Out of Sight: Who Cares?
The Care Quality Commission (CQC) has published an excellent and much needed review of restrictions and restraint in services for people with learning disabilities or autism with recommendations for ways to improve practice. Everyone working in this field must read it, and surely will. But I am struck by how relevant this work is to all adult social care, and indeed to providers of health services too.
Learn from Good Practice
Rightly, the report noted excellent practice when the reviewers found it, and the principles underpinning these examples can be applied to services caring for older people, or for those living with acquired brain injury.
Better care comes with staff training combined with active learning, both about relevant practice issues but also about the individuals who are cared for. ‘There was a positive culture of “no force first” and of active learning about the young people and about how to minimise the need to use restraint’… Jennifer had choice and control about who she has in her living space, if she does not want a member of staff with her, she tells them, if she wants them to come back later or for another member of staff to support her, she has control over these decisions.”
What are the wider messages here? Firstly, any sort of restraint or restriction must be the last resort, not the first. Choice and control are essentials for anyone to feel happy and preserve their dignity. So, learn as much as you can about what this person feels and wants. Approach personal care tactfully, with calm helpfulness, and allow the time to enable the person to exercise some ‘choice and control’. Fran loves having her hands gently cleaned and cosseted with her hand cream, and her hair brushed; if staff do this first, then Fran accepts the intimate personal care she needs without staff having to restrain her. Not only is this actually quicker and less demanding of staff time than restraint, it results in a happy, confident resident who co-operates with staff because she trusts carers not to frighten her, but to enable her to retain her dignity and personality.
Excellent training is available on dementia and neurological conditions, to demystify them and encourage staff to see the person rather than the symptoms of the illness: the challenge is to embed the human rights-based principles of the training into practice. There is no place for ‘blanket restrictions’ which assume that everyone is the same: in all services, staff should be supported to find less restrictive ways to meet the care needs of each individual. People’s relatives are gold mines of information about how to care tactfully and with shared humour; share individualised tips in supervision and team meetings to enable staff to see people as individuals, and find ways to preserve their precious dignity.
Teach Staff Communication Skills
Secondly, training must translate the human rights principles of good care into practical learning. The CQC found that when staff were not trained in common ways to communicate with people with learning disabilities, such as Makaton or Picture Exchange Communication System (PECS), service users easily became frustrated and angry at their needs and wants not being satisfied. Far too easily the problem was seen as being their personality rather than in this lack of staff training, and they were then labelled ‘challenging’ and restrained.
Services providing care to other groups of adults, for example older people, don’t always ensure that staff understand how to communicate, for example, with people who use sign language, or those whose eyesight or hearing has worsened with age.
As the CQC review discovered, ‘When people’s communication needs were met, we found that they were less distressed, and it could result in fewer incidents and restraints. This highlights the important role of communication in good quality care.’
Promote and Protect Good Physical Health
The review praised ‘…people receiving good physical health care within the settings, where staff were aware of any medical conditions and continuously monitored people for any changes. This was particularly important for those who had communication needs and may have struggled to communicate when they were in pain or needed help. We also found examples of comprehensive health action plans and where people were receiving regular check-ups. Good physical health care plans incorporated information from associated care plans, hospital passports and existing risk assessments.
The importance of oral health is far better recognised than it has been, but still is too often overlooked. When someone also has communication difficulties, good individual physical health plans are essential to avoid stereotyping someone in pain as just being difficult.
Ways to Reduce Restraint
The CQC found that restraint is used less in adult social care than in hospital settings; but where an individual is restrained, this seems to become the norm, with one person restrained 100 times in a month. Seclusion is often used but not recognised, which means the breaches of this person’s human rights are also not recognised so there is no request for a deprivation of liberty safeguards (DoLS) authorisation. Jim moved to a care home after the death of his wife. Forgetting she was dead, he would look for her persistently, so staff shut him in his room apart from mealtimes. He told a visitor: ‘I must be very bad to be in this prison.’
This reminds us how easy it is to stereotype someone as ‘challenging’, and how, when we do this, it is then far too easy for staff to go straight to restraining that individual – ‘she needs to be held down for intimate personal care’ or ‘just shut him in his room, he’ll calm down in a bit’ – without considering alternatives, or trying to find a person-centred way to minimise someone’s anxiety or enable them to accept care without fear. This is why we always say, consider restraint in all supervisions, and whenever a care plan is being reviewed – do not accept that it is inevitable, look for ways to reduce and, wherever possible, eliminate its use.
