Reviewing Restrictive Practices in Dementia Care: How to Stay Safe Without Normalising Control
Restrictive practices in dementia care rarely arrive as a single decision. More often, they emerge through repeated “small” responses to risk: doors locked for safety, informal observation increased, mobility limited to prevent falls, or items removed to prevent distress. Over time, restrictions can become normalised without ongoing review, which increases legal, safeguarding and inspection risk. This article sits within Assessment, Review & Changing Needs and links to Service Models & Care Pathways, because restriction risk varies by setting and pathway, and the review approach must match operational reality.
What counts as a restrictive practice in dementia services
In practice, restrictions include more than physical restraint. In dementia care, common restrictions include:
- Locked doors or controlled access to areas
- Increased observation without clear purpose or review
- Preventing a person from leaving, walking, or making choices
- Withholding items “for safety” (keys, phones, outdoor clothing)
- Using medication primarily to manage behaviour or distress
The key question is whether the person’s freedom is being limited beyond what is necessary, proportionate and least restrictive.
Why “restriction drift” happens
Restriction drift is the gradual escalation of control in response to repeated risk. It happens when:
- Staff are anxious and feel personally liable
- There is high turnover and inconsistent practice
- Documentation is weak, so staff rely on “what we do here”
- Escalation routes are unclear, so restrictions become the default
A robust review process is the operational safeguard against drift.
A review framework that inspectors and commissioners recognise
Every restriction should have:
- A clear risk rationale (what harm are we preventing?)
- Evidence of attempts at less restrictive alternatives
- A decision trail (capacity / best interests where relevant)
- Defined parameters (what, when, by whom, recorded how)
- A review date and step-down plan
This moves restrictions from informal habits to governed, accountable interventions.
Operational example 1: Care home review of locked door practice
Context: A home routinely keeps an external door locked because several residents have tried to leave. One resident becomes distressed, repeatedly testing the door and shouting.
Support approach: The manager triggers a restriction review focusing on this resident’s rights and wellbeing, not just general safety. The team explores alternatives and documents the rationale for any continued restriction.
Day-to-day delivery detail: The plan introduces scheduled accompanied outdoor access, meaningful roles near exit points (e.g., “help check the garden”), and environmental signage to reduce exit seeking. Staff are instructed to use reassurance and redirection linked to life story, rather than blocking or arguing. If locking remains necessary, the plan specifies how access is provided promptly on request and how distress is monitored.
How effectiveness or change is evidenced: Distress incidents at the door are tracked for 14 days, showing reduction as access routines improve. The restriction is reviewed monthly with recorded consideration of step-down.
Capacity and best interests: do not avoid the hard decisions
Restrictions often relate to decisions about leaving, supervision, medication or mobility. Where a person lacks capacity for the specific decision, providers must evidence best-interests decision-making, including consultation with family/advocates and a least restrictive analysis.
Operationally, this means the review record must show:
- What decision is being made
- What the person has communicated (verbally or behaviourally)
- What alternatives were tested
- Why the chosen approach is proportionate and time-limited
Operational example 2: Homecare restriction review around “forced bathing” patterns
Context: A person receiving homecare increasingly refuses personal care. Staff begin completing tasks quickly while the person is distressed, believing it is “necessary for hygiene”. Family complain.
Support approach: The provider treats this as a restrictive practice review, not a staff performance issue alone. The focus is on consent, dignity and safe care delivery.
Day-to-day delivery detail: The care plan is updated to include graded prompts, choice-based sequencing (wash face/hands first, then step-by-step), and alternatives (strip wash instead of bath, preferred toiletries, same-gender staff if needed). Staff are instructed to stop when distress escalates beyond threshold and to escalate rather than persist. The plan includes a “how to evidence consent/refusal” section for daily notes.
How effectiveness or change is evidenced: Refusals decrease, complaints reduce, and staff report improved relationships. The provider evidences change through daily notes quality, supervision records, and outcome tracking.
Medication and restriction: keep the rationale explicit
Where medication is used to manage distress or agitation, review must ensure it is clinically justified, monitored and not used as convenience. Providers should evidence:
- What behaviour is being targeted and why
- What non-pharmacological interventions were attempted
- Side effects monitoring and escalation
- Clinical review frequency and outcomes
Operational example 3: Supported living review of increased observation
Context: Following several near-misses at night, staff increase checks to every 15 minutes without a documented decision, and the person becomes more unsettled by repeated interruptions.
Support approach: The provider initiates a restrictive practice review and redefines observation as a time-limited, purposeful intervention with step-down triggers.
Day-to-day delivery detail: Night support changes from intrusive checks to quieter safety measures: environmental cues, sensor-based prompts where appropriate, and a consistent bedtime routine. Where checks are still required, the plan defines frequency, recording method, and an escalation route if patterns change. A review is scheduled after 7 days and again after 14 days.
How effectiveness or change is evidenced: Sleep improves, incidents reduce, and checks are stepped down. Governance evidence includes the review record, outcome trends and clear rationale for each change.
Commissioner expectation: least restrictive practice evidenced through review
Commissioner expectation: Commissioners expect providers to evidence that restrictions are not default risk management. They look for time-limited measures, alternatives tested, and a review system that prevents drift and protects rights.
Regulator / Inspector expectation: safeguarding, rights and accurate records
Regulator / Inspector expectation (CQC): Inspectors will look for evidence that restrictive practices are understood, recorded, and reviewed, and that staff can explain why approaches are proportionate. Unrecorded restrictions are a high-risk inspection finding.
Governance: how to monitor restrictive practices across a service
- Maintain a restrictive practice register (what, why, review dates, step-down plans)
- Audit observation levels and night-time controls
- Sample care plans against daily notes to test consistency
- Review themes in incidents and safeguarding alerts
- Use supervision to test staff understanding and confidence