Restrictive Practice Governance in Dementia Services: Reducing Risk Without Removing Rights

Restrictive practice in dementia services is rarely introduced as a deliberate “restriction.” More often, it grows from risk anxiety, staffing pressure, inconsistent routines, or a belief that restriction is the safest option. Over time, locked doors, constant observation, covert administration, bedrails, limited community access, and rigid routines can become normalised. Strong governance is what prevents restriction becoming the default and ensures rights are protected.

This article forms part of Dementia – Quality, Safety & Governance and aligns with Dementia – Service Models & Care Pathways, because restrictive practice risk varies significantly depending on service model, environment, staffing and how risk is managed day to day.

What counts as restrictive practice in dementia services

Restrictive practice is any practice that limits a person’s liberty, autonomy or rights. In dementia services, common restrictions include:

• Locked doors or limited access to outdoor space.
• Supervision that prevents free movement or independent choice.
• Physical interventions to complete care tasks.
• Covert medication or “hidden” administration methods.
• Rules-based routines that override individual preference.

Good governance ensures restrictions are lawful, proportionate, individually justified, and regularly reviewed with an active plan to reduce them.

Commissioner expectation: least restrictive practice with evidence of review

Commissioner expectation: commissioners expect providers to demonstrate that restrictions are not used as a substitute for staffing or skill. They commonly expect:

• Clear recording of restrictions and their rationale.
• Best interests decision-making where relevant.
• Active plans to reduce restriction over time.
• Evidence of multi-agency involvement for complex cases.

Regulator / CQC expectation: rights-based care and challenge of “normalised” restriction

Regulator / Inspector expectation (CQC): CQC expects providers to evidence a rights-based approach, including:

• Person-centred care that promotes choice and control.
• Understanding of restriction and deprivation risks.
• Robust governance systems that monitor restrictions.
• Evidence that restrictions are challenged, reduced and not routine.

Building a restrictive practice governance system

A practical governance approach usually includes:

• Restriction register: a live log of all identified restrictions, including environmental restrictions.
• Decision record: capacity/consent considerations, rationale, and who was involved.
• Review schedule: time-limited reviews with clear owners and outcome tracking.
• Reduction planning: specific steps to reduce restriction through support adaptation, not “waiting for improvement.”

Governance must also include escalation routes when restriction is becoming embedded or when staff feel forced into restrictive responses due to service pressure.

Operational Example 1: Locking doors in a residential dementia unit

Context: A dementia unit routinely kept the front door locked. The rationale was “risk of wandering,” but the practice applied to everyone regardless of individual risk.

Support approach: The service introduced a restrictive practice review and shifted from blanket restriction to individualised risk enablement.

Day-to-day delivery detail:

• A restriction register was created listing “locked front door” as an environmental restriction.
• Individual risk assessments were updated to identify who was at actual risk of unsafe wandering and under what circumstances.
• Staff introduced structured outdoor routines and accompanied walks for those who benefited.
• For lower-risk residents, supervised access was enabled via a safer exit route and clear signage.

How effectiveness is evidenced: Residents accessed outdoor space more regularly, distress incidents reduced, and audits demonstrated that the restriction was actively reviewed rather than accepted as “how the unit works.”

Operational Example 2: Covert medication governance in community dementia care

Context: A person with advanced dementia refused medication, leading staff and family to consider covert administration to manage health risks.

Support approach: The provider implemented a formal governance process to ensure lawful, best interests decision-making and ongoing review.

Day-to-day delivery detail:

• A decision-specific capacity assessment was completed regarding medicine consent.
• A best interests meeting was held with family, GP and pharmacy input, documenting the rationale, alternatives attempted, and the proposed method.
• Staff were briefed on safe administration and monitoring for distress or adverse impact.
• A review date was set for four weeks, with a plan to re-test non-covert approaches periodically.

How effectiveness is evidenced: The audit trail showed structured decision-making, time-limited review, and a clear record of alternatives attempted, meeting both commissioner assurance and inspection scrutiny.

Operational Example 3: Restrictive routines in extra care support

Context: In an extra care scheme, staff began imposing fixed meal and hygiene times “for efficiency,” leading to distress and resistance in people with dementia.

Support approach: Leaders treated this as restrictive practice creep and introduced governance controls focused on routine flexibility.

Day-to-day delivery detail:

• Care plans were reviewed to reinstate personal preferences and timing flexibility.
• Shift handovers included “what matters today” prompts for each person to avoid task-led patterns.
• Observation audits focused on choice points, communication style, and whether staff offered alternatives.
• A monthly governance dashboard tracked distress incidents and complaints as potential restriction signals.

How effectiveness is evidenced: Distress incidents reduced, staff reported fewer confrontational interactions, and commissioners could see a structured approach to promoting rights rather than managing convenience.

How to demonstrate least restrictive practice in audits and inspections

Practical evidence that stands up to scrutiny includes:

• A restriction register showing identification, rationale, and review dates.
• Decision records showing involvement, alternatives tried, and time-limited decisions.
• Care plan content that evidences choice, flexibility and risk enablement.
• Incident trends showing reduced distress and fewer restrictive responses over time.
• Quality assurance minutes demonstrating senior oversight and challenge.

Restrictive practice governance is not about avoiding risk; it is about managing risk in a way that protects dignity, autonomy and lawful decision-making.

---