical intervention for each service user.

Staff will use standard Incident Report forms to record all instances of challenging behaviour.  This process will include the identification of the circumstances leading up to the incident, the nature of the incident itself and how the incident was dealt with.

Staff will collate relevant information on each service user to identify any behavioural or environmental ‘triggers’ which may cause or lead to incidence of challenging behaviour.  Any ‘triggers’ thus identified will be recorded in the service user’s Care Plan, which will be reviewed and amended as necessary, on a regular basis.

An individual Risk Assessment form will be completed for each service user, using information obtained from past history, initial application forms and on-going records.

Individual Risk Assessments will be reviewed regularly and amended as necessary.  Risk Assessment forms will be retained along with individual Care Plans.

Managers will be responsible for ensuring that staff are undertaking the requirements to report and record all incidents of challenging behaviour and that information is collated, reviewed and applied as stated above.

Crisis Intervention, Prevention and De-escalation

Hayfield is committed to non-aversive approaches and positive programming to prevent or minimise crisis situations developing.  In order to achieve this, the focus of all Care Plans will be on assisting individual service users to maintain self control.

Staff will aim to be proactive in their planning by using information available through the Care Planning and Risk Assessment process.  This information should help staff to identify ‘triggers’ which may lead to challenging behaviours or crisis situations.

Staff will use the following key elements in such an approach:

• Consistency in the handling of situations.

• Unambiguous planning in Risk Assessment and risk taking

• Knowledge of the individual service user

• Calming techniques identified for that service user.

• Having a practiced scale of interventions and strategies that all staff follow.

• Positive care programmes, clearly understood by service users and staff

Managers will be responsible for providing adequate resources to cope with potential problem situations which have been identified and for supporting staff in the use of proactive approaches to prevention and de-escalation, through regular staff supervision and training.

Safeguarding the Welfare of Service Users

Hayfield recognises that the care and protection of service users is the primary function of the organisation. 

Within the framework of promoting prevention and de-escalation of challenging behaviour, it is essential that Hayfield managers and staff should also be proactive in ensuring the prevention of abuse of service users by staff, other service users or any other individual or agency.  Staff will use the following guidelines as a way of minimising opportunities for abuse and as a way of identifying potential abusive situations.

Staff will plan work so as to reduce to a minimum those situations where it may be possible for service users to be abused.

Wherever necessary, staff will arrange activities, involving a single service user, in such a way that observation can be readily but discreetly maintained. 

In high risk situations staff will minimise the occasions where a single worker is alone in the company of a lone service user.

When necessary, staff will ensure that gender issues are sensitively handled with or by a person of the same sex, wherever possible.

Managers and staff will use the supervision and training processes to maintain awareness of abuse and welfare issues and to keep colleagues aware of these guidelines and promote positive practice.

Wherever possible, staff will try to teach service users the skills required to say “no” and how to report incidents of abuse and to seek help.

Hayfield will encourage service user awareness of an independent person to contact on any matter of concern. 

Managers will be responsible for informing all staff about these guidelines and on how to bring matters of concern to their attention.

Managers will ensure that issues such as service user protection and the creation of positive relationships is a principal feature of the staff supervision process.

Guidelines for the Disclosure of Actual or Suspected Abuse

All staff members who witness or suspect abuse against a service user must report this immediately to a Manager.  Failure to do so may result in disciplinary action.  (In exceptional circumstances, staff may choose to notify the Social Work Department and / or Police).

Staff members who require guidance as to what constitutes abuse should discuss the matter with a senior member of staff or Manager.

Once an allegation of abuse has been made it will be the responsibility of the receiving Manager to record this allegation and to initiate an investigation.

Hayfield management must ensure that all allegations of abuse are taken seriously, that all investigations are recorded and that the member of staff who has made the allegation is kept informed of the process.

With all allegations, Managers should ensure that action is taken to protect the service user from the alleged abuser during any period of investigation.

Similarly, Managers must act to ensure that members of staff who make allegations are protected and supported during the investigation so that there is no suggestion of blame or recrimination.

Guidelines Related to the use of Physical Restraint

The primary objective of all Hayfield staff dealing with challenging behaviour or crisis situations must always be Prevention and De-escalation.  However, Hayfield recognises that in extreme or exceptional circumstances, and solely to prevent or minimise harm to themselves, service users or others, staff may have to intervene physically and use some form of restraint, in the context of fulfilling a duty of care.

Hayfield staff must only use physical restraint techniques in which they have been trained and accredited. 

Hayfield will NOT employ the use of any other methods of restraint (e.g. by use of mechanical restraint, locked doors, medication, etc), unless previously agreed by a multidisciplinary procedure and recorded in service user’s Care Plan.

Coercive methods of restraining a service user, such as psychological pressure or bullying, will be regarded as abuse against that person and must be dealt with accordingly.

Principles Relating to the Use of Physical Restraint

Physical restraint should only be used by staff who have had the appropriate training and accreditation for such activity.

Physical restraint must only be used when a service user is in immediate danger of harming themselves or others or in danger of seriously damaging property.  Staff should have good grounds for believing this, and the service user should be warned, by any means possible, that physical restraint will be used unless they desist.

Only the minimum force necessary to prevent injury or damage should be applied.

Every effort should be made to ensure the presence of other staff before applying restraint.  These staff can act as assistants or witnesses.

As soon as it is safe to do so, restraint should be relaxed to allow the service user to regain self control.

Restraint should be an act of care and control, NEVER a punishment.

Physical restraint should not be used purely to force compliance with staff instructions or when there is no immediate danger to people or property.

The circumstances and justification for physical restraint must be recorded immediately, using the appropriate Incident Report forms.  All staff who took part or who witnessed the incident should complete independent reports.

Following any use of restraint, the staff member’s line manager should take an early opportunity to discuss the incident, or to respond to any request for supportive discussion.  (De-briefing).

The service user should be counselled on why restraint was necessary, and if appropriate, should be examined for any sign of physical injury or emotional stress.

Recording of Incidents

Hayfield recognises that within the communal care setting of this organisation there are likely to be incidents involving unusual or unacceptable behaviour.  These may be regular occurrences or ‘one-off’ incidents, and may vary in severity and length.

For the purposes of this Policy, Incidents which require to be recorded would include any occurrence which involved a service user displaying aggression, loss of self-control or behaviour which required the use of physical intervention.

Hayfield staff will use management direction, backed by training and their experience of individual service users to determine which incidents will be recorded. 

All such incidents involving services users, staff, visitors or others must be recorded using the appropriate documentation.

Staff should be aware that the information obtained form Incident Reports is crucial to the identification of significant “triggers” or risks, and allows for the review of the conditions which may have led to the incident and, in turn, for planning for remedial action to avoid or minimise the chances of similar circumstances arising again.

Specific details of appropriate recording systems to be used by staff should be provided within each location.  The principal documentation will include:

Accident Book: 

To be completed to show all injuries which have occurred and treatment given.

Incident Reports:    

To detail specific incidents that have occurred, including all antecedents, what actually happened and what actions were required and by whom.

Service User Case Files / Care Plan / Risk Assessments: 

To record ongoing strategies and changes to details such as emotional “triggers” or staff response to particular behaviours.

Managers will be responsible for ensuring that records are maintained and updated as required and that Incident Reports are completed following each incident.

De-Briefing

Hayfield recognises that it has a duty of care not only to the service users, but also to all members of staff.  Staff involved in dealing with incidents of challenging behaviour may require particular support.

The aim of de-briefing after an incident will be to offer time and support to the individuals involved. 

Managers will ensure that de-briefing is used as a way of reviewing what had happened and the ways in which it had affected people.  The process can also allow people to express their anxieties and feelings without apportioning blame or criticism.

In practice, Managers will ensure that staff are offered the opportunity for de-briefing as soon after the incident as possible, but will also recognise that staff may wish to take up this opportunity at a later time.

The process of reviewing an incident can allow issues to be discussed openly and can be used to identify what were the potential causes and what actually occurred.  This information can then be used to inform and direct future practice.

De-briefing is NOT a form of counselling and individuals should feel free to participate only as much as they feel able and comfortable to do so.  Some individuals may feel that they are able to handle any stress that arises from an incident without support.

De-briefing is NOT about blame and should not be used as part of a formal investigation.  Some incidents may require investigation but this must be done formally through reports and interviews at a later stage, when staff have the appropriate supports available.

De-briefing can take place as part of a group activity, as long as each individual feels comfortable with this situation.

Hayfield recognises that some staff may feel uncomfortable about discussing the feelings or emotions aroused by their involvement in crisis situations with Managers or colleagues.  Hayfield has therefore contracted an external agency which would be available to offer additional supports to staff  in such a situation.  Contact information is available in each work location.

Similarly, staff involved in dealing with such incidents will be given opportunities to seek formal medical advice or treatment for any physical injury or emotional stress caused by this involvement.

Managers will take responsibility for ensuring that staff involved in such incidents have access to information about sick leave, insurance and compensation, police involvement and the availability of internal and external supports and advice, through the de-briefing and supervision process.

The de-briefing process can also be used as a way of identifying additional staff needs, such as time to restore self confidence, opportunities to work in different locations, or additional training needs.

Appendix

Calm Training

Introduction

In line with ongoing service and staff development processes, Hayfield Support Services have adopted policies and training in the areas of dealing with challenging behaviour and the use of physical intervention.  The aim of this development is to ensure that Hayfield remains at the forefront of the development of specialist services and to ensure that the organisation meets the requirements of the National Care Standards.

Hayfield uses the services of CALM Training Ltd to provide the necessary theoretical and practical training for all care staff and managers.  (CALM is a recognised training agency and is accredited as an appropriate training resource by the British Institute for Learning Disability).

The following section aims to give an outline of CALM principles and techniques and to link these to the attached policy framework for the establishment and development of Challenging Behaviour and Physical Intervention services within Hayfield.

CALM : Crisis and Aggression Limitation Management

CALM is taught as an operational strategy that is to be used within Hayfield’s services specifically to deal with situations where unacceptable behaviour has to be challenged and where physical intervention may have to be used.

Additional information about CALM can be obtained from the CALM Training agency or from the CALM website (www.calmtraining.co.uk)

Staff Training

All care staff and managers working within Hayfield will be trained in the principles and techniques of the CALM approach and all new staff will be offered the same opportunities at an appropriate time.

Care staff and managers will be presented for annual re-training or re-accreditation. 

CALM Training will be carried out by staff who are trained and accredited at Instructor Level and who can show that they have received annual re-accreditation.  Each training course will be externally verified by assessors who are appropriately qualified.

Staff or managers who are not trained or accredited or who do not renew their accreditation on an annual basis shall not attempt to use any techniques for physical intervention.

Quality Assurance

All CALM training is to be delivered in the context of a quality assured system, which is designed to maximise the safety and consistency of the techniques and programmes used.  This will include:-

All techniques are subject to Bio Mechanical evaluation.

Expert scrutiny of the system and training process.

Comprehensive training manuals and support.

Independent external verification of all training courses.

Time-limited certification and programmes for annual re-accreditation.

Internal opportunities to practice techniques learned in training.

Delivery of training within the context of de-escalation of behaviours and the principles highlighted in the attached Policy and Procedure.

Principles of Physical Intervention

Both the CALM programme and the philosophy of Hayfield are based on the principle that physical intervention is only ever used as a last resort.

The CALM techniques are based on a hierarchy of interventions and to the principle that any intervention must be proportional to the presenting behaviour.  Once the situation has been made safe, any restraint applied should be de-escalated in order to allow the service user to gradually regain control.

CALM techniques and their use within Hayfield services must be used in context with other approaches that can be taken in dealing with challenging behaviour.  De-escalation of behaviour is the primary responsibility of all care staff.

Physical intervention must only be considered when it is the safest course of action available.  It is to be used only when the risk has been assessed and all other options have been exhausted.

Understanding of each individual service user and the behaviours which they display is vital to addressing, dealing with and minimising challenging behaviours.  An individual, person-centred care planning process should detail the expectations for any specific interventions with each service user, based on their presentation of known behaviours.  Such plans must be regularly re-evaluated and revised in the light of changing behaviours.

Habitual and/or excessive use of physical intervention is considered as abuse, and will be treated as such.  This view will also apply to lack of proportionality of response.

The aim of introducing and use of CALM within Hayfield is the promotion of safe systems of working for both service users and staff.

Behaviour

The CALM approach highlights the fact that it is the aim and intention of Hayfield that all service users should, wherever possible, be enabled and encouraged to manage and take responsibility for their own behaviours.

All care staff have a crucial role in supporting service users towards this objective and in doing so, they must safeguard and promote the dignity, rights and welfare of all service users at all times.

Positive Interventions

Through the use of the CALM approach, Hayfield is committed to the use of non-aversive approaches and positive interventions to seek to prevent crisis situations from developing.

As such, Hayfield regards as unacceptable any interventions which result in:

Any sign of physical pain experienced by the service user.

Actual or potential side effects, including tissue damage, physical illness or emotional stress.

Dehumanisation of an individual by use of procedures which are normally unacceptable for non-disabled people in any environments.

Ambivalence or disapproval by staff, family or other carers.

The focus of all care programmes must be on assisting the individual service user to maintain self-control.  This is best achieved by being pro-active in care and education planning, so that, wherever possible, “triggers” for crisis situations can be identified and strategies put in place to minimise risk.

The key elements to such planning are:

• Knowledge of the individual.

• Calming techniques identified for that person.

• Consistency in handling situations.

• Relationship building between service user and care staff.

• Positive programmes understood by both service user and care staff.

• Avoidance of ambiguity in risk assessment, risk taking and programme planning.

• Having a practical scale of interventions and strategies which all carers can follow.