Responding to Distress Without Restrictive Practice in Older People’s Services
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Older people’s services are under increasing scrutiny for how they respond to distress, agitation, refusal, and behaviour that challenges. Commissioners and CQC are clear that restriction must never be the default response. Instead, providers are expected to demonstrate lawful, proportionate, and person-centred approaches that prioritise understanding, prevention, and de-escalation. This article builds on learning from our Person-Centred Planning and Positive Risk-Taking content, focusing specifically on responding to distress without drifting into restrictive practice.
Why restrictive responses still creep into older people’s services
Restriction rarely begins as a conscious decision. It often emerges through routine: staff positioning themselves to block exits, insisting on compliance, removing choice “for safety”, or escalating verbal control when a person is distressed. These responses are usually driven by anxiety, time pressure, or fear of incidents, rather than intent. However, for the person, they can increase distress, erode trust, and escalate behaviour further.
What counts as restrictive practice in older people’s services
Restriction is not limited to physical restraint. In older people’s services it may include:
- Preventing a person from leaving a space without lawful authority.
- Insisting on personal care at a fixed time regardless of distress.
- Withholding meaningful activity to maintain “order”.
- Using threats, raised voices, or repeated commands to gain compliance.
- Environmental restriction (locked doors, inaccessible outdoor areas) without individual assessment.
CQC expects providers to recognise these risks and evidence how they actively work to avoid them.
Principles for responding to distress without restriction
Understand the function of distress
Distress is communication. It may indicate pain, fear, confusion, boredom, grief, loss of control, or unmet need. Responding effectively means asking “what is this telling us?” rather than “how do we stop it?”
Reduce perceived threat
Approach, tone, body language, and pacing matter. Slowing down, offering space, lowering voice, and reducing demands often prevents escalation.
Restore control and choice
Even small choices — where to sit, what to do first, who supports — can significantly reduce distress and avoid confrontation.
Use early intervention, not crisis response
Responding at the first signs of distress (withdrawal, restlessness, repetitive questioning) is far more effective than waiting for escalation.
Operational examples (minimum 3)
Example 1: Avoiding forced personal care
Context: A person frequently becomes distressed and refuses morning personal care, leading to staff pressure and verbal escalation. Support approach: The team reframes refusal as communication rather than non-compliance. Day-to-day delivery detail: Care is offered later in the morning, with a choice of staff member, clear explanation, and a preferred activity beforehand. Staff are instructed to withdraw and return later if distress rises. Evidencing change: Refusals decrease, care is completed with consent, and incident records show reduced escalation.
Example 2: Reducing exit-seeking without blocking
Context: A person repeatedly attempts to leave the service, becoming distressed when stopped. Support approach: The team identifies exit-seeking as a response to boredom and loss of routine. Day-to-day delivery detail: Staff walk with the person rather than blocking exits, offer outdoor time at predictable intervals, and introduce purposeful roles linked to the person’s past routine. Evidencing change: Attempts to leave reduce, mood improves, and no physical restriction is required.
Example 3: De-escalating agitation during busy periods
Context: Distress increases during staff changeovers, with raised voices and confrontational behaviour. Support approach: The team reduces environmental stressors rather than increasing control. Day-to-day delivery detail: Handover noise is reduced, one staff member remains consistently present, and the person is offered a calm space and familiar activity during transitions. Evidencing change: ABC data shows reduced agitation and no use of restrictive responses.
Commissioner and regulator expectations
Commissioner expectation: Providers should evidence how they prevent restrictive practice through proactive planning, staff training, and outcome monitoring, particularly where distress creates perceived risk.
Regulator / Inspector expectation (CQC): Inspectors expect services to minimise restriction, evidence lawful decision-making, and show that staff understand how to support people safely while respecting rights and dignity.
Governance and assurance
Good governance includes routine review of incidents for restrictive elements, supervision discussions focused on de-escalation, and audits that test whether care plans genuinely guide staff away from control-based responses. Providers should be able to show learning and adaptation over time.
Why this matters for outcomes
Responding to distress without restriction improves trust, reduces incidents, and supports wellbeing. It also protects providers from regulatory action, safeguarding concerns, and reputational damage. Most importantly, it ensures older people experience care that is respectful, lawful, and genuinely person-centred.
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