Restrictive Practice Governance in Dementia Services: Reducing Risk Without Removing Rights
Restrictive practices in dementia services rarely begin as deliberate attempts to remove rights. More often, they emerge incrementally through well-intentioned decisions made in response to risk anxiety, staffing pressures or single incidents. High-performing providers embed oversight within structured dementia quality and governance systems and align day-to-day decision-making to coherent dementia service models. Commissioners and inspectors expect evidence that restrictions are proportionate, time-limited, lawfully authorised and regularly reviewed.
Recognising restrictive drift
Restrictive drift occurs when measures introduced as temporary responses become routine without review. Examples include permanent chair alarms after a single fall, continuous door locking following one wandering incident, or routine PRN sedation without clear behavioural analysis. Governance systems must identify and challenge this drift.
Operational example 1: Door access controls
Context: External doors locked following an episode of absconding risk.
Support approach: Individualised risk assessment and capacity review undertaken.
Day-to-day delivery detail: Best interest decision documented where capacity lacking, supervised garden access scheduled daily, and risk reviewed weekly in governance huddle.
How effectiveness is evidenced: No further absconding incidents, documented least restrictive analysis and family feedback evidencing maintained quality of life.
Operational example 2: Bed rails and falls prevention
Context: Bed rails introduced after one night-time fall.
Support approach: Multidisciplinary review explores alternatives.
Day-to-day delivery detail: Low-profile bed trialled, floor mats introduced and increased orientation support provided. Capacity assessment completed and reviewed.
How effectiveness is evidenced: Bed rails discontinued safely with no increase in falls and improved mobility confidence recorded.
Operational example 3: PRN sedation for distress
Context: PRN medication used frequently for agitation.
Support approach: Behavioural analysis and non-pharmacological plan implemented.
Day-to-day delivery detail: Staff identify triggers, adjust environment and increase meaningful engagement. PRN rationale scrutinised at weekly governance review.
How effectiveness is evidenced: PRN use reduces by 60% over two months and no escalation in behavioural incidents observed.
Commissioner expectation: lawful and proportionate restriction
Commissioner expectation: Commissioners expect clear documentation of capacity assessments, best interest decisions and time-bound reviews demonstrating least restrictive practice.
Regulator / Inspector expectation (CQC): rights-based, person-centred care
Regulator / Inspector expectation (CQC): Inspectors assess whether restrictions are necessary, proportionate and regularly reviewed, and whether people’s autonomy is maximised wherever safely possible.
Embedding restrictive practice registers
Services should maintain a restrictive practice register reviewed monthly, linking restrictions to safeguarding, falls and incident data. Governance minutes must evidence challenge and review, not passive acceptance. When restrictive practice is governed robustly, dementia services reduce harm while protecting rights and dignity.