A 70+ year-old resident who had been exhibiting combative behaviour for many weeks, was in the home’s severe dementia unit. Her behaviour was becoming more and more ’confused’ as time went by.  One evening, the woman insisted on wearing her bra on over her dress. On discovering this, the home's manager asked the staff on duty to remove the woman back to her bedroom and "dress her properly" in order to preserve the resident’s dignity. The team approached the woman and she became combative, lashing out at staff.  The report describes the woman's subsequent behaviour as 'like a wild animal' and 'like nothing I had ever seen before'. Four staff were present. One senior member of staff who was trying to de-escalate the situation was assaulted and attempted to physically hold the resident.   This incident was happening in the day-room and many other residents were in the vicinity.   Two other staff - care assistants on an apprenticeship scheme - refused to assist the senior carer, fled the scene and locked themselves in the staff toilet. One other member of staff on-scene had not had their physical intervention training and so declined to intervene to assist the restraint. The single member of staff who engaged in the restraint suffered minor injuries (bruising to her arm, strained muscles) as the resident used her free arm to punch her in the face. Importantly, the two staff who retreated from the scene *were* in-date for their restraint training, but took the decision that the training they received *did not* prepare them for the level of violence they faced that evening. During the resolution of the incident, the manager assisted the carer to hold the woman and escort her, under resistance, to her room.   The manager suffered a bruised cheekbone and black eye during the struggle.   The resident was subsequently removed to a psychiatric unit.

KEY ISSUES: 1)  Person-Directed-Care:   If the woman who is wearing her bra outside her clothes is perfectly happy and content, and the other residents don't mind or don't notice, and the staff who know her and look after her are satisfied that she is safe and secure, then WHY would a manager or supervisor demand an intervention to re-dress her and ON WHAT BASIS would she be doing so?   Fear of relatives?  Fear of CQC inspection?  Personal standards of 'appropriate' dress?   Are any of these reasons sufficient to warrant an intervention?   The result of this intervention was that the woman, who was content at the beginning of the incident, had to be removed from the home because of "her behaviour".   It is important to note that her behaviour was 'created' here. 2)  Duty of Care:   Staff who are trained in physical interventions should be under no illusion that, if circumstances warrant the use of restrictive interventions to prevent harm to their residents or to their colleagues, that they are duty-bound to make the situation safer by their presence, their communication skills or their physical actions.  In the case where they fail to act, then there may be serious legal consequences if their omission results in injury to another. 3)  Recruitment and Selection and Training:  Staff in Care Homes for Older People must be recruited and selected (and THEN trained) to deal professionally and competently with the full spectrum of behaviours that they are likely to face in their role.  Caregiving for the elderly (especially in the increasingly complex world of dementia care and later life) is becoming increasingly dependent on skills which are more akin to those of the largely qualified and well-trained care workers in learning disability services, which is years ahead.  Carers should be under no illusion that the days when giving cups of tea and tucking people into bed as core tasks are long in the past and that they can be called on to do far more demanding inter-personal work, including managing conflict and using physical force. Care Home Safe Holding training can help your staff to have a pre-planned and practiced response to aggressive or distressed behaviours in your service and bring about preplanned outcomes which are more positive and safer for all involved.

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Gerard O’Dea is a conflict management, personal safety and physical interventions training consultant.  He is the training director for Dynamis, a specialist provider of personal safety and violence management programmes and the European Adviser for ‘Verbal Defense and Influence’, a global programme which addresses the spectrum of human conflict.  www.dynamis.training https://www.youtube.com/watch?v=kUpaRBEAfRQ