Building Better Care: The Journey Towards Least-Restrictive Practices
-Blog Series with our Restrictive Practice Lead, Georgina (George) Rickard-
About Georgina:
Restrictive Practice Lead and Specialist Clinical Practitioner.
Georgina's Expertise:
Managing and reducing high-risk behaviour of concern, working with vulnerable people and their support teams for over 25 years in a wide range of education, community, and in-patient settings using a range of evidence-based positive approaches.
Advocacy:
A published researcher focusing on Practice Leadership and implementing skilled staff support; leader, autism specialist, practice lead and trainer.
The use of restrictive practices in health and social care settings has a long history. In the last few decades following scandals such as the abuse uncovered at Winterbourne View and numerous other settings, there has been a growing recognition of the negative impacts of restrictive practices, both physically and psychologically, on supported people, staff and families.
Many people affected have faced trauma, adverse life experiences, co-occurring conditions and other vulnerabilities such as social isolation known to increase the risk of developing difficult behaviour and associated mental health issues, which without ‘the right support in the right place’ can lead to increased risk, placement breakdown and inpatient admission.
There have been increased efforts to hear and empower people who have experienced practices such as the over-use of restraint or anti-psychotic medication both in institutions and ‘the community’ and to recognise the trauma these practices and environments can cause. Research and services aim to be more inclusive of those with lived experience. This has led to a shift towards reducing the use of restrictive practices through policy changes at a national and local level. Commissioners and families seeking the best services for people facing complex challenges involving behaviour of concern expect to see restriction reduction as a key area of focus for providers. George shares:
‘‘At Catalyst, we work collaboratively to achieve this. Our Therapy Team can assist services seeking to increase the quality of life while managing risks for those vulnerable to restrictive practices, supporting people and their networks to understand restrictions and how they impact people’s rights, well-being and personal development, and together find less restrictive alternatives.
For people at risk, restrictive practices often occur in response to high-risk behaviours of concern. Many of those we support may have a lifelong condition such as learning disability or autism and co-occurring conditions, have experienced trauma, mental health issues or significant life challenges that mean their coping and resilience levels are low, and they are more vulnerable to behaviour that at times can harm themselves or others. The people with the highest risk behaviour can be the most at risk of restrictive practises.’’
What Restrictive Practices Were Used in the Past?
When reflecting on past times and practices, the evolution in health and social care has been significant, as people were moved out from long-stay hospitals, where they experienced institutionalisation, into smaller community group homes, where it was expected that conditions would improve. The aim was to develop person-centred care and move away from medical models of support. While much has improved, Georgina reflects on experiences widely known to have taken place in previous years with one thing in mind- never to happen again.
‘’Many years ago, when I started working with vulnerable individuals facing complex challenges, there were very different approaches to restrictive practices for behaviours of concern. For example, a person who bit others or themselves might have had all their teeth removed to eliminate the risk. Or someone who hit their head with their fist would be made to wear ‘arm splints’ to make this impossible. Such practices, seen as normal 20 or 30 years ago, may seem unimaginable today. There was a lack of understanding of the conditions that can cause and maintain or reduce risk behaviour. However, people facing complex challenges continue to face the prospect of having their rights and freedoms restricted, even when living in their own homes.
Restrictions can cover a wide spectrum of controls over others. At one end, it can be restrictions like saying to the person, for example: ‘Alice, you haven’t eaten your lunch today, you threw your plate. That’s bad. So, you can’t go out on your trip this afternoon.’ While it might seem like the intention is to teach Alice the importance of eating her meals, what’s actually happening is a form of punishment. But there could be some reasons why Alice did not eat her lunch. Perhaps she didn’t feel well or like the food, or something was bothering her. Maybe she was expecting someone else to join her, or the smell of the cooking put her off. Whatever the reason, responding by restricting her ability to go out isn’t the solution. It does not teach Alice anything positive, such as how to get help when she’s feeling confused or can’t communicate. And is more likely actually to increase upset behaviour than reduce it.’’
While this example may appear mild, these controlling approaches can happen frequently.
In addition, many severe restrictions continue to occur, such as locking someone in a room, physically restraining them, or implementing court-ordered restrictions that severely limit their autonomy. While attempting to reduce risk, these significant restrictions often come with risks of their own.
A Change Must Be Made: Advocating for Human Rights
To move forward, we must adopt a human rights approach, focusing on respect and amplifying the voices of those we support. Georgina has supported individuals who have shared about the traumatic physical interventions some of them have faced in the past and how disturbing the restraints can be. Many have spent years after leaving institutions needing support to cope with the ongoing stress and trauma of these experiences and conditions such as PTSD.
‘In the past, physical interventions and restraints were often used with the belief among professionals that these actions were justified, thinking: ‘We didn’t mean to hurt the person. We’re holding them for their own safety and in their best interests. It’s OK. It’s just for a short time.’ With time, it came to understanding the considerable risks and negative impacts these approaches can have. For many, they leave lasting trauma, shaping their lives in profoundly challenging ways.
This issue holds great significance for us at Catalyst, as many of those we support have had similar experiences. Listening to their experiences and promoting person-centred, proactive support is key to reducing restrictions. My role at Catalyst Care Group is to ensure we have the culture and tools to empower care teams to showcase their heartfelt work in reducing these practices while increasing people’s quality of life.
When people begin receiving support from us, we use restrictive practice audits to learn more about any limitations to a person’s everyday freedoms and choices. These audits thoroughly assess every restriction in place, its necessity, and whether it adheres to legal and ethical standards.”
- You can now download the short guides of the Human Rights Act and the Mental Health Act 1983, which together provide a comprehensive framework for addressing the use of restrictive practices in UK healthcare settings, particularly in mental health care.
The Audit Process: Using Least-Restrictive Practices
Reducing restrictive practices in social care and healthcare settings has been a growing focus in the UK, strongly emphasising creating environments prioritising safety, dignity, and positive outcomes for people receiving care. This movement is rooted in national frameworks such as the Positive and Proactive Care Guidelines and the Mental Health Act 1983 Code of Practice, which advocate for minimising interventions like physical restraint and seclusion.
Care teams must adhere to ethical care standards, focusing on building trust and therapeutic relationships. This approach ensures that people feel valued, respected, and supported throughout their care journey. Georgina reflects:
“We use the audit to review all aspects of a person’s care. For example, a person might only be able to visit the supermarket during quieter periods, which could be considered a restriction. They may be unable to see a family member for specific reasons or require a vehicle with a screen rather than a standard one. There may even be times when the person is held using a physical intervention to reduce the risk of significant harm to themselves or others. To address these needs, we collaborate with the RM and support workers, asking detailed questions about how they support the person and identifying any risks involved. Together, we aim to implement the least restrictive measures to manage those risks effectively.’’
There are occasions where the people the therapy team supports, these could be young people or adults with limited life experience, may lack awareness of certain risks or the ability to manage them without support and guidance. Georgina shares an example of adapting practices that might involve kitchen safety:
‘’Many people we support might not fully understand the dangers in a kitchen, such as handling sharp knives or using a hot oven, or they may feel overwhelmed and stressed, leading to behaviour which could potentially cause harm.
In such situations, we ask ourselves: How can we minimise the risks involved when this person wants to cook in the kitchen? One approach often used in the past might be to simply lock the kitchen and restrict their access entirely, ensuring ‘safety’. However, we recognise that such a solution comes with significant drawbacks, including not allowing the person the opportunity to learn new skills and coping strategies. Instead, we aim to focus on finding less restrictive ways to maintain their safety while cooking while ensuring they have access to their own kitchen.
For example, we could prepare the kitchen in advance by securely storing any dangerous items. If they’ve just made a cup of hot tea, we might pour away all the boiling water and put the kettle away after before starting the next activity. We might lock away individual sharp knives or risk objects rather than lock a whole drawer or cupboard. Taking such measures creates a safer environment without having to restrict access to the kitchen entirely. This approach balances safety with the person’s opportunity to participate and learn, fostering independence and choice in a supportive way.’’
Services across Catalyst are committed to reducing restrictive practices. One way services do this is by conducting audits to review and identify ways to minimise restrictions while safeguarding people and their clinician teams. Therapies Team PBS leads and practitioners, as well as the RP lead, can assist services to do this on request. Audits and plans can also be done sensitively and supportively with the individual involved.
‘’We’ll do the audit with the person– to identify if there are any restrictions.
So it’s very important to review them regularly and say as a team: How can we have a new look at this risk? Is there a better way to reduce the risk? We prioritise addressing the most significant restrictions affecting the person and work closely with clinicians, the registered manager, care coordinators, and the wider support team to explore gradual ways to ease them. Even small, gradual changes can make a difference. Over time, we reflect on the progress made, no matter how slow it may seem. For instance, there’s a current case we’re working on that illustrates this approach.’’
Positive Relationships with Well-Trained Care Teams
‘’It is often that we support people who have experienced many months and years of placement breakdown, often in restrictive environments such as hospital or secure settings. And they often have large numbers of staff and staff turnover, affecting their ability to develop trusting relationships. One individual recently had eight staff members supervising them 24 hours a day! This level of supervision can feel incredibly restricting and frightening, and having someone following you around all day, all night is very, very stressful.’’
By focusing on staff training and confidence-building, we can gradually reduce the number of staff involved, fostering a better quality of life.
‘’So one thing that Catalyst is brilliant at is getting really well-trained, confident staff. They don’t need five staff to support this person, and they can reduce the number of people supporting to a more reasonable level. That allows us to build positive relationships with the person. Also, we are really good at looking at that restriction and ensuring they have trained clinicians who can provide enough support but with fewer people. So that is one way. For example, during last week’s continuous improvement meeting, the services showcased examples of the remarkable progress they had achieved with the people we support.’’
Reducing Restrictive Practices Through Collaborative Care
Recent NHS data highlights progress, showing efforts to reduce restrictive interventions, though challenges remain. For instance, a 6.2% increase in seclusion in some mental health services demonstrates the ongoing need for strategies like staff training, audits, and awareness campaigns to promote least-restrictive alternatives.
‘‘We’ve had a young man whom we supported and who initially was said to require the constant support of four male staff members throughout his time with us. This was partly because he was living in an unsuitable environment that did not meet his needs. Since moving into his new home, the level of support has gradually been reduced to three staff, with plans to reduce this further to just two. That’s an amazing change for him in his life. Supporting teams to achieve such outcomes is at the heart of our approach.’’
One key activity that helps services achieve this is the Risk Panel. Services can refer cases to the panel or be invited when there’s been an escalation in risk, concerns about restrictions, or challenging incidents with the people they support.
‘’There is a group of us making up the panel who have different expertise and experience with high-risk behaviour, who can offer solution-focused advice and support for services. In one case, for example, the supporting staff brought forward concerns about a young woman who had recently experienced multiple distressing incidents while travelling in a vehicle. On one particularly alarming occasion, there were injuries to staff and serious concerns about the person’s safety on a busy road, leaving the team determined to ensure such incidents would not recur.’’
The team, despite these challenges, did an amazing job. The team shared that, despite facing significant challenges they would be willing to persevere with supporting the person to continue using the vehicle. They felt that stopping this would have a huge negative impact on her, as she loved to go out and would likely increase behaviour of concern. Some members had proposed using a harness seat belt for the young woman—a five-point harness designed to prevent the person from unbuckling their seatbelt, but they were willing to give things a different go.
‘’Unlike a standard seat belt that most of us can unbuckle and adjust independently, this harness would completely restrict her movement. Given the difficulties the team had already experienced, there was hesitation to take her out without this harness. Having worked with people in similar circumstances for many years, I fully understand how stressful it can be to manage such situations in the confined space of a moving vehicle. You can’t always simply pull over on a busy road or motorway, which adds to the pressure.
But the team took a step back and considered alternatives with the risk panel. They recognised that this young woman, now 25 years old, had never used a harness before. Introducing such a restrictive measure would, therefore, be a major change in her life. Importantly, it would not meet the underlying need that led to the behaviour of concern or help her communicate when she needs help. Instead of rushing into this option as a solution, the team explored other options suggested by the panel, offering support to boost the team’s confidence and help them address the underlying issues.’’
Commitment to a Least Restrictive Approach
The team chose empathy, courage, and persistence. They’ve shown how to work in the least restrictive way possible, ensuring the young woman hasn’t been subjected to restraint, aversive experiences or undue control. By focusing on how to improve the experience and meet the needs of the young person, they’ve supported her autonomy and well-being.
’We organised more trips, gathered information about what was causing the difficulties, and sought input from the therapy team. The Positive Behaviour Support (PBS) team analysed her behaviours and reviewed records over several months to identify possible reasons for her distress during vehicle rides. This process took months of consistent effort and collaboration among the PBS practitioners, occupational therapists, speech and language therapists, and the service team.
A PBS practitioner has been visiting with the team regularly, accompanying the clinicians and the young woman on outings. By modelling supportive strategies and building the team’s confidence, they’ve helped create a safer and more empowering experience for everyone involved.
I am incredibly proud of what they’ve achieved. The young woman has been able to enjoy successful trips without the high levels of behaviour of concern seen before, something that felt impossible just a few months ago. Had she been with a different service provider, they might have opted for the easiest solution—keeping her home or enforcing a restrictive travel setup. It’s still early days, but the progress has been really positive. I couldn’t be prouder of their commitment to giving her the opportunity to continue living her life to the fullest without unnecessary limitations.’’
Reducing restrictive practices is a continuous journey. It comes not through ‘managing behaviour of concern’ but by focusing on increasing wellbeing and quality of life. We learn more every time we see things from the individual’s perspective. By fostering well-being, respecting human rights, and promoting less restrictive alternatives, we enable people to lead fuller, freer lives.
Practice Leadership and Its Role in Delivering High Quality and Skilled Support
‘’Since my early days as a support worker and practitioner working with people whose behaviour can be challenging, I have had a longstanding interest in how skilled approaches, statutory guidance, and complicated support plans are actually delivered in practice. For example, ‘How do we get a consistency of approach? How do we apply evidence-based theory in practice?’, particularly when different teams may have very different opinions and experiences about the best approach to respond to behaviour of concern.
Scandals like Winterbourne View and numerous similar examples have repeatedly shown that training and paperwork alone are not enough to ensure high standards of care. And that service culture and leadership ‘on the ground’ are typically the key drivers to how well staff deliver and implement support plans. Effectively leading and developing teams that support vulnerable people in challenging situations is key to achieving a truly trauma-informed, least restrictive approach, and Practice Leadership has been shown to improve outcomes for both staff and individuals. I have found that when everyone is ‘in charge’, it usually means no one is! Or the person with the loudest voice and confidence gets listened to instead of the person with the most relevant knowledge. In my next instalment, I will share more about Practice Leadership, what it is and the benefits it brings, and how we can use the approach to assist in our work, reducing restrictive practices and improving quality of life.’’
Georgina’s Publications:
- Contextual and individual barriers to providing practice leadership by frontline managers in community services for adults with intellectual disabilities: A qualitative study.
- Frontline managers’ experiences of practice leadership for when supporting autistic adults with complex support needs residing in community housing.
To get the full copy of both publications, send a direct email to Georgina at georgina@catalystgrp.co.uk
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