Restrictive Practices Policy and Process

About this policy

HomeMade is dedicated to achieving restraint-free environments for our customers through actively seeking effective alternative approaches to reach desired customer safety outcomes. We achieve this by identifying restraint use where it exists in home care settings and partnering with customers and their representatives to avoid commencing or cease using restraint practices where possible. If no other less restrictive option is available, we would seek to minimise restraint use while adhering to evidence-based processes for consent, oversight, review and documentation. This policy outlines our commitment to promoting individual autonomy, dignity, and safety while avoiding, removing, or minimising the use of restraint in home care settings. This policy applies to all staff and contractors involved in the delivery of care and support to HomeMade customers.

Key Definitions

Restraint: A restrictive practice is any practice or intervention that has the effect of restricting the rights or freedom of movement of an aged care customer. Under the legislation (Aged Care Act 1997 and the Quality of Care Principles 2014), there are five types of restrictive practices:

Chemical restraint: Chemical restraint is a practice or intervention that is, or that involves, the use of medication or a chemical substance for the primary purpose of influencing a customer’s behaviour, but does not include the use of medication prescribed for:

• The treatment of, or to enable treatment of, the customer for a diagnosed mental disorder, a physical illness or a physical condition; or
• End of life care for the customer.

An example of chemical restraint would be administration of a medication to a customer, which has been prescribed for the purpose of reducing physically aggressive behaviour.

Environmental restraint: Environmental restraint is a practice or intervention that restricts, or that involves restricting, a customer’s free access to all parts of the customer’s environment, including items and activities, for the primary purpose of influencing the customer’s behaviour.

Examples of environmental restraint are restricting a customer’s access to an outside space, removing or restricting access to an activity, or limiting or removing access to a wanted or needed item, such as a walking frame, by putting it out of reach.

Mechanical restraint: Mechanical restraint is a practice or intervention that is, or that involves, the use of a device to prevent, restrict or subdue a customer’s movement for the primary purpose of influencing the customer’s behaviour. It does not include the use of a device for therapeutic or non behavioural purposes in relation to the customer. Examples of mechanical restraint include use of a lap belt or princess chair, bed rails, or use of clothing which limits movement and is unable to be removed by the customer.

Devices used for therapeutic purposes or non-behavioural purposes are not considered to be mechanical restraints, such as use of a wheelchair for someone who needs mobility support. However, if the service provider leaves a person in the wheelchair and applies the brakes so they remain in one position and they are unable to move themselves, this is mechanical restraint.

Devices in place for safety purposes or to prevent harm, even if consented to by the customer, are considered to be a mechanical restraint if not used for therapeutic or non-behavioural purposes.

Physical restraint: Physical restraint is a practice or intervention that is or involves the use of physical force to prevent, restrict or subdue movement of a customer’s body, or part of a customer’s body, for the primary purpose of influencing the customer’s behaviour.

This does not include the use of a hands on technique in a reflexive way to guide or redirect the customer away from potential harm or injury if it is consistent with what could reasonably be considered the exercise of care towards the customer.

Examples of physical restraint are physically holding a customer in a specific position to force personal care issues such as showering to be attended to or for administration of medication, pinning a customer down, or physically moving a customer to stop them moving into a specified area where they may wish to go. Assisting a customer with activities of daily living where this has been requested and the customer is unable to assist themselves, guiding them away from danger or catching a customer if they are about to fall are not considered physical restraint.

Seclusion: Seclusion is a practice or intervention that is, or that involves, the solitary confinement of a customer in a room or a physical space at any hour of the day or night for the primary purpose of influencing the customer’s behaviour where voluntary exit is prevented or not facilitated or it is implied that voluntary exit is not permitted.

Examples of seclusion are placing a customer alone in a space or room from which they cannot exit, including in a space by themselves where their access to communication devices or mobility aids is limited, or imposing a ‘time out’.

A customer who decides to close and lock a door behind them, such as in their own room or bathroom is not considered seclusion, as they are able to enter and leave the area of their own free will. Where customers are required to isolate for the purpose of complying with state and territory public health directives, this is not considered to be seclusion, as the primary purpose of such an action is not to influence the customer’s behaviour but to comply with the health order.

Key Principles

Individual Autonomy: HomeMade upholds the principle of individual autonomy, respecting each customer’s right to make decisions about their care and daily life.

Dignity: We prioritise the preservation of customer dignity, ensuring that care is provided in a manner that respects their rights and preferences.

Safety: Safety is paramount. Measures are taken to ensure the safety of customers, representatives, contractors, and staff when challenging behaviours pose a risk.

Restraint-Free Care: HomeMade emphasises the provision of restraint-free care whenever possible, with the understanding that restraint should only be considered as a last resort.

Decision Making

HomeMade recognises the importance of having a clear decision-making process in place to address challenging behaviours in the home setting. We provide the following guidance to follow when identifying the potential use of a restrictive practice in a home care setting:

• Ensure immediate safety for all concerned.
• Identify possible causes for any behaviour that may have been causing concern, and provide approaches to deliver safe, restraint-free care.
• Review the support plan and assess whether the concerns related to the restrain have been identified and whether alternate solutions could be offered.
• Communicate clearly and transparently with the customer and their representative about the concerns and seek to resolve those concerns and ensure restraint-free care is in place as soon as possible.
• Communicate with HomeMade team members including Onboarding Partners, Support Partners, Clinical Nurses, Team Leaders, representatives, and contractors to consider options that will support the customer and their representative to cease restraint use and continue to achieve safety and independence goals.

Interim Arrangements for Consent to Restrictive Practices

The Quality of Care Principles 2014 include a hierarchy of who can consent to the use of a restrictive practice when the care recipient cannot consent themselves or there is no explicit legal avenue under relevant state or territory laws to appoint a Restrictive Practices Substitute Decision-Maker (RPSDM). The hierarchy consists of:

1. Restrictive Practices Nominee: An individual or a group of individuals nominated by the care recipient who can give informed consent if the care recipient lacks capacity and has agreed in writing.
2. Partner: The partner of the care recipient, who has a close continuing relationship with the care recipient, has agreed in writing to act as the RPSDM, and has capacity to give consent.
3. Relative or Friend Who Was the Carer: A person who was the carer on an unpaid basis immediately before the care recipient entered care, has a personal interest in the welfare of the care recipient, has a close continuing relationship with the care recipient, has agreed in writing to act as the RPSDM, and has capacity to give consent.
4. Relative or Friend Who Was Not the Carer: A person who has a personal interest in the welfare of the care recipient, has a close continuing relationship with the care recipient, has agreed in writing to act as the RPSDM, and has capacity to give consent.
5. Medical Treatment Authority: An individual or body appointed in writing under the law of the state or territory where the care recipient receives aged care and can give informed consent for medical treatment if the care recipient lacks capacity.

Roles and responsibilities

• Customers: Customers have the right to actively participate in decisions about their care, express their preferences, and provide informed consent.
• Restrictive Practices Substitute Decision-Maker (RPSDM): Representatives and substitute decision makers provide valuable insights and support in decision-making processes regarding restrictive practices. Their input is essential in understanding the customer’s needs and preferences.
• Contracted Service Providers: Contracted service providers are responsible for immediate safety measures, thorough assessments, and the provision of restraint-free care. They should document actions taken and communicate effectively with Onboarding Partners, Support Partners, customers, and substitute decision makers.
• Onboarding Partners: Onboarding Partners conduct the initial assessment and are responsible for identifying any restrictive practices in use and responding as per this policy.
• Support Partners: Support Partners play a pivotal role in assessing and documenting behaviours, reviewing support plans, and facilitating communication among all parties involved including following HomeMade processes for clinical review, clinical escalation and high-risk customer escalation where indicated.
• Clinical Nurses: Clinical Nurses act to provide clinical advice and recommendations on ensuring that appropriate assessments and referrals are arranged and advice is given to safely cease restraint use, where it has been identified.
• Leadership team:
  • Maintain a database of care strategies including resources to act as prompts when developing support plans.
  • Promote open disclosure and consultation with customers, HomeMade staff, Service Providers and customer representatives
  • Provide mandatory education to HomeMade staff on identifying triggers for challenging behaviours, restraint-free options and the specific requirements that must be met in the rare cases where all other options have been exhausted and a restraint practice has been approved for use in a customer’s home.
• General Manager/Approved Provider Delegate/ Board: Hold relevant team members accountable to develop and maintain policies and practices that reflect both legislative and regulatory requirements. Review and approve those policies. 

All staff are required to carry out their duties in accordance with their job descriptions, with the knowledge and skills attained as part of their profession or any qualifications, and in accordance with any applicable codes of conduct, practice or standards expected by HomeMade. Staff are expected to adhere to the Code of Conduct for Aged Care, engage with customers appropriately and respectfully, and to maintain professional boundaries.

Staff who are subject to professional standards (e.g. medical, nursing, and allied health professionals), will have a higher threshold of professional training and qualifications, knowledge and skills, and scope of practice, and hence a higher threshold of conduct expected.

Restrictive Practices Process

This process outlines the requirements and procedures for the use of restrictive practices in home care. Restrictive practices must only be used as a last resort to prevent harm to the customer or others, and strict compliance with legislative and quality standards is essential.

1. Assessment and Documentation

Restrictive practices should only be considered after a thorough assessment, and these assessments must be documented.

An approved health practitioner with day-to-day knowledge of the customer must assess the customer as posing a risk of harm to themselves or others.

In the case of chemical restraint, assessments must be conducted by a medical practitioner or nurse practitioner who subsequently prescribes the medication.

Assessments should include the customer’s behaviours relevant to the need for the restrictive practice, the reasons it is necessary, and information informing the practitioner’s decision.

Best practice alternative behaviour support strategies must be used and documented before considering restrictive practices.

2. Emergency Use of Restrictive Practices

Emergency situations are unanticipated or unforeseen serious or dangerous situations that require immediate action.

HomeMade actively engages in customer’s day-to-day care and support needs, which includes behaviour support planning, to reduce the incidence of emergencies.

Situations requiring restrictive practices in emergencies should be rare.

Some requirements, such as consent, are exempt during emergencies to protect customers or others from immediate harm.

An emergency is considered to have ended when there is no immediate risk of harm or injury.

In case of using a restrictive practice in an emergency, the contracted Service Provider must inform the restrictive practices substitute decision-maker as soon as possible and document specific details.

3. Use of Restrictive Practices

Restrictive practices should only be used in proportion to the risk of harm, in the least restrictive form, and for the shortest period possible.

The need for, use of, and effectiveness of restrictive practices must be continually monitored, reviewed, and documented.

Consideration of individually appropriate alternative strategies should be ongoing, and restrictive practices should be reduced or stopped when possible.

In the case of chemical restraint, contracted health professionals are encouraged to provide information about the effects and use of the chemical restraint to the prescribing practitioner.

4. Informed Consent and Documentation

Informed consent for the use of a restrictive practice must be obtained from the customer or their restrictive practice substitute decision-maker.

Consent must comply with state and territory requirements and be properly recorded. Detailed documentation must include:

• The customer’s relevant behaviours.
• Alternatives considered or used.
• Reasons for the necessity of the restrictive practice.
• Care related to the customer’s behaviour.
• Notification to the restrictive practices substitute decision-maker.
• All assessments, information, and decisions relevant to the use of the restrictive practice. 

Any additional advice or support sought.

5. Post-Emergency Procedures

Once the emergency is over, Contracted Service Providers must revert to HomeMade’s usual policies and process regarding the use of any restrictive practice for the customer.

Contracted Service providers must ensure that the least restrictive form of a restrictive practice is applied and that it is for the shortest period possible.

Continuous monitoring and assessment for alternative strategies should persist even after an emergency situation.

Restrictive Practices and The Aged Care Quality Standards

Legislative / Compliance obligations

HomeMade complies with all relevant legislation, regulatory requirements, professional standards, and guidelines. Consent for restraint should be obtained from parties with the legal capacity to provide it. In cases where ongoing restraint use is contemplated, consultation with the applicable Guardianship Board or its equivalent may be necessary. Legal advice is sought when any doubts arise regarding the use of restraint.

Conclusion

HomeMade’s Restraint-Free Environment Policy emphasises our commitment to providing aged care services that prioritise individual rights, dignity, and safety. We are dedicated to upholding a restraint-free approach while recognising the importance of informed decision-making, thorough assessments, and continuous monitoring to ensure the well-being of our customers and compliance with legislative requirements.

Evidence Base

Aged Care Quality and Safety Commission (2019) Aged Care Quality Standards and Guidance Material

Aged Care Quality and Safety Commission (2019) Charter of Aged Care Rights (under User Rights Principles 2019)

Aged Care Quality and Safety Commission (2019) Glossary of Terms

Aged Care Quality and Safety Commission (2023) Restrictive practices provider resources

Aged Care Quality and Safety Commission (2021) Overview of restrictive practices

Australian Government, Department of Health and Ageing (2012) DECISION-MAKING TOOL: Supporting a Restraint Free Environment in Community aged care

The Aged Care Act (1997) and the Quality of Care Principles (2014)

Associated Documents

• Clinical Governance Framework
• Deteriorating Customer Policy & Process
• Infection Control Policy & Procedure
• Medication Support Policy
• Incident Management Policy & Process
• High Impact High Prevalence Policy & Process
• Examples of Clinical Risk
• Clinical Controls & Resources
• Principles of a Good Clinical Review
• SOP clinical Referrals
• SOP Dignity of Risk in Home Care
• Validated Assessments for Care Planning and Management
  

Version date September 2023