Supporting Distress Without Restrictive Practice in Older People’s Services
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In older people’s services, distress is one of the most common drivers of restrictive practice — often unintentionally. Commissioners and inspectors increasingly expect providers to demonstrate how restraint is avoided, alternatives are used, and staff are supported to respond safely without escalating risk. This article builds on person-centred planning and safeguarding foundations, drawing on practical delivery and governance approaches set out in our Person-Centred Planning mini-series and Safeguarding mini-series.
Why restrictive practice still appears in ageing well services
Restrictive practice rarely begins with poor intent. It usually emerges from pressure points: understaffing, time-limited visits, fear of falls, medication refusal, or repeated distress that staff feel ill-equipped to manage. Without clear frameworks, teams default to control rather than understanding. In older people’s services this can include physical prompts that escalate, blocking movement “for safety”, repeated verbal instruction, or inappropriate PRN use.
Defining least restrictive practice in day-to-day terms
Least restrictive practice is not an abstract principle; it is a sequence of everyday decisions. In practice, it means:
- Starting with comfort, explanation, and choice before task completion.
- Allowing time and pauses rather than insisting on immediate compliance.
- Adjusting routines, environment, and staffing approach before restricting movement.
- Recording why alternatives worked or failed, not just what was done.
Providers that embed this thinking reduce distress and protect staff from unsafe escalation.
Embedding a “pause and assess” response model
A reliable model for reducing restrictive responses is the “pause and assess” approach. When distress escalates, staff are trained to pause the task and assess four core areas: physical comfort, emotional state, environment, and communication. This creates space to de-escalate without abandoning care.
Physical and health check
Is pain, breathlessness, infection, hunger, thirst, or toileting need contributing? Older people frequently express discomfort through behaviour rather than words.
Emotional and relational context
Is the person frightened, confused, rushed, or feeling controlled? Have staff explained what is happening and checked consent?
Environmental stressors
Noise, lighting, temperature, clutter, or unfamiliar staff can significantly increase distress.
Communication style
Multiple instructions, raised voices, or standing over someone can escalate risk quickly.
Operational examples (minimum 3)
Example 1: Preventing restraint during personal care
Context: A person becomes physically resistant during washing, leading staff to hold arms “for safety”. Support approach: Care plans are updated to include consent checks, slower pacing, and choice of timing. Day-to-day delivery: Staff introduce themselves, explain each step, allow pauses, and offer the person control over water temperature and order of tasks. Evidencing change: Incident reports reduce; care notes show fewer aborted tasks; staff supervision records reflect improved confidence.
Example 2: Reducing restrictive responses to walking and pacing
Context: A resident is repeatedly stopped from walking due to fall concerns, leading to agitation. Support approach: Positive risk assessment balances mobility with safety. Day-to-day delivery: Clear walking routes, mobility aids, footwear checks, and supervised walks are introduced instead of blocking movement. Evidencing change: Falls do not increase; distress incidents reduce; mobility and mood improve.
Example 3: Avoiding PRN escalation during medication refusal
Context: Medication refusal leads to anxiety and PRN consideration. Support approach: Communication and timing are reviewed. Day-to-day delivery: Staff explain purpose, offer choice of timing, provide water first, and reduce sensory overload. Evidencing change: MAR shows improved compliance; PRN use decreases; audits demonstrate lawful decision-making.
Commissioner and regulator expectations
Commissioner expectation: Providers must evidence reduction of restrictive practice through training, care planning, and outcome data, not rely on policy statements alone.
Regulator / Inspector expectation (CQC): Inspectors expect services to follow least restrictive principles, record rationale, learn from incidents, and demonstrate staff understanding of lawful, proportionate responses.
Governance and assurance
Strong providers track restraint, PRN, and distress trends monthly, review care plans after incidents, and ensure staff supervision explicitly covers de-escalation and lawful practice. This turns “good intent” into defensible evidence.
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