Managing Escalation Without Restrictive Practice in Dementia Services
Escalation in dementia care is one of the moments where restrictive practice risk increases most sharply. When distress, falls risk or refusal of care rises, poorly supported staff may feel pressure to “do something now”. Providers that manage escalation safely build clear safeguards into dementia transitions and escalation, aligned to defensible dementia service models that prioritise rights, consent and proportionality.
The goal is not to avoid action, but to ensure action remains lawful, ethical and effective.
Why escalation increases restrictive practice risk
Restrictive practice often emerges from uncertainty rather than intent. Common escalation pressures include:
- Fear of immediate harm.
- Lack of clear alternatives.
- Inconsistent staff skill or confidence.
- Absence of timely senior decision-making.
Without structure, escalation can drift from support to control.
Principles for managing escalation without restriction
Effective providers anchor escalation decisions to:
- Clear purpose (what risk are we addressing?).
- Least restrictive options first.
- Time-limited measures with review points.
- Documented consent and capacity consideration.
This creates defensible decision-making even in pressured situations.
Operational example 1: Preventing bed-rail use through proactive night support
Context: Night-time wandering increases and staff consider bed rails to prevent falls.
Support approach: The escalation review reframes risk as mobility and orientation rather than containment.
Day-to-day delivery detail: Staff introduce low-level lighting, clear pathways, scheduled reassurance checks and daytime activity adjustments to improve sleep. A sensor mat is used only as an alert, not restraint.
How effectiveness is evidenced: Wandering continues safely, falls do not occur and no restrictive equipment is introduced.
Operational example 2: Managing refusal of medication without coercion
Context: A person begins refusing medication, raising health risk.
Support approach: The service treats refusal as communication, not non-compliance.
Day-to-day delivery detail: Staff adjust timing, presentation and explanation. Consent and capacity are reviewed, and clinical advice is sought. Medication is not forced.
How effectiveness is evidenced: Acceptance improves, records show respectful practice and escalation remains proportionate.
Operational example 3: Escalation during aggression without physical intervention
Context: A person becomes verbally aggressive during personal care.
Support approach: Staff pause care and follow agreed de-escalation guidance.
Day-to-day delivery detail: Care is re-offered later with different staff and altered approach. Triggers are logged and reviewed at escalation meeting.
How effectiveness is evidenced: Aggression reduces, care is delivered with consent and no physical intervention occurs.
Commissioner expectation: lawful, proportionate escalation
Commissioner expectation: Commissioners expect providers to manage risk without defaulting to restriction. They look for evidence of alternative strategies, time-limited controls and regular review.
Regulator expectation (CQC): least restrictive practice
Regulator / Inspector expectation (CQC): CQC closely scrutinises escalation leading to restriction. Inspectors expect clear rationale, consent processes, review records and evidence that alternatives were tried.
Governance that protects people and providers
Strong governance includes:
- Restrictive practice registers and review cycles.
- Senior sign-off for any restriction.
- Thematic analysis of escalation cases.
- Staff supervision focused on ethical decision-making.
When escalation is governed well, providers protect both people’s rights and organisational credibility.