Refusal, fluctuating capacity, restraint, and restrictions

When someone says no, pulls away, becomes distressed, or resists care, staff should not automatically see this as bad behaviour. It may reflect a refusal by someone who has capacity for that decision, pain, fear, misunderstanding, trauma, fatigue, or fluctuating capacity. The response must be thoughtful and lawful.

Responding to refusal safely

• Pause and check what is happening: is the person refusing, or are they confused, frightened, in pain, or unable to process what is being asked?
• Re-explain and adjust: try simpler language, a different time, a familiar staff member, more privacy, or a slower approach.
• Respect refusal where the person can decide: if the person has capacity for that decision, their refusal matters even when others disagree.
• Escalate essential care concerns: repeated refusal of hydration, food, medicines, wound care, or urgent assessment should not be managed informally for too long.
• Avoid staff-convenience thinking: the care plan and timetable do not override the person's rights.

Restrictions, restraint, and deprivation of liberty

CQC expects adult social care services to promote supportive practice that avoids the need for physical restraint wherever possible. If restraint is ever used under the Mental Capacity Act, it must be necessary to prevent harm and proportionate to the likelihood and seriousness of that harm.

Restrictions can include locked doors, constant supervision, bed rails, lap belts, sensor-based restrictions, taking away walking aids, or holding someone to complete care. Staff should think carefully about whether a restriction is truly necessary, whether a less restrictive option exists, and whether the care plan and legal authority are clear.

In England and Wales, care homes and hospitals still use Deprivation of Liberty Safeguards (DoLS) where an adult lacks capacity to consent to care or treatment arrangements, is under continuous supervision and control, and is not free to leave. Proposed Liberty Protection Safeguards have not replaced DoLS. Scotland and Northern Ireland use different legal safeguards, so staff should follow local policy and escalate possible deprivation of liberty concerns promptly.

What managers and supervisors should review

Refusal should trigger curiosity and lawful review, not automatic force. If restrictions are needed, they must be necessary, proportionate, and properly authorised.