Understanding Behaviour Through Personal Care Routines in PBS: Protecting Dignity, Choice and Trust

Positive Behaviour Support requires services to understand how personal care routines affect behaviour, dignity and trust. The Positive Behaviour Support knowledge hub supports providers to connect behaviour, communication, proactive support, rights and reduction of restrictive practice.

In specialist services, understanding behaviour through PBS means looking carefully at what the person experiences during washing, dressing, toileting, continence support, shaving, hair care, oral care and medication-related routines.

This reflects PBS principles and values, because personal care must be delivered with respect, consent, privacy and control. Strong services do not treat refusal or distress as obstruction without first understanding what the routine feels like for the person.

Concept Explained Clearly

Personal care can be physically, emotionally and sensory demanding. It may involve touch, exposure, water, noise, temperature, smells, close staff presence, unfamiliar products, time pressure or previous experiences of rushed or restrictive care.

Behaviour during personal care may include refusal, pushing staff away, shouting, leaving the bathroom, covering the body, withdrawing, self-injury, grabbing items or repeated questioning. In PBS, these behaviours are treated as communication about privacy, pain, fear, sensory discomfort, lack of control or poor preparation.

Why It Matters in Real Services

When personal care behaviour is misunderstood, staff may become task-led. They may focus on completing washing, dressing or continence support rather than adapting the routine. This can increase distress and make future care harder.

The risks are significant. Poorly understood personal care can affect hygiene, skin integrity, health, dignity, safeguarding and relationships. Commissioners and CQC will expect providers to evidence that support is person-centred, safe, respectful and delivered in the least restrictive way possible.

What Good Looks Like

Strong services demonstrate that personal care plans are detailed, practical and individual. Staff know preferred timing, communication, products, privacy needs, sensory sensitivities, pain indicators, gender preferences where relevant, and how the person communicates pause, refusal or discomfort.

Good PBS practice protects dignity while maintaining health. Staff prepare the person, offer meaningful choices, move at the right pace, reduce unnecessary language and stop or pause when early distress signs appear. Providers should be able to evidence how adapted personal care reduces distress and improves outcomes.

Operational Example 1: Morning Washing and Loss of Control

Step 1 – Presenting concern: A person in supported living regularly refused morning washing and shouted when staff entered the bathroom. Staff recorded personal care refusal, but the pattern was strongest when support began immediately after waking.

Step 2 – Routine reviewed: The provider looked at timing, staff approach, privacy and choice. The person had little control over when care began, which products were used or whether they could pause.

Step 3 – Support approach: Staff introduced a visual morning sequence, offered washing before or after breakfast, and gave the person a choice between two preferred wash products.

Step 4 – Day-to-day delivery detail: Staff knocked, waited for a response, used one agreed phrase and kept towels within reach so the person felt covered. If the person turned away, staff paused rather than repeating prompts.

Step 5 – How effectiveness was evidenced: Refusals reduced, washing was completed more calmly and staff records showed fewer distress indicators. The provider evidenced that increasing control improved dignity and care completion.

Deepening the Understanding: Personal Care Is Not Just a Task

Personal care routines often expose the quality of support more clearly than formal reviews. A plan may say care is person-centred, but the person experiences the reality through staff tone, timing, touch, privacy and response to refusal.

Strong PBS services review whether staff are completing care with the person, not to the person. This includes consent, pacing, body language, explanation, sensory adjustments and recovery time after difficult routines.

The related article on seeing behaviour as communication in PBS reinforces why resistance during personal care should be heard as information about support quality, not simply non-cooperation.

Operational Example 2: Oral Care and Pain Communication

Step 1 – Behaviour pattern: In a residential service, a person began refusing toothbrushing and pushing the toothbrush away. Staff initially recorded this as declining oral care.

Step 2 – Health and sensory factors checked: Staff noticed facial grimacing, reduced appetite and distress when harder foods were offered. The provider considered dental pain and sensory sensitivity.

Step 3 – Support response: Staff changed to a softer toothbrush, offered the person more control over holding it, and shortened the routine while a dental appointment was arranged.

Step 4 – Clinical escalation: The provider prepared the person for dental review using a visual sequence and shared communication needs with the dental team.

Step 5 – Evidence and outcome: A dental issue was identified and treated. Oral care tolerance improved, and records showed earlier recognition of pain indicators. The provider evidenced that behaviour had communicated discomfort, not simple refusal.

Systems, Workforce and Consistency

Personal care support must be consistent across the workforce. If one staff member respects pauses and another pushes through distress, the person may lose trust in the whole routine. Strong services include personal care guidance in PBS plans, care plans, handovers, supervision and competency checks.

Managers should observe practice sensitively and review records for patterns. Supervision should explore whether staff feel rushed, whether staffing arrangements protect dignity, and whether personal care is being adapted when distress appears. Handovers should include what worked, what did not, and any health or pain concerns.

Operational Example 3: Continence Support and Privacy Distress

Step 1 – Initial issue: A person receiving outreach support became distressed during continence support, sometimes shouting and refusing to leave their bedroom afterwards. Staff recorded embarrassment and refusal but had not reviewed the routine in detail.

Step 2 – Dignity factors explored: The provider reviewed privacy, staff communication, timing and room layout. The person appeared most distressed when staff discussed continence items openly or moved too quickly through the routine.

Step 3 – Practical changes made: Staff used discreet language, prepared items before entering, offered the person control over clothing choices and allowed extra time before moving to the next activity.

Step 4 – Staff consistency: The approach was added to the care plan and all staff were briefed. New staff shadowed before supporting continence care directly.

Step 5 – Evidence reviewed: Distress reduced, recovery time shortened and the person resumed routines more quickly after support. The provider evidenced that privacy and pacing were central to safer continence care.

Governance and Evidence

Governance should show how personal care behaviour is understood, reviewed and acted on. Providers should be able to evidence care plan updates, PBS reviews, health escalation, dignity observations, staff supervision, incident analysis and outcome monitoring.

Strong governance connects behaviour to support quality. Records should show what the person communicated, what staff changed, whether health concerns were considered and whether dignity improved. This creates a clear line of sight from behaviour to personal care need, from need to staff action, and from staff action to outcome.

Commissioner and CQC Expectations

Commissioners expect providers to deliver personal care safely while protecting dignity and reducing distress. They need assurance that providers can support intimate routines without defaulting to pressure, restriction or missed care.

CQC will expect care to be safe, respectful, person-centred and responsive. Inspectors may review whether people’s privacy is protected, whether staff understand communication, whether health concerns are escalated and whether care plans reflect individual needs. Strong services demonstrate that personal care support is governed, skilled and rights-based.

Common Pitfalls

• Recording personal care refusal without reviewing timing, privacy, pain or sensory factors.
• Prioritising task completion over dignity and consent.
• Using repeated prompts when the person needs processing time or a pause.
• Failing to recognise dental pain, skin discomfort or continence-related distress.
• Allowing different staff to use inconsistent approaches during intimate care.
• Not evidencing whether changes improve both care completion and wellbeing.

Conclusion

Understanding behaviour through personal care routines helps PBS teams protect dignity while maintaining safe support. Behaviour may communicate pain, fear, sensory discomfort, embarrassment, lack of control or poor preparation.

Strong providers respond by adapting routines, training staff and reviewing outcomes. They evidence how personal care becomes calmer, safer and more respectful. This gives people better daily experiences and gives commissioners and CQC confidence that PBS is embedded in the most personal parts of support.