“‘When I use a word,’ Humpty Dumpty said, in rather a scornful tone, ‘it means just what I choose it to mean — neither more nor less.’”
In Alice Through the Looking Glass, by Lewis Carroll, Alice challenges Humpty Dumpty for using words in a way that sounds fine but is actually misleading. I sometimes find myself thinking of Humpty Dumpty when I look at care plans and daily recording notes.
“Say what you mean and mean what you say!”
We all remember being told this by teachers and parents. But it’s so easy to get into using jargon: we copy words and phrases, from care plans and reports, that sound impressive, and we do this because we believe that we have to write very differently from the way we talk or think.
Support and direction
One of the biggest bees in my bonnet is the way that ‘support’ and ‘direction’ are used all too often to mean restraint. Remember that the MCA definition of restraint has two parts.
You are restraining a person who lacks capacity if you:
- Use force – or threaten to use force – to make someone do something that they are resisting, or
- Restrict a person’s freedom of movement whether they are resisting or not.
Restraint is often needed in the best interests of the person who lacks mental capacity. Think of someone living with dementia who tries insistently to get out of the front door in the middle of the night because they think they’re going to be late for school, or someone with a learning disability or acquired brain injury who impulsively runs across the road whenever they see a cute dog or cat.
Once you’ve recognised the need for restraint, it needs to be transparently right that it’s in the person’s best interests and that no less restrictive option can be identified.
That way, once you’ve recognised restraint, you can find ways to avoid it or to minimise its use. And you can make sure that staff aren’t thoughtlessly using restraint because it’s easier for them.
Protection from liability
The MCA is clear that you and your staff are protected from liability if restraint is the lightest possible, for the shortest possible time. But it must have been decided using the best interests checklist (see MCA code of practice chapter 5) and it must also meet two extra conditions, to gain protection from liability: it must be
- necessary to prevent harm to the person; and
- a proportionate response to how likely the harm is to happen, and how serious it would be.
You may also need to apply for a deprivation of liberty safeguards (DoLS) authorisation, if the entire care plan meets the ‘acid test’; but a major part of best interests decision-making is to start by recognising that every locked door or restraining arm around someone’s shoulders is a restraint, and to record that you’ve followed the right way to work out whether it’s necessary and proportionate.
And you’ll only do this if you remember that Humpty Dumpty can’t get away with calling restraint by other names.
For the MCA code of practice, see
https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice
