Restrictive Practice and Dementia Governance: Reducing Risk While Preserving Autonomy

Restrictive practice in dementia services rarely begins as a conscious choice to limit someone’s freedom. More often, it develops gradually through everyday decisions made under pressure: closing a door to prevent wandering, discouraging walking due to falls risk, or rushing care tasks to avoid distress. Without strong governance, these practices can become normalised, undocumented and unlawful.

This article forms part of Dementia – Quality, Safety & Governance and links closely to Dementia – Service Models & Care Pathways, because the nature and scale of restrictive practice risk varies significantly across home care, supported living, care homes and nursing services.

What counts as restrictive practice in dementia services

Restrictive practice includes any action that limits a person’s rights, freedom of movement, choice or control. In dementia care, this may include:

• Locked doors, coded exits or restricted access to outdoor space.
• Discouraging walking or activity due to perceived risk.
• Rushed or task-focused personal care that removes choice.
• Use of medication primarily to manage behaviour.
• Environmental restrictions such as removing personal items.

Governance must ensure these practices are lawful, proportionate, time-limited and continually reviewed, rather than embedded by default.

Regulator / CQC expectation: least restrictive practice with evidence

Regulator / Inspector expectation (CQC): inspectors expect providers to demonstrate that any restriction is the least restrictive option available and is supported by lawful decision-making. This includes clear evidence of:

• Capacity assessments and best interests decisions.
• Consideration of alternatives prior to restriction.
• Proportionality and time limitation.
• Regular review and reduction planning.

In dementia services, CQC scrutiny often focuses on whether restrictions have become routine rather than exceptional.

Commissioner expectation: proactive reduction of restriction

Commissioner expectation: commissioners expect providers to actively manage and reduce restrictive practice risk. This means being able to demonstrate:

• Visibility of restrictions across services.
• Clear governance oversight at senior level.
• Reduction strategies embedded in care planning.
• Staff competence in positive risk-taking.

Commissioners are increasingly wary of services that rely on restrictive environments rather than skilled support.

Operational Example 1: Reducing movement restriction in a care home

Context: A care home supporting people with moderate to advanced dementia restricted access to outdoor areas following a cluster of falls incidents. Doors were locked as a precaution, and residents’ agitation increased.

Support approach: The provider introduced a restrictive practice review framework linked to falls governance.

Day-to-day delivery detail:

• Falls risk assessments reviewed with physiotherapy and OT input.
• Environmental adaptations introduced to reduce trip hazards.
• Staff rota adjusted to provide supervised outdoor access.
• Restrictions logged on a register with review dates.

How effectiveness is evidenced: Outdoor access restored for most residents, reduced distress behaviours, and no increase in serious falls incidents.

Operational Example 2: Managing personal care distress without coercion

Context: In a supported living service, staff frequently rushed personal care for tenants with dementia due to agitation and refusal, resulting in covert restriction of choice.

Support approach: Care plans were redesigned to prioritise consent, pacing and relational care.

Day-to-day delivery detail:

• Life history information used to structure personal care routines.
• Staff trained in pause-and-return and distraction techniques.
• Care refusal patterns reviewed in supervision.
• Advocacy involved where capacity was unclear.

How effectiveness is evidenced: Reduced distress incidents, improved cooperation, and clearer documentation of consent and best interests decisions.

Operational Example 3: Medication as a restrictive practice

Context: A nursing service relied heavily on PRN medication during periods of agitation among residents with dementia.

Support approach: Medication governance was reframed to treat PRN use as a restrictive practice requiring oversight.

Day-to-day delivery detail:

• Weekly PRN usage reviews by senior clinicians.
• Non-pharmacological strategies trialled first and recorded.
• Trigger thresholds set for medication review.
• Care plans updated with effective alternatives.

How effectiveness is evidenced: Reduced PRN reliance, improved staff confidence, and positive inspection feedback on restraint reduction.

Governance tools that prevent restrictive practice drift

Effective dementia services use governance tools to prevent gradual drift into restriction, including:

• Restriction registers with rationale and review dates.
• Regular multidisciplinary review of restrictions.
• Supervision focused on ethical decision-making.
• Family and advocate involvement in complex decisions.

Evidence for tenders and inspections

Strong evidence of restrictive practice governance includes:

• Clear links between MCA, best interests and care planning.
• Examples of restriction reduction over time.
• Staff training records on positive risk-taking.
• Audit outcomes showing improved autonomy and wellbeing.

Restrictive practice governance in dementia is not about eliminating risk, but about ensuring safety is achieved without eroding dignity, autonomy or legal rights.

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