Organisational responsibilities

All staff have responsibilities relating to clinically related challenging behaviour. They must:

  • be aware of the risks of challenging behaviour
  • attend training
  • maintain their skills
  • report incidents
  • implement appropriate care strategies
  • maintain a positive, compassionate attitude.

Organisations, at corporate and senior management level, must ensure that there are adequate resources, appropriately trained and skilled staff and support available for staff to meet their responsibilities. In this way organisations will meet their own legal responsibilities as employers and providers of NHS healthcare, and also promote a culture where quality of care is a top priority.

Senior-level engagement

Chief executives, directors and other senior managers should demonstrate strong leadership and good governance by using their influence to support implementation of the recommendations in this guidance. This is essential for achieving high-quality, safe and individualised care, and it should form a central strand of clinical governance and effectiveness.

Organisational strategy

An organisational strategy to prevent and manage challenging behaviour should cover:

  • The delivery of high-quality, individualised treatment and care, where the patient or service user’s experience is of equal importance to any other organisational goal
  • A commitment to the safety of patients, service users and staff
  • A commitment to prevention strategies as a primary objective
  • Proactive strategies to reduce the use of physical interventions
  • An emphasis on compassionate, personalised care
  • Availability of adequate resources, minimum staffing levels, and a highly skilled and trained workforce
  • Strong leadership from senior clinicians, directors of nursing, general and clinical managers and ward managers, who oversee the care delivered by staff
  • Robust risk assessments
  • A process for seeking assurance that these priorities are being achieved, through regular feedback and analysis of incidents and outcomes
  • A challenging behaviour group or lead, where appropriate, to roll out the prevention strategy across the organisation

Organisational culture

Some organisations may find that a change is needed in the organisational culture and the way priorities are communicated from senior managers to staff. A change in attitudes requires leadership and genuine buy-in from managers at all levels. Cultural changes take time, resources and continuous effort.

All staff need to be aware of the benefits that preventing challenging behaviour can bring to quality of care, staff and patient/service user safety and satisfaction, and the organisation’s reputation. Staff should receive support and assistance in implementing the appropriate care strategies. They should be encouraged to share their concerns about the delivery of care and should feel supported to raise issues without fear of recrimination.

Benefits to the organisation

An effective strategy to prevent challenging behaviour can have many benefits, such as:

  • More efficient and effective delivery of care and better outcomes
  • Delivery of important national priorities concerning better quality of care and placing compassion and dignity at the centre of healthcare
  • Increased staff confidence, satisfaction and motivation, and better rates of staff retention
  • Increased satisfaction of patients, service users and carers, and a reduction in complaints and litigation
  • Better communication and better ways to report and discuss solutions
  • Enhanced organisational reputation.

Preventing challenging behaviour can also bring financial savings due to:

  • shorter lengths of stay
  • lower re-admission rates
  • lower levels of staff absence due to sickness and stress
  • lower staff turnover
  • lower requirements for security personnel, safety equipment and medication.

Legal responsibilities

Quality of care

The Care Quality Commission’s (CQC) regulatory framework describes the essential standards of quality and safety that people who use health and adult social care services in any sector have a right to expect. Preventing and managing challenging behaviour is essential to compliance with CQC standards. Please see the CQC website for further information.

Health and safety

Minimising challenging behaviour is a key part of ensuring the health and safety of staff, patients and visitors. In particular, employers are required to:

  • assess the risks posed by challenging behaviour to the health and safety of staff, patients and visitors
  • identify and take any precautions needed
  • appoint competent people to advise on health and safety
  • provide information and training to employees.

More information is on the Health and Safety Executive website.

Local security management specialist (LSMS)

Where applicable, organisations must employ or have access to a Local Security Management Specialist (LSMS) to ensure the safety and security of those who work within and use NHS services. The LSMS should work to ensure the safety and security of staff, patients and service users, and should take part in implementing the organisational strategy to manage the risks associated with challenging behaviour.

Risk assessment

Directors/senior managers should ensure there is a process in place for robust assessment of the risk of clinically related challenging behaviour. Risk assessment provides a good basis for decision making. Where risk assessments identify serious risks relating to challenging behaviour, the organisation will need to examine staff training needs, staffing levels, the design of care, including environmental factors, and current working practices.

Risk assessments can take place at different levels:

  • Individual, e.g. on admission or after an incident. This risk assessment should feed into the care plan.
  • Local, e.g. at unit or ward level. This risk assessment may require a multidisciplinary response to change the delivery of care.
  • Organisational, e.g. by the risk management group for serious incidents which threaten service delivery and require senior-level response.

Lone workers are particularly at risk from challenging behaviour. Guidance on the protection of lone workers is available from NHS Protect.

More details on risk assessment are available in the Managing risk section.

Reporting

Staff may take the view that challenging behaviour is ‘just part of the job’. They may fear that reporting incidents of challenging behaviour would reflect poorly on their abilities or that no action will be taken as a result. Reporting processes may be too complicated, time consuming or unsuitable.

In order to increase the rate of reporting, managers should pass on key messages to staff, such as:

  • High levels of reporting are a sign that the organisation is committed to improving care, recognising individual needs and supporting victims.
  • Good incident reporting assists in identifying trends and patterns, making the organisation aware of high-risk individuals or of wider issues requiring action.
  • Good reporting contributes to improved care quality by highlighting the need for changes to care plans, models of care or the environment.
  • Reporting provides a way for staff to receive support and feedback as well as a learning opportunity.

The organisation should make reporting as easy as possible, by reducing duplication with other risk and care planning documentation. Organisations may consider using a less detailed incident form for lower-level episodes. Organisations should consider ways for staff to take ownership at ward level of challenging behaviour and implement innovative solutions.

Training

A one-size-fits-all approach to training is not an efficient use of resources. Careful analysis of staff training needs and the delivery of bespoke training are essential.

Staff should be supported to attend training in order to increase their awareness of challenging behaviour, as well as to gain and maintain role-specific skills and have access to targeted training commensurate to the risks. At an organisational level, this requires adequate resources to enable staff to take time away from their normal duties. Particularly in high-risk areas, staff should not be expected to manage patients if they have not received the appropriate training.

See the Training section for more detail.

Staffing levels

The approach to preventing and managing challenging behaviour set out in this guidance requires adequate numbers of appropriately skilled staff. Organisations must take responsibility to ensure that risks are addressed, and low staffing levels are not an appropriate reason for falling short of this standard.

Organisations should consider the following in relation to staffing:

  • Optimal staffing levels, including skill levels and mix
  • Continuity of care and its benefits for preventing distress
  • The appropriate use of agency and bank staff, particularly in high-risk areas
  • Keeping a central register of those with physical intervention skills.

For further information on organisational responsibilities, please consult the full guidance document.