Distressed Behaviours in Care Homes - what are the risks?

We have met hundreds of care home staff in our training sessions, and this article aims to clarify some of the issues related to managing aggression and violence with older people, or vulnerable adults in care.

We recently received gratitude from a client company that achieved a quick return on investment from our training. They were able to dismiss a negligence claim against them after a staff member was attacked and injured. Good management, appropriate training around Distressed Behaviours, and sound thinking were all on the company’s side. Here are some of our thoughts on the issues involved.

Our experience of surveying staff in care homes for vulnerable (sometimes older) people revealed that:

• Many staff have been kicked, slapped, or shoved by a resident.
• Some staff have had to run away from, push away, or hold a resident to stay safe.
• Many staff have received training on how to manage these incidents.

We gathered this anecdotal evidence from our Distressed Behaviours training in care homes for older people across the country. These were "normal" care homes, where the residents are not a particularly special population prone to violence or aggression.

Talking to staff about these incidents, we learned about some more extreme types of Distressed Behaviours that happen in these environments. We hear personal and frightening stories of carers from different homes who have been:

• Held against a wall, with their throat being squeezed in the resident's hands.
• Pulled to the ground backwards while being grabbed by their hair.
• Cornered in a room, punched in the face, and kicked in the stomach while pregnant.

These incidents occur even in homes where management carries out their due diligence to risk-assess new residents on admission, finding out about their histories and habitual behaviors before welcoming them into their environment, and then continually assessing their care needs and personal care plans.

These incidents happen despite the best efforts of management to carry out their due diligence on resident admission and risk assessment.

Now, imagine that one resident, one day, possibly completely out of character, becomes agitated and subsequently involved in a confrontation with staff.

Imagine that during that scenario, one member of staff is violently attacked and is shoved hard against a doorway by the resident, receiving a broken arm in the process. The staff member is then taken to the hospital for treatment and is advised that because of their injuries, they must stay off work for several weeks or months.

The staff member may even suffer traumatic stress associated with the incident and have trouble coming back to work, possibly resulting in a claim for injury compensation.

This type of Distressed Behaviours incident may not sound familiar, but it is a credible story. In fact, a similar incident happened at one of our client's care homes recently, which provoked deep thinking about the issues involved.

Some of the issues raised include:

• Admission procedures and risk assessment for violence
• Pre-Incident Indicators that a resident’s behavior may become harmful
• Foreseeability of incidents where imminent harm is a possibility
• Training Needs Analysis and consultation with staff
• Leadership and Expectations of Staff Performance
• Contributory Negligence and Vicarious Liability

When Distressed Behaviours incidents like these occur, it is important for managers and senior staff to ask themselves and their teams some key questions. Here are a few questions to consider:

Question 1: Are our admission procedures thorough enough? Are we being informed of everything we need to know before making a decision about admitting a new resident?

The Management of Health and Safety Regulations specifically reference the need for staff being placed in potentially dangerous situations to be informed of them. This need extends back to the admission of new residents in a care home. A resident's history of Distressed Behaviours is a crucial factor in determining what level of care and staffing will be required for their safe admission. This information should be collected, collated, and examined. The resident's family, social care workers, and current caregivers, if applicable, will have this information.

Question 2: Was this particular incident, with this resident or with these staff members, foreseeable? Were there 'pre-incident indicators'?

Staff who interact with residents on a daily basis are the best judges of changes in behavior. They are experts at spotting "pre-incident indicators," which are changes in behavior that could indicate future Distressed Behaviours. Observing and developing an awareness of stress triggers is a critical way to ensure staff and resident safety. Passing on information about changes in behavior is also crucial to prevent other staff from unwittingly stumbling across identified triggers. Risk assessment principles underpin this practice, in which constant identification of possible hazards is one of the key tenets of the risk assessment process.

Question 3: Are incidents of this nature foreseeable, where staff may need to intervene to control or safely break away from a violent incident?

In a case in Scotland, a teacher who worked at a special school was awarded over £70,000 by a court. The teacher had been attacked numerous times by one of her students and suffered phobic-level anxiety symptoms when faced with going back to work in the same environment. According to the court's findings, her employer owed her a duty of care, which had been breached. The employer's inability to manage and control risks according to the HSE's guidelines on risk assessment had not been followed. The incidents of Distressed Behaviours with the individual were not unique but repeated and foreseeable.

Question 4: What training can be implemented to eliminate, reduce, or control the occurrence of this type of incident?

If staff must deal with aggression and violence in the workplace, they must be provided with training and support to safely deal with such behaviors. They are entitled to work in an environment where management practices reduce such risks.

It is important to note that it should not be assumed that a person who is older and perhaps somewhat physically infirm cannot hurt or injure a member of staff during an incident of Distressed Behaviours. This is a common misconception in the sector and an attitude that often results in staff not being asked whether they are suffering attacks and the seriousness of those attacks.

In the chaotic moment of a confrontation, when one person seeks to control the movement of another, injuries may occur. A hair grab can lead to long-term whiplash damage to the neck, a slap can cause an eye injury, and a push can result in a broken wrist. Many staff members in care homes for older people are surprised at the level of strength some of their residents still possess. People can get hurt much more easily than is sometimes thought, even with what may be regarded as innocuous or unintentional force.

Training needs must be analyzed and met as closely as possible. The process of asking staff about the levels of resistance, aggression or violence they face, the risky situations they are involved in, and the ways they can cope with those situations is the beginning of the risk-control process.

Question 5: Are our staff aware of their obligations and responsibilities in incidents where a resident becomes violent?

Staff who have not received training on the legal, ethical, and tactical issues related to aggression in the workplace may not know how to properly handle incidents that arise. It is important to ensure that staff are clear on their duty of care to themselves, clients, colleagues, and other residents, and that they can quickly make sound judgments about what to do when they encounter Distressed Behaviours.

Do staff members know about the issue of contributory negligence? If they have been trained to use de-escalation, control, or safe holding methods, they should use them when required and appropriate. Business managers must clearly lead their staff to ensure that they use these methods.

Are staff aware of the requirement to report and document all incidents of violence or aggression? Is there a useful policy that they can refer to? Are there documents available to help them report the incident clearly and appropriately so that an investigation into the incident can be carried out?

Peter Drucker, a management guru, applied the principle that “What isn’t measured, isn’t managed!” Without incident reports and analysis, incidents of aggression and violence cannot be managed effectively or reduced over time (see Restraint Reduction).

If no training is provided to help staff defuse, de-escalate, or otherwise manage Distressed Behaviours, the issue of vicarious liability may apply. This means that the employer is responsible for their staff's actions, regardless of whether training is in place. As an employer, you may be held responsible for the actions of your staff.

Training provides a safety net for everyone, setting a baseline for expected staff behavior and proving that management is appropriately addressing staff and resident safety issues. Additionally, it can ultimately save your organization from costly media attention, negligence claims, and damages awards.

Most importantly, paying due attention to this issue will help ensure that you reduce the chance of harm to anyone in your home, staff or resident.

Our training courses in Managing Aggression and Understanding Safe Holding and Distressed Behaviours are growing in popularity and have saved some clients from paying expensive negligence and damages sums after incidents.

Please contact us today to learn how to bring our training team to your care home.  Click here to see feedback on these courses.