1. Declaration

I first became aware of the Restraint Reduction Network™, in or around 2016.

Frankly, I liked what I saw and on 31st March 2016, I happily made the ‘pledge’ required of RRN™ members, i.e. to agree to ensure the 12 common values and principles are at the core of all our services and all our practice.

I would advocate all NHS service providers commit to the same pledge. However, for the reasons outlined herein, I do not support the imposition of the RRN Training Standards accreditation and certification process.

2. About the Restraint Reduction Network™

The Restraint Reduction Network™ (RRN™) is an independent network which brings together committed organisations providing education, health and social care services for ‘people who may challenge’.

The network has an ambitious vision to deliver restraint-free care and support and make a real difference in the lives of people who use education, health and social care services.

The RRN™ was originally co-founded by the Crisis Prevention Institute (CPI) along with other key figures, to facilitate the spread of best practice and access to guidance on restraint reduction.

In 2017, the RRN™ began to develop training standards based on the Six Core Strategies for Reducing Seclusion and Restraint Use produced by the National Association of State Mental Health Program Directors (USA) and revised 20/11/2006 by Kevin Ann Huckshorn.

3. In 2018, HEE was tasked with providing ‘Certificated Training Standards’

When the Mental Health Units (Use of Force) Bill was introduced to Parliament on 19th July 2017 by Steve Reed MP, it was initially proposed that the Care Quality Commission (CQC) would be responsible for producing the Guidance/Code of Practice to accompany the legislation and also for setting and enforcing standards of training for staff working in Mental Health Units.

However, at the first sitting of the Bill, this was changed to be the responsibility of the Secretary of State. As a consequence, Health Education England (HEE) was then tasked to ensure ‘quality standards’ were in place for training and that training was ‘certificated as complying with the Training Standards’.

HEE then commissioned the Restraint Reduction Network to develop Training Standards for ‘training in the prevention and use of restrictive interventions’ to support best practice in supporting people who may become distressed and also meet the Mental Health Units (Use of Force) Act 2018 requirements for training.

On 30th April 2019, it was announced that HEE had also commissioned the UK Accreditation Service (UKAS) to establish a process to deliver ‘Accredited Certification’ of training services as ‘complying with the Restraint Reduction Standards (RRN) Training Standards’.

4. The BILD Restraint Reduction Network

In or around 2019, the British Institute of Learning Difficulties (BILD) took over responsibility for the facilitation and stewardship of the RRN™ and set up a separate charity organisation called the BILD Restraint Reduction Network (BILD RRN) for the purpose.

The charity’s Patron is Sir Norman Lamb, (formerly Minister of State at the Department of Health.)

BILD RRN officially launched the Restraint Reduction Network Training Standards in April 2019.

BILD RRN owns the Restraint Reduction Network Training Standards 2019 and the Certification Scheme (as agreed by UKAS and HEE) and licences* the Standards to certification bodies, subject to agreement to the scheme rules.

* Certification bodies licence the standards from Restraint Reduction Network for agreed royalty rate (of 20%).

5. The BILD Association of Certified Training is a ‘Licensed’ Certification body

BILD Association of Certified Training (BILD ACT) is another registered charity separate from BILD and is a certification body accredited by United Kingdom Accreditation Service (UKAS) as complying with the ISO 17065:2012 certification standards.

BILD ACT is licensed by the Restraint Reduction Network to use the Restraint Reduction Network Training Standards and deliver the Restraint Reduction Network Certification Scheme.

As at, 31st March 2020, 38 organisations were certified under the RRN Certification Scheme, with a further 23 working towards certification. (It takes approximately one year to work through and achieve certification.)

6. Compliance is a ‘contractual requirement’ for some NHS commissioned services

In April 2020, providers of NHS commissioned providers of mental health and learning disability services and providers of mental health secure services were ‘required’ to only use certified training services for training in ‘restrictive practices’. The requirement was included in the NHS Standard Contract 2020/21 – Technical Guidance. (See 41.5)

The same contractual ‘requirement’ was repeated in the NHS Standard Contract 2021/22 – Technical Guidance. An extract appears below in Italics.

41.5 We normally set out national requirements for specific areas in which commissioners and providers should agree Service Development and Improvement Plans (SDIPs) for the coming year. Given the unusual circumstances of 2020/21, we are largely rolling these requirements forward for 2021/22.

Commissioners should agree SDIPs for 2021/22:

  • with providers of mental health and learning disability services and with providers of mental health secure services, to set out how the provider will now roll out certified training in restrictive practices to all relevant staff (this builds on the 2020/21 requirement for the provider to identify a training supplier (whether in-house or external) certified (by a UKAS accredited certification body) as complying with the Restraint Reduction Network Training Standards published at http://restraintreductionnetwork.org and in accordance with the Mental Health Units (Use of Force) Act 2018;

41.6 As in previous years, the intention of these mandatory SDIPs is not to require significant additional investment from commissioners or providers; rather, it is to encourage joint management action to tackle these important priorities to the extent possible within available resources.

7. The RRN Training Standards

The Restraint Reduction Network Training Standards 2019 provide cross sector standards* (i.e. not NHS specific) for training in restrictive practices that are recognised and endorsed by relevant government departments, professional bodies and charities. The RRN Training Standards are claimed to be “evidence based” and informed by government policy, guidance and the consensus views of professionals and experts in the field.

* Whilst the RRN Training Standards may be useful to the private security industry, they are not specifically designed for training providers outside of education, health and social care sectors.

8. The primary aim is to reduce risks associated with poor training and practice

The rationale for the RRN Training Standards 2019 is stated (at page 12 of 185) as:

“There are a number of organisations providing training in supporting people in crisis, and there is a range in the quality of their provision. The lack of quality assurance and oversight of such training programmes leads to a concern that staff may be trained to use a range of restrictive interventions that may not necessarily be appropriate or properly risk assessed for use. These concerns have been highlighted on many occasions through service reviews, and by training commissioners, families and staff who have been through training. The Training Standards aim to address these concerns. Poor quality training focuses primarily on reactive approaches such as physical restraint and places insufficient emphasis on human rights, meeting needs, prevention, de-escalation and recovery. Most importantly, it fails to sufficiently explain the traumatic nature of restraint. If training places insufficient emphasis on restraint prevention and de-escalation, staff will understandably be more likely to use restrictive interventions as a first resort, rather than last resort, resulting in an over reliance on restrictive interventions.”

And, (at page 13 of 185) as:

“Training that includes restrictive interventions is potentially dangerous and distressing for everyone involved and therefore quality standards are essential.”

The RRN Training Standards are aimed to ensure staff training is directly related and proportional to the needs of populations and individual people and also to ensure that training is delivered by competent and experienced training professionals (who can evidence knowledge and skills that go far beyond the application of physical restraint or other restrictive interventions).

In addition to improving training and practice, the RRN Training Standards are aimed to:

  • Protect people’s fundamental human rights and promote person centred, best interest and therapeutic approaches to supporting people when they are distressed;
  • Improve the quality of life of those being restrained and those supporting them;
  • Reduce reliance on restrictive practices by promoting positive culture and practice that focuses on prevention, de-escalation and reflective practice;
  • Increase understanding of the root causes of behaviour and recognition that many behaviours are the result of distress due to unmet needs;
  • Where required, focus on the safest and most dignified use of restrictive interventions including physical restraint.

Note: The Restraint Reduction Network Training Standards (2019) aim to facilitate culture change, not just technical competence.

9. The purpose of Certification

The purpose of certification is to:

  • Demonstrate compliance with the Restraint Reduction Network Training Standards 2019;
  • Provide a quality mark to support commissioning of high-quality training;
  • Provide an enabling scheme that not only offers quality assurance but also supports a culture of continuous improvement;
  • Provide a robust, effective, consistent system and to be equitable and impartial in its application;
  • Reduce risks associated with poor training and practice.

Note: The RRN Training Standards Certification Scheme does not certificate providers, curricula or trainers separately. Valid certification only applies when all three are in combination, though the certification scheme trainers are authorised to deliver approved curricula on behalf of the training provider.

10. Is Certification costly?

Yes.

See the BILD ACT Customer Handbook – page 12

And the cost doesn’t end with application!

11. What’s involved in Certification?

The BILD ACT – Certification Customer Handbook 2021, version 6 issued 22/02/2021 (40 pages) sets out how training organisations will be assessed against the Restraint Reduction Network Training Standards.

The Certification Customer Handbook 2021 needs to be read alongside the RRN Training Standards Certification Scheme (17 pages).

Applicant training providers must complete an online self-assessment tool and are given log in details after payment of the £6,995 Application fee.

Training organisations must be able to show how they have embedded a ‘human rights-based approach’ within their training curriculum.

The training must make clear reference to how the Human Rights Act 1998 and other key legislation work together in practice and MUST include reference to:

  • Mental Health Act 1983 (amended 2007)
  • The Children’s Act 1989 (as amended) and the Children and Families Act 2014
  • Criminal Law Act 1995
  • Criminal Justice Act 1995
  • Adults with Incapacity (Scotland) Act 2000
  • Mental Health (Care and Treatment) (Scotland) Act 2003
  • Mental Capacity Act 2005 (including Deprivation of Liberty Safeguards (DOLS) or its equivalents)
  • Equality Act 2010
  • The Care Act 2014
  • Mental Health Act Code of Practice 2015, Chapter 26
  • Mental Capacity Act (Northern Ireland) 2016*

Note: No mention of the Mental Health Units (Use of Force) Act 2018 in the ‘required’ list?

The training must provide an understanding of the positive obligation* of staff to take action to protect human rights, including safeguarding against serious harm arising from the use of restrictive interventions.

* Actually, whilst public authorities may have positive obligations under the HRA, staff don’t.

The training also needs to include content on trauma-informed care and how trauma exposure can affect patients’ neurological, biological, psychological and social development.

12. The ‘Standards’ that stand out to me

This section provides a selection of the RRN Training standards, that caught my eye.

Section 1

Standards 1.1–1.8 (These standards cover the part of the process that needs to be completed before a curriculum is developed.)

RRN TS Page 37
1.1.3 As part of the agreement to provide any training in physical restraint and before commencing the training, both the training provider and the trainer who delivers the programme must satisfy themselves that the commissioning organisation has the appropriate level of immediate life support training (including required refresher training). This should be in accordance with the guidelines of the UK Resuscitation Council for immediate life support – see Resuscitation Council (UK).

Note: The Immediate Life Support course accredited by Resuscitation Council (UK) is a One-Day course (6 hours 50 minutes)

RRN TS Page 39
1.2.1 The training provider (a named person) must develop a written proposal for the curriculum that covers both theory and practical elements. If restrictive interventions are being taught, participants must have completed a minimum of two days’ training (12 hours) in the underpinning theory, including training in preventative and secondary strategies, as specified in standards 2.1– 2.15, prior to participating in a practical, physical skills training session.

The majority of these two days must be face-to-face to ensure that discussion and demonstration can take place, and blended learning could be considered for some elements where it enhances understanding.

Training providers must be able to evidence that the training methods they choose are effective in supporting learning and cultural change.

RRN TS Page 45
1.3.7 These standards do not support the use of pain to gain compliance. Training providers must not include the teaching of any restrictive intervention that uses pain to force an individual to comply (see also appendices 21a and 21b).

RRN TS Page 46
1.4.4 Training providers must have a Restraint Reduction Plan which details measurable outcomes and actions that support the reduction of the use of restrictive practices. The plan must be updated at least annually and shared with commissioning organisations or published via Restraint Reduction Network membership.

RRN TS Page 47
1.5.1 Training providers must ensure that the views and experiences of people with lived experience of being in receipt of restrictive interventions should both inform and be explicit in training content.

1.6.5 Training providers should take into consideration the likely gender balance of participants and trainers. (No further advice or info on what action to take is provided?)

RRN TS Page 48

1.7.1 Accessible information must be available to everyone who will be directly or indirectly impacted by the training.

The information must:

  • Be available to the commissioning organisation to disseminate and also readily available for any individual or representative of an individual who makes a request;
  • Be in a format that best suits people’s communication requirements and needs;
  • Cover both the theory and practical aspects of the training. All restrictive interventions that are to be taught must be described, alongside potential risks and the rationale for their inclusion in the programme.

Section 2

Standards 2.1–2.15 (These Standards describe areas that the curriculum must cover.)

2.9.1 Training content must cover service factors that may include, among other things, inadequate policies, poor leadership, lack of appropriate training and supervision, inadequate staffing levels, negative team or organisational cultures, power imbalances, and lack of opportunity or encouragement for reflective practice.

Section 3

Standards 3.1–3.6 (These standards relate to post-delivery processes.)

RRN TS Page 80
Standard 3.1
Training must include a competence-based assessment within each programme, with participants being assessed for both knowledge and skills. It is recognised that such assessments can only assess participants’ skills within a training environment.

3.1.1 Training providers must establish assessment criteria which are consistent with the level of training which has been commissioned.

3.1.2 The training provider must have assessment methods which take into account any reasonable adjustments that people need. (NB: When testing the competence to apply a restrictive intervention any reasonable adjustments must not compromise the safety of the restrictive intervention when it is applied in practice.)

3.1.5 If participants fail to reach the level of competency required by the training provider, the training provider must agree with the commissioning organisation (service provider) the necessary actions for the participant. This may for example involve a personal learning plan, a repetition of the training within six months, a bespoke training programme or a coaching intervention. The training provider must recommend that the participant should not be involved in the direct application of restrictive interventions until they are able to provide evidence of competence.

3.1.6 The training organisation must provide the commissioning organisation (service provider) with written feedback on the assessed performance of each course participant.

3.2.1 Training providers must ensure that their trainers maintain complete, accurate and up to date records of each course they deliver. (This must include confirmation of each participant’s fitness to attend the programme as well as any concerns related to the conduct or values of any of the participants.)

3.3.1 Training providers must have a policy that outlines the procedure for handling any concerns about the conduct of participants arising during training sessions. This policy must be available to the trainer before any training is delivered.

Standard 3.5
Training providers must have internal quality assurance systems and be able to provide evidence that they effectively monitor the quality and consistency of all of their training services.

Training providers must be able to evidence that their training services are being consistently delivered and that they routinely adhere to all the training standards.

Training providers must use their own quality assurance process to identify and action improvement priorities.

Note: Page 17 of the RRN Training Standards Certification Scheme (5. Assessor Competency) states: ‘All training organisations must have a named assessor. All new assessors must meet the competency criteria of the Restraint Reduction Network scheme and be subject to a peer review facilitated by CABs. Restraint Reduction Network will issue the competency criteria and peer review criteria to CABs. Assessors that do not meet the criteria may shadow but not lead an assessment.’

Section 4

Standards 4.1–4.7 (These standards relate to trainers)

4.2.2 All trainers delivering training in restrictive interventions must hold current first aid certification including immediate life support.

4.3.2 All trainers must have been continuously employed in a support or care role within social care, education or a health care environment for a period of not less than two years.

4.3.3 All trainers must have successfully completed a face-to-face ‘train the trainer’ programme of a minimum of 30 hours or 5 days in length (which may be an accredited qualification for example a diploma or BTEC). The competence to deliver the whole of the curriculum must be assessed during and at the end of the train the trainer programme.

4.3.4 All senior trainers must successfully complete a minimum of two days’ refresher training annually.

4.3.5 Training providers must specify CPD requirements for all trainers who deliver their programmes. Evidence of relevant CPD records of trainers must be kept by the training provider to ensure quality, knowledge and skills are maintained.

4.6.6 Trainers must exclude any participant from the course whom they believe to be unsuitable for training.

4.7.2 All trainers must have at least one peer evaluation per year. Trainers must be able to show evidence of having one peer evaluation per year and be able to demonstrate how they have used it to further their professional development.

In some circumstances, a commissioning organisation will already have a model of preventative working in place, such as Safewards or Positive Behaviour Support, and this training may be delivered by another agency. In this circumstance the training programme that is commissioned with a restrictive intervention component may not need to include the content covered in standard 2.5, but the trainer must have the knowledge to teach all the other areas of the curriculum covered in the standards.

13. Observations

There can be little doubt that a decision to invest in the RRN Training Standards Certification Scheme is going to tie NHS Trusts, Training Providers and Trainers into a hamster-wheel of recurring expenses and time consuming bureaucracy – for not a lot in return.

Unfortunately, it would seem that HEE have just created a cash cow for BILD (and UKAS).

When you pear it down, the RRN Training Standards Certification Scheme is nothing more than a quality assurance process, (similar to an ISO 9000 quality assurance process), that just supports the NHS Trust’s own quality assurance processes which, if they are robust and effective, would call into question why the reason for needing to get them ‘seconded’ by the RRN Training Standards Certification Scheme?

This is what training provider Mark Dawes (National Federation for Personal Safety) said in an article titled: ‘Why The RRN Standards Are Unworkable’, published September 2020:

“What do I get by adopting the RRN standards and BILD certification? The answer seems to be nothing, apart of course from increased interference and more complicated logistical and bureaucratic processes.”

The RRN Training Standards Certification Scheme does not advise on or recommend or accredit or endorse or promote any brand of physical intervention or restraint training.

Will participation in the RRN Training Standards Certification Scheme reduce risks associated with poor training and practice? Possibly, but only if the training that was previously being provided was inappropriate!

Will the certification scheme improve staff performance and practice? In my opinion it’s unlikely.

Will the RRN Training Standards Certification Scheme result in reduced variation in the quality of training provided to NHS Staff? No. The only way to do that would be for HEE to specify the training content, timings, etc., and also specify competency requirements and associated assessment methods. It beggars the question why they haven’t done that?

Will RRN Certified Training result in improved reporting of restrictive practices or less abusive mistreatment of patients? In my opinion that would be unlikely, because that would require a significant culture change.

Will the RRN Training Standards Certification Scheme result in the necessary culture change? Again, that is unlikely. Culture change is driven by positive leadership, role-modelling and effective supervision, not through training (especially on its own).

Some commentators, including myself, share concerns that the costs of compliance will strangle smaller training providers out of business, (some say ‘by design’), thereby increasing market share for larger organisations, such as CPI International, (a founder member of the Restraint Reduction Network™ and the provider of the training programme framework used by the RRN as the basis for the RRN Training Standards.)

The Restraint Reduction Network Training Standards appear to be designed for mental health in-patient settings and can’t easily be applied to other NHS services (e.g. acute hospitals, where any necessary physical restraint is conducted by security officers.)

The cost and the logistics involved in meeting the ‘requirements’ for RRN Training Standards Certification will mean some NHS service providers (and in particular, acute hospital service providers) may find it simply impractical to comply.

For example, if 5,000 staff at an NHS Trust were identified as needing the training then, since the minimum training requirement for training in ‘restrictive practices’ is three-days of face-to-face, classroom-based training per person and, with a maximum of 18 delegates per course, that would equate to 833 training days and the equivalent of 15,000 individual days spent away from the normal workplace. On top of that, you also need to factor in how many NHS staff will FTA on training days (for a range of reasons) and the extra training days that’ll be needed for them to be trained and, in addition, factor in all the extra time that will be needed to conduct the obligatory ‘competency assessments’ and complete the ‘reporting processes’ and then, you also need to factor in the requirement for annual (one day) refresher training.

The overall expense (in time, effort and money) involved in participating in the RRN Training Standards Certification Scheme, when balanced against the supposed benefits, would simply not be a justifiable business proposition. This would excuse ‘non-compliance’ with the contractual requirement* for providers of NHS commissioned providers of mental health and learning disability services and providers of mental health secure services to only use certified training services for training in ‘restrictive practices’.

*s.41.6 NHS Standard Contract 2021/22 – Technical Guidance makes it clear that the intention of mandatory SDIPs is not to require significant additional investment from commissioners or providers; rather, it is to encourage joint management action to tackle important priorities to the extent possible within available resources.

And, for some, the rigmarole involved in certification and maintaining certification would also fail the test of being a ‘reasonable and practicable’ step to reduce risk that employer organisations would be required to take under S.2 Health & Safety at Work Act.

It should be noted that, if a decision is taken to defer participating in the RRN Training Standards Certification Scheme, NHS Mental Health Units must still comply with the requirements of the Mental Health Units (Use of Force) Act 2018 (as previously discussed in NHS-Security-Info-Free-download-#8-AEGIS-Protective-Services) and need to be able to demonstrate to CQC Inspectors how they are meeting those legal requirements.

It’s important to recognise that when CQC Inspectors are conducting an inspection they will not be delving into the ‘ins and outs’ of the RRN Training Standards Certification Scheme but, instead, will be looking to assess compliance with the Essential Standards of Quality and Safety (See page 92, Outcome 7: Safeguarding people who use services from abuse.

Exactly what CQC Inspectors are looking for during an inspection will vary according to the type of inspection it is and will be informed by the relevant CQC ‘Brief guide’.

Note: Brief guides are a learning resource for CQC inspectors. They provide information, references, links to professional guidance, legal requirements or recognised best practice guidance about particular topics in order to assist inspection teams.

For example:

See a full list of CQC Brief guides here.

Whatever decision you choose to take, I hope you have found the info in this report useful.

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If you would like to discuss any aspect Healthcare Security, please feel free to give me a call.

Jim O’Dwyer
Senior Consultant
AEGIS Protective Services

T: 01202 773736

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