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The Management of the Organisation recognises the right of the individual service user to live the lifestyle of his / her choosing, subject to an appropriate Health & Safety Risk Assessment of the individual. Specifically, this Policy summarises the philosophies regarding the use of bed rails as an effective means of restraint when a service user is bed-bound:

1. As part of the original Baseline Assessment of Needs for a service user, Senior Care Staff will have verified the need for careful restraint when the service user is in bed. The following issues will be addressed:

1.1 Whether or not the service user has previously been using bed rails;

1.2 Whether or not bed rails are actually required, or whether alternative equipment may be appropriate.

2. When the service user has been allocated his / her room a full Risk Assessment of the need for bed rails will be made using Form No 3-010. The Risk Assessment will address the following:

  • General Assessment of the service user

  • Suitability of bed rails with bed and service user

  • Design of bed rails

  • Maintenance of bed rail systems

3. A signature allowing the use of bed rails must be obtained from the service user's GP, the Domiciliary Care Services Manager or delegate, and the service user or family. This will be retained in the service user's clinical notes.

4. Bed Rails will be selected according to the following criteria:

4.1 Design of the bed;

4.2 The physical profile of the service user;

4.3 The mattresses and overlays in use - this is of particular importance when pressure relieving mattresses are used. The thickness of these mattresses will effectively reduce the height of the bed rails relative to the top of the mattress and increase the risk of the service user rolling over the top of the rails, and extra height rails will be needed.

5. Care will be taken in the selection and design of the bed rail system in relation to the bed upon which it will be fitted. In particular the following criteria will render the bed rails unsuitable for use:

5.1 Where there is an excessive amount of space between the bars which may present an entrapment hazard.

5.2 Where fittings are not secure.

5.3 Where the height of the rail system leaves a large amount of space between the bottom rail and the mattress.

5.4 Where there is a large gap between the end of the bed rail and the headboard or wall.

5.5 Where it is perceived that the telescopic components of the rail system can easily be moved by the service user.

5.6 Where the bed rail system is not marked with an appropriate BS or CE-mark.

6. Each bed rail system in use will be assigned a unique reference number (“asset number”) for purposes of traceability and planned maintenance. Maintenance of these systems will be carried in accordance with the manufacturer’s instructions, and maintenance records retained as part of the Quality Records System.

7. Whenever there is a change of bed and / or bed rail system, a new Risk Assessment, reference 2. above, will be undertaken.

8. The use of bed rails will be documented in the service user’s Care Plan.


Form No: 3-010 Risk Assessment - Bed Rails

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