Restraint Reduction and Positive Behaviour Support Audit - Care Homes

Evidence to check

• • Current restraint reduction and restrictive practice policy.
• • Policy covers physical restraint, environmental restrictions, observation, sensor use, medication-related restraint and covert restrictions.
• • Staff can explain the least-restrictive principle in practical care home situations.
• • Observed practice and care plans show restrictions are not used for staff convenience or routine control.

Evidence to check

• • PBS, de-escalation and restraint reduction training records.
• • Staff can describe proactive strategies for residents they support.
• • Training includes dementia, delirium, pain, trauma, communication and unmet need.
• • Competency is checked through supervision, observation or post-incident review.

Evidence to check

• • Behaviour support plans are available for residents who need them.
• • Plans identify triggers, early warning signs, communication needs and calming strategies.
• • Plans include prevention, early intervention, crisis response and recovery.
• • Staff can explain the plan and use it consistently.

Evidence to check

• • Resident views, wishes and preferences are recorded where possible.
• • Family, advocate or representative input is included where appropriate.
• • Professional input from mental health, GP, psychology, SALT, dementia specialist or behaviour specialist is recorded where needed.
• • Plans are reviewed when professional advice changes.

Evidence to check

• • Incident records describe what happened before, during and after the event.
• • Records include staff response, resident impact, duration and outcome.
• • Use of restriction or restraint is clearly identified.
• • Incidents are reviewed by senior staff and learning is documented.

Evidence to check

• • Physical intervention records show immediate risk of harm and rationale for intervention.
• • Staff involved have appropriate training and competency where required.
• • Intervention was proportionate, time-limited and stopped as soon as safe.
• • Resident injury, distress and dignity were reviewed afterwards.

Evidence to check

• • Care plans show decision-making support and communication needs.
• • Mental capacity assessments are decision-specific and not global.
• • Unwise decisions are not automatically treated as lack of capacity.
• • Best-interest decisions are recorded where the resident lacks capacity.

Evidence to check

• • Each restriction is clearly identified in the care plan and risk assessment.
• • Consent, capacity or best-interest decision is recorded where relevant.
• • Least-restrictive alternatives have been considered.
• • Restrictions are reviewed for ongoing need, impact and proportionality.

Evidence to check

• • Post-incident debrief records for staff.
• • Supervision discusses staff response, emotional impact and learning.
• • Debriefs identify what could prevent recurrence.
• • Learning is shared without blame while maintaining accountability.

Evidence to check

• • Incident analysis by time, location, activity, staff, trigger and resident need.
• • Environmental factors such as noise, lighting, crowding, pain, hunger or fatigue are considered.
• • Patterns lead to changes in care plans or environment.
• • Low-level distress and near misses are reviewed, not only serious incidents.

Evidence to check

• • PRN protocols include clear indications, dose, maximum frequency and review arrangements.
• • Records show reason for administration and outcome or effectiveness.
• • GP, pharmacist, mental health or prescriber reviews are completed where needed.
• • Non-medication strategies are tried and recorded where appropriate.

Evidence to check

• • Consent records for restrictions where the resident has capacity.
• • Decision-specific capacity assessments where capacity is in doubt.
• • Best-interest records include resident wishes, family or advocate input and least-restrictive options.
• • Emergency restrictions are reviewed afterwards and not allowed to become routine without proper authorisation.

Evidence to check

• • Care plans identify communication needs, pain signs, triggers and comfort strategies.
• • Behaviour changes lead to health checks or professional escalation where appropriate.
• • Staff avoid blaming or labelling language.
• • Records show consideration of physical, emotional, sensory and environmental causes.

Evidence to check

• • Restriction reduction plan or review record.
• • Restrictions have review dates and clear criteria for reduction or removal.
• • Staff trial less restrictive alternatives where safe.
• • Governance monitors whether restrictions are reducing over time.

Evidence to check

• • Care plans include environmental strategies such as noise reduction, lighting changes, meaningful activity or quieter spaces.
• • Staff adapt routines, activities or surroundings before distress escalates.
• • Environmental triggers are reviewed after incidents.
• • Changes are evaluated for impact on resident wellbeing.

Evidence to check

• • Resident views are sought after incidents in a sensitive way.
• • Accessible communication methods are used where needed.
• • Non-verbal signs of distress, comfort or refusal are considered.
• • Feedback leads to changes in behaviour support plans or staff approach.

Evidence to check

• • Records of communication with families, advocates or representatives.
• • Consent and confidentiality are considered.
• • Legal authority such as LPA or deputyship is verified where relevant.
• • Resident's own wishes remain central where possible.

Evidence to check

• • Team meeting and supervision records include PBS or restriction themes.
• • Staff share what works well for individual residents.
• • Learning from incidents is discussed across shifts.
• • Managers challenge inconsistent or restrictive practice.

Evidence to check

• • Restrictive practice or PBS audit records.
• • Governance reports include incidents, restrictions, PRN use, restraint and trends.
• • Actions have owners and timescales.
• • Senior leaders review whether restrictions are lawful, proportionate and reducing.

Evidence to check

• • Evidence of learning from local authority, NHS, CQC, professional networks or sector guidance.
• • Staff briefings or training reflect updated learning.
• • External advice is sought for complex or persistent restrictive practice.
• • Learning is adapted to the home's residents and setting.

Evidence to check

• • Reviews include incident frequency, severity, triggers and resident wellbeing.
• • Quality of life outcomes such as sleep, mood, relationships, activity and choice are considered.
• • Plans are changed where outcomes are not improving.
• • Success is measured by resident wellbeing, not only fewer incidents.

Evidence to check

• • Records avoid terms such as manipulative, aggressive or attention-seeking without context.
• • Language describes behaviour factually and considers unmet need.
• • Staff are corrected and supported where language is disrespectful.
• • Care plans focus on support needs, triggers and reassurance strategies.

Evidence to check

• • Staff can explain how to raise concerns about restrictive practice.
• • Whistleblowing and safeguarding routes are accessible.
• • Records show concerns about restrictions are reviewed.
• • Managers respond openly and take action where practice is too restrictive.

Evidence to check

• • Examples show restrictions reduced or removed safely.
• • Resident wellbeing, activity, relationships or independence improved.
• • Resident, family or advocate feedback is included where possible.
• • Improvement is sustained and reviewed over time.

Evidence to check

• • Restriction log includes planned and low-level restrictions.
• • Environmental and technological restrictions are reviewed, not ignored.
• • Consent, capacity and best-interest records are in place where relevant.
• • Analysis includes cumulative impact on residents' freedom and dignity.

Evidence to check

• • DoLS status is recorded for residents subject to continuous supervision and control and not free to leave.
• • DoLS applications, authorisations, conditions and expiry dates are monitored.
• • Restrictions are reviewed when DoLS conditions change or expire.
• • Legal advice or local authority guidance is sought for complex cases.

Evidence to check

• • Audit includes observations, staff questioning and review of resident outcomes.
• • Audit checks whether restrictions are actually used as documented.
• • Resident, family or advocate feedback is included where possible.
• • Actions from audits lead to measurable reduction in restrictive practice and improved quality of life.