What happened
Rifford Road is a Devon County Council children’s home in Exeter. It provides planned and emergency short-term care for up to seven young people with emotional or behavioural difficulties. Four boys aged 12 to 17 were living there when Ofsted inspected.
The inspector visited in July 2013 and found a high number of physical interventions. Staff did not “always use effective de-escalation techniques”, and behaviour sometimes escalated as a result. Her report said: “The use of restraint has increased and high level restraints are used, including prone positioning.” Many of those restraints were judged inappropriate and excessive. Injuries sustained during restraint were not adequately followed up.
The judgement was inadequate. Six months earlier the home had been rated good. The inspection came months after Ofsted had found child protection services in the county inadequate.
The outcome
The council suspended 11 members of staff and installed new management. It stopped new admissions until it was satisfied that lessons had been learned, and moved three of the four children to other placements. It said risk assessments had since been carried out on the children and that it was confident they were safe and well cared for.
The council began working with Barnardo’s to review all three of its children’s homes, and a Children’s Safeguarding and Looked After Children Improvement Board was set up. No prosecution, enforcement notice or other legal outcome is recorded beyond the inspection judgement.
What went wrong
Four findings sit together and describe one mechanism. Physical interventions were frequent. De-escalation was not reliable, so behaviour escalated to the point where staff felt a hold was needed. The high-level techniques in the mix included prone positioning, face down, and many of the holds were judged inappropriate and excessive. Then the fourth: injuries from restraint were not properly followed up, so nothing came back to the people deciding how holds were used.
A home can hold all four of those facts and still look calm on paper. That is why the drop from good to inadequate in six months surprised the council.
What it teaches
Prone restraint in the high-level mix at a short-break home is the pattern to look for. Rising numbers, weak de-escalation, and injuries nobody follows up. Ask for the restraint log and the injury record together, because either one alone hides the other.
The number tells you volume. The injury record tells you whether the holds were safe. A service that counts restraints but does not read the injuries is measuring activity, not safety.
Eleven suspensions is what an unexamined restraint culture looks like when it reaches an inspector. It is also a question about supervision. If eleven people were applying holds that a regulator called excessive, who was watching before the visit?
Questions for the room
- The home went from good to inadequate in six months. What would you expect to find in the log that an inspector saw and a manager did not?
- You are the manager and the restraint numbers are climbing. What do you change first, and how would you know it worked?
- Injuries were recorded and not followed up. Who should read that record, and how often?
- Eleven staff were suspended. What does that number say about supervision before the visit?
Evidence and limits
Confidence: probable. Two outlets reported the inspection, but both rest on one Ofsted report, and that report was not opened. The judgement as printed here rests on press quotation. The second outlet’s page returned no article text when checked.
The children are not named and none is identified. The record gives no inspection date beyond July 2013, so none is stated.
Our restraint reduction training covers how services bring restraint numbers down, and how to keep them down.
Sources
Reviewed 20 October 2026.