HSPOL30 Bed Rails Provide Policy by Provide Community

Version: V1

Ratified by: Quality Reference Group

Date ratified: 27/01/2026

Job Title of author: Head of Health, Safety and Compliance

Reviewed by Committee or Expert Group Frailty Task and Finish Group

Equality Impact Assessed by: Head of Health, Safety and Compliance

1. Introduction

Bed rails (sometimes knows as cot sides) should only be used to reduce the risk of a person accidentally slipping, sliding, falling or rolling out of a bed.

Bed rails used for this purpose are not a form of restraint. Restraint is commonly accepted as the intentional restriction of a person’s voluntary movement or behaviour. Bed rails will not prevent someone leaving their bed and falling elsewhere and therefore should not be used for this purpose.

Bed rails are not intended as a moving and handling aid.

Bed rails are not appropriate for everyone and using bed rails also involves risks. National data suggests around 1,250 inpatients injure themselves on bed rails each year, usually scrapes and bruises to their lower legs.

Based on reports to the Medicines and Healthcare Products Regulatory Agency (MHRA), the Health and Safety Executive (HSE) and the (National Patient Safety Authority (NPSA) deaths from bedrail entrapment in hospital settings in England and Wales occur less often than one in every two years and could probably have been avoided if MHRA advice had been followed. Staff should continue to take great care to avoid bedrail entrapment and need to be aware that in hospital settings there is a greater risk of harm to patients from falling from beds.

Bedrails should not be used for anything but their assessed purpose.

NHS ‘Never events’ number 11 (1) covers chest or neck entrapment in bed rails. NHS ‘never events’ are defined as serious, largely preventable patient safety incidents that should not occur.

2. Purpose

This policy outlines the use of bed rails Provide CIC aims to take all reasonable steps to ensure the safety and independence of people using our services and respects their rights to make their own decisions about their care.

3. Definitions

The Health and Safety Executive (HSE) - is the national independent watchdog for work-related health, safety and illness. They are an independent regulator and act in the public interest to reduce work-related death and serious injury across Great Britain’s workplaces.

The Medicines Healthcare Regulatory Agency (MHRA) is the government agency which is responsible for ensuring that medicines and medical devices work and are acceptably safe. The MHRA is an executive agency of the Department of Health.

Bedrails – In general, manufacturers intend their bed rails to be used to prevent bed occupants from falling and sustaining injury. They are not designed or intended to limit the freedom of people by preventing them from intentionally leaving their beds; nor are

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they intended to restrain people whose condition disposes them to erratic, repetitive or violent movement.

Rigid bed rails can be classified into two basic types:

• integral types that are incorporated into the bed design and supplied with it, or are offered as an optional accessory by the bed manufacturer, to be fitted later

• third party types that are not specific to any particular bed model. They are intended to fit a wide range of domestic, divan or metal framed beds from a different supplier.

Published Guidance - MHRA Safe Use of Bed Rails January 2021 Version 4.0

Deprivation of Liberty Safeguards (DoLS) DoLS are part of the Mental Capacity Act 2005, designed to protect individuals aged 18+ who lack the capacity to consent to care arrangements that deprive them of liberty.

4. Duties

CEO Health and Chief Nurse, Divisional Leads, Directors are responsible for ensuring that this policy is implemented and adhered to across all clinical areas and Provide Care Solutions sites.

Head of Estates, Health and Safety will review incidents that involve the use of bedrails and will investigate as appropriate and report to through Quality and Safety committee.

Ward Manager will assess the conditions of bed rails on the ward, assess their fitness for purpose and will arrange for faulty equipment to be repaired.

• Undertaking audit of bed rail assessments for assurance

• Ensure Risk Assessments are carried out

• Staff are suitably training

• Reporting incidents and near misses relating to patient injury involving the use of bedrails and link with the

Nurse in charge of the ward is responsible for risk assessing the need to use bed rails whenever they are required. If the rails are needed on an ongoing basis this should be reviewed by the multi-disciplinary team and noted in the recovery plan of person using Trust services. Bed rails should not be used routinely and only in cases of reducing risk of falls and improving comfort.

Occupational Therapist may assess the need for bedrails as part of their care for the person using Provide services, wards and in patients own homes.

Registered Manager for Enablement & Care will assess the conditions of bed rails in use assess their fitness for purpose and will arrange for faulty equipment to be repaired. Ensure risk assessments carried out and staff suitably training if bed and grab rails in use.

Medical Device Safety Officers (MDSO)

The MDSO shall ensure that Provide meets its obligations for the monitoring and associated actions of incidents related to medical devices as defined by the MHRA, as well as co-ordinating/ facilitating other device-related safety activities as laid down in national guidelines and this policy.

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Commented [DC1]: Occupational Therapists and Nurses will do this for patients in their own homes as well. As well as some of the Occupational Therapists on the wards will order equipment for use at home.

5. Consultation and Communication

Policy was shared with Quality, Ward Manager, Health and Safety and Falls Group lead

This policy will be shared with all and communicated.

6. Monitoring

The use of bed rails should be monitored by the Divisional Leads and the Registered Manager for Enablement & Care. All incidents reported involving bed rails are to be reviewed by the Health and Safety Team and are reportable to the Health and Safety Oversight Group.

7. Responsibility for Decision Making

The use of bed rails is based on the clinical risk assessment which should be carried out and then appear in the person’s electronic care record clearly recording that the use of bed rails is the safest option when a person is at rest on their bed. This should be in the form of a care plan clearly documenting the rationale for use of bed rails, what alternatives have been considered and the risk considerations that have been looked at. They are not an alternative for high standards of care, nor should they ever be used as a means of restricting a persons’ movements as this would be considered a form of mechanical restraint.

Decisions about bed rails need to be made in the same way as decisions about other aspects of treatment and care as outlined in the Mental Capacity Act 2005. Deprivation of Liberty Safeguards are part of the Mental Capacity Act 2005, designed to protect individuals aged 18+ who lack the capacity to consent to care arrangements that deprive them of liberty. This means:

• the person should decide whether or not to have bed rails if they have capacity. Capacity is the ability to understand and weigh up the risks and benefits of bed rails once these have been explained to them. This may include the use of total communication techniques.

• If the person lacks capacity, staff have a duty of care and must decide if bed rails are in their best interests

• A DoLS to be carried out in Enablement and Care before been used.

In the event of a person sustaining an injury by the use of bedrails e.g. a fall or graze this should be reported via the online incident reporting system.

8. Bed Rails and Falls Prevention

Adjustable variable height beds with integrated sides for all inpatient areas. Note: newly purchased beds or hire beds do not always come with bed rails as standard so staff should assess if they will be needed before procurement.

All bed rails or beds with integral rails have an asset identification number and are regularly maintained.

Commented [DC2]:

Where bed rails are not integrated within the bed frame, they should be cleaned before fitting and cleaned regularly when in use and should not be stored under thebed. When not in use they should be stored safely.

Decisions about bed rails are only one small part of preventing falls. Good practice dictates that a falls risk assessment is completed.

9. Individual Risk assessment

There are different types of beds, mattresses and bed rails available, and each person on is an individual with different needs in line with their care plan.

Most decisions about bed rails are a balance between competing risks. The risks for individuals can be complex and relate to their physical and mental health needs, the environment, their treatment, their personality and their lifestyle. Staff should use their professional judgement to consider the risks and benefits for people who use Trust services.

Bed rails should not usually be used:

• if the person is agile enough and confused enough to climb over them

• if the person would be independent if the bed rails were not in place

• if the person is able to exercise personal preference.

The use of bed rails should be clearly documented on the person’s care record and reviewed regularly by the clinical/Care team on the date stated in the care plan and the risk assessment. This could be as a result of a change in clinical needs or if it is the person’s stated and recorded preference to have bed rails in place as a way of enhancing personal safety or comfort. The use of bedrails is a restrictive intervention and so should always be incident reported, the process of incident reporting serves to acknowledge that all staff are aware that this is a restrictive intervention which the Use of Force Act 2018 requires Mental Health units to monitor and to report.

Bed rails need to be assessed for their use as a ligature point before use and should appear on the units’ ligature audit document compiled by the ward manager or deputy A ligature point is any fixed or protruding structure that could be used to secure a ligature. Common examples include gaps between bed rails, hooks, or exposed joints.

Plus-Sized Patients – Admission of plus sized patients to wards may require the acquisition of specialist equipment from a specialist supplier, example Arjo Huntleigh.

10.Reducing Risk

If a person is at risk of lying dangerously in bed due to agitation, restlessness or other conditions, staff must be aware that this could lead to entrapment. For, feet or arms through rails, halfway off the side of their mattress or with legs through gaps between split rails, this should be taken as a clear indication that they are at risk of serious injury from entrapment.

Should the person be assessed as at risk then urgent changes must be made and recorded in the person’s care record. These could include changing the type of bed, bed rails or adding protective padded sides or an appropriate floor covering such as a crash mat but not a mattress from another bed.

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Commented [DC3]: What is a ligature point - hopefully ward staff will know what this means.

The following should be considered:

Risk of using bed rails

1) Would bed rails stop the person in bed from being independent?

2) Are they likely to climb over their bed rails?

3) Could they injure themselves on their bed rails?

4) Will using bed rails cause them distress?

5) Is there a known or possible trauma history?

6) The use of bed rails need to be clearly communicated during hand over as well as any associated risk with their use.

7) Has a DoLS been completed

Risk of not using bed rails

1) How likely is it that the person will fall out of bed?

2) How likely is it that they could be injured in a fall from bed?

The above principles equally apply to rails on trolleys.

Implementation and Awareness

Ward managers and Registered Managers have a responsibility to ensure that all staff are aware the correct use of bed rails at handovers, business meetings, care planning meetings and in supervision.

Adverse Incidents

All adverse incidents involving bedrails are to be reported via the electronic risk management system Datix/Access

Adverse incidents can be caused by:

• Shortcomings in the device itself

• inadequate instructions for use

• insufficient servicing and maintenance

• locally initiated modifications or adjustments

• inappropriate user practices, including inadequate training

• inappropriate management procedures

• the environment in which the devices are used or stored

• Incorrect provision.

The Health and Safety Team will be responsible for reporting any bed rail adverse incidents to the MRHA via the Yellow Card Scheme

11.Training

Training must be completed in line with the training needs analysis. Staff failing to complete this training will be accountable and could be subject to disciplinary action.. Compliance with training is monitored through the L&D team with monthly reports to managers.

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EQUALITY IMPACT ASSESSMENT TEMPLATE

Stage 1: ‘Screening’

The Equality Impact Assessment needs to be completed so that any decisions made are compliant with the aims of the Public Sector Equality Duty – and that any adverse impact for any protected characteristics are identified and resolved.

Policy Title

CPOL78 Bed Rails Policy

Provide a brief summary (bullet points) of the aims of the Policy

EQIA Assessor Name and Job Title

Head of Health, Safety and Compliance

Date of Assessment

September 2025

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community or whether it is “equality neutral” (i.e. have no effect either positive or negative)

Q1. Will this policy affect one of the following groups more or Less favourably than another?

Details

Group

Age

Consider impact and detail across age ranges on old and younger people. This can include safeguarding, consent and child welfare

Disability

Consider and detail impact on attitudinal, physical, and social barriers.

Sex

Consider and detail impact on men and women (potential to link to carers)

Gender reassignment (including transgender)

Consider and detail impact on transgender and transsexual people. This can include issues such as privacy of data and harassment.

Pregnancy and maternity

Consider and detail impact on working arrangements, part-time working, infant caring responsibilities.

Race

Consider and detail impact on different ethnic groups, nationalities, Roma

More Less Neutral

If more or less, explain impact and any valid legal and/or justifiable exception. Include the source of any evidence

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gypsies, Irish travellers, language and communication barriers.

Religion or belief

Consider and detail impact on people with different religions, beliefs or no belief.

Sexual orientation

Consider and detail impact on heterosexual people as well as lesbian, gay and bi-sexual people

Carers

Consider and detail impact on part-time working, shift-patterns, general caring responsibilities

Other identified groups

Consider and detail on different socioeconomic groups, area inequality, income, resident status (migrants) and other groups experiencing disadvantage and barriers to access.

Assessed Impact overall  Positive X Neutral  Negative

Is the impact of the initiative – whether positive or negativesignificant enough to warrant a more detailed Stage 2 assessment?

 Yes X No

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

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QUALITY IMPACT ASSESSMENT TEMPLATE

Stage 2

To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities?

Are any of these groups under- or over-represented?

Do they have access to the same resources?

What are your sources of data and are there any gaps?

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations?

If yes, how? Which are the main groups it will have an impact on?

Q3. Will the initiative have an adverse impact on any particular group or community/community relations?

If yes, in what way? Will the impact be different for different groups – e.g. men and women?

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative?

Summarise (bullet points) any important issues arising from the consultation

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact?

Are there specific factors which need to be taken into account?  Yes  No

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

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