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Registration Number: {{org_field_registration_no}}

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Locking Service User’s Doors Policy

1. Purpose

This policy sets out {{org_field_name}}’s arrangements for the lawful, safe and proportionate use of locks on service users’ bedroom and other personal doors. It is intended to protect each person’s privacy, dignity, autonomy, safety and right to liberty whilst ensuring that appropriate emergency access, security and fire-safety arrangements are maintained.

Any restriction on a service user’s movement, including locking a door in a way that prevents or limits the person from leaving a room or area, must have a clear and lawful basis. A risk assessment alone does not provide legal authority to restrict a person’s liberty. Any restriction must comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulations 9, 10, 11, 12, 13, 15 and 17, the Mental Capacity Act 2005 where applicable, relevant deprivation-of-liberty requirements and current case law.

The service will distinguish between:

• a service user choosing to lock their own door for privacy or security;
• staff locking or controlling access to a door as part of the person’s agreed care arrangements; and
• locking arrangements that restrict or prevent a person from leaving a room, area or the care home and which may constitute restraint or contribute to a deprivation of liberty.

No service user will be locked in a room, prevented from leaving, or otherwise subjected to restrictive door arrangements solely for staff convenience, routine organisational practice, behaviour management or because this is easier than providing appropriate care and supervision.

2. Scope

This policy applies to all employees at {{org_field_name}}, including care workers, nurses, support staff, and management. It covers the circumstances under which service users’ doors may be locked, the rights of service users, security protocols, emergency access, and staff responsibilities.

3. Legal and Regulatory Framework

This policy must be implemented in accordance with the following legislation and regulatory requirements, as applicable:

• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 9: Person-centred care. Care and treatment, including decisions about door security and restrictions, must be appropriate, meet the service user’s needs and reflect their preferences.
• Regulation 10: Dignity and respect. The service must respect each person’s privacy, dignity, independence and autonomy.
• Regulation 11: Need for consent. Care and treatment must be provided with the consent of the relevant person. Where an adult lacks capacity to give consent to the particular decision, the service must act in accordance with the Mental Capacity Act 2005.
• Regulation 12: Safe care and treatment. Risks arising from door locking, access, emergency access and associated care arrangements must be properly assessed and mitigated.
• Regulation 13: Safeguarding service users from abuse and improper treatment. A service user must not be subjected to unnecessary or disproportionate control or restraint and must not be deprived of their liberty without lawful authority.
• Regulation 15: Premises and equipment. Security arrangements, including locks on doors, must be suitable, properly used and maintained, protect people when lawful and necessary, and must not inadvertently or unlawfully restrict the movement or liberty of other service users.
• Regulation 17: Good governance. Accurate, complete and contemporaneous records must demonstrate the assessments, decisions, authorisations, monitoring and reviews relating to restrictive practices and door-locking arrangements.
• Mental Capacity Act 2005. Staff must follow the statutory principles of the Act, including the presumption of capacity, support for decision-making, best-interests requirements and the requirement to consider whether the purpose of an intervention can be achieved in a less restrictive way.
• Mental Capacity Act 2005 provisions concerning restraint. Where a person lacks capacity for the relevant decision, any restraint relied upon under the Act must be necessary to prevent harm to that person and proportionate to the likelihood and seriousness of that harm.
• Deprivation of Liberty Safeguards and other applicable lawful authority. Where care arrangements amount to a deprivation of liberty, the service must ensure that the deprivation is authorised through the applicable legal process.
• Human Rights Act 1998 and Article 5 of the European Convention on Human Rights. The service must respect the right to liberty and security and must not deprive a person of liberty without lawful authority and appropriate procedural safeguards.
• Human Rights Act 1998 and Article 8 of the European Convention on Human Rights. Door-locking arrangements must respect private and family life, home and personal autonomy.
• Equality Act 2010. Decisions and arrangements must not discriminate unlawfully against a service user because of a protected characteristic.
• Regulatory Reform (Fire Safety) Order 2005, as amended. Locking arrangements must be consistent with the home’s fire risk assessment, means-of-escape arrangements and other applicable fire-safety requirements.
• Current case law relating to deprivation of liberty, including [2026] UKSC 16. Decisions about whether particular arrangements amount to a deprivation of liberty must reflect current law and applicable CQC or Government guidance.

Where the legal position is uncertain, particularly in relation to whether restrictive arrangements amount to a deprivation of liberty, the Registered Manager must obtain appropriate professional or legal advice rather than relying on local custom or previous practice.

4. Principles of Locking Service Users’ Doors

{{org_field_name}} will apply the following principles:

• Privacy and autonomy: A service user who has capacity to make the relevant decision should normally be able to decide whether to lock or unlock their bedroom door, subject to lawful and necessary fire-safety and premises requirements.
• Presumption of capacity: Staff must not assume that a person lacks capacity because of age, disability, diagnosis, dementia, communication difficulty, behaviour or because the person makes a decision that staff consider unwise.
• Individual decision-making: Door-locking arrangements must be based on the individual person’s circumstances and must not be imposed as a blanket rule on a group of service users.
• Consent: Where the person has capacity, their informed consent or refusal must be respected unless another specific lawful authority permits intervention.
• Least restriction: Where a restriction is necessary, staff must consider whether the purpose can be achieved effectively in a way that is less restrictive of the person’s rights and freedom of action.
• Necessity and proportionality: Any restrictive intervention must be necessary for its identified purpose and proportionate to the likelihood and seriousness of the harm it is intended to prevent.
• No restriction for convenience: Doors must never be locked or controlled merely because this is easier for staff, because staffing arrangements are inadequate or as a routine method of managing behaviour.
• Emergency access: The service must have a safe means of obtaining prompt access to a locked room where access is lawfully required because of an emergency or an immediate risk to life or safety.
• Fire safety: Locks and associated arrangements must not undermine fire precautions, means of escape or the requirements identified through the fire risk assessment.
• Regular review: Restrictive arrangements must continue only for as long as they remain lawful, necessary and proportionate and must be reviewed whenever circumstances change.

5. When and How Service User Doors May Be Locked

Service User Choice and Privacy

A service user who has capacity to decide whether to lock their bedroom door may choose to lock or unlock it for privacy and security, provided that the locking arrangement is compatible with applicable fire-safety requirements and does not place other people at risk.

Where reasonably practicable, the person must be provided with an appropriate means of locking and unlocking their door independently. Any key, electronic access device or alternative arrangement must be suitable for the individual’s abilities and needs.

Staff must explain any essential emergency-access arrangements to the service user.

Staff-Imposed or Staff-Controlled Locking

Staff must not lock a service user in their bedroom or otherwise prevent them from leaving a room merely because a risk assessment identifies a risk.

Before any staff-imposed restriction is implemented, the Registered Manager or appropriately delegated competent person must establish:

• the precise risk or harm being addressed;
• whether the person has capacity to make the specific decision about the proposed arrangement;
• the person’s wishes, feelings, preferences and objections;
• whether a less restrictive option can safely achieve the intended purpose;
• the lawful basis for the proposed restriction;
• whether the restriction constitutes restraint for the purposes of the Mental Capacity Act 2005;
• whether the restriction, alone or together with the person’s wider care arrangements, may amount to a deprivation of liberty;
• whether a DoLS authorisation, Court of Protection order or other lawful authority is required; and
• how and when the arrangement will be monitored and reviewed.

Where the person lacks capacity and staff rely upon the Mental Capacity Act 2005 in relation to restraint, the restraint must be necessary to prevent harm to that person and proportionate to the likelihood and seriousness of that harm.

Consent must never be described as having been obtained “where possible”. Either the person has the relevant capacity and gives valid consent, or there must be another lawful basis for the intervention.

Emergency Access

The service must maintain a reliable method of emergency access to service users’ rooms.

Master keys, override devices or other emergency-access systems must:

• be securely controlled;
• be available promptly to authorised staff;
• be tested or checked in accordance with the home’s maintenance and fire-safety arrangements; and
• only be used where there is a legitimate and lawful reason for entering the person’s room.

Emergency entry into a service user’s room must be recorded where the circumstances are significant, including the reason for entry, action taken and any follow-up required.

Welfare Checks

Staff must not carry out routine room entry or observation solely because a service user has chosen to lock their door.

Any welfare checks requiring access to a private room must be individually assessed, proportionate to the identified risk and recorded within the person’s care plan or risk-management arrangements. Wherever practicable, the person’s wishes and preferences about how checks are undertaken must be respected.

6. Assessing Capacity, Consent, Best Interests and Deprivation of Liberty

Capacity

Capacity must be presumed unless it is established that the person lacks capacity to make the particular decision at the time the decision needs to be made.

Where there is a reasonable basis to doubt capacity, an assessment must relate specifically to the decision in question, for example:

• whether the person wishes to lock their own bedroom door;
• whether the person understands and agrees to staff having access;
• whether the person agrees to a proposed restrictive locking arrangement; or
• whether the person can consent to the wider care and residence arrangements relevant to a possible deprivation of liberty.

Before deciding that a person lacks capacity, staff must take all practicable steps to support the person to make the decision themselves. This may include providing information in an accessible format, using communication aids, involving interpreters or communication specialists, choosing an appropriate time and environment, and giving the person sufficient time to understand and communicate their decision.

The capacity assessment and the evidence supporting its conclusion must be recorded.

Service Users Who Have Capacity

Where a service user has capacity to make the relevant decision:

• their informed consent or refusal must be respected;
• staff must not override their decision merely because it appears unwise or involves some degree of risk;
• identified risks must be discussed with the person and proportionate risk-reduction measures explored; and
• any intervention contrary to their wishes must have a separate and clearly documented lawful authority.

Service Users Who Lack Capacity

Where the service user lacks capacity to make the relevant decision, any decision made on their behalf must comply with the Mental Capacity Act 2005 and be made in their best interests.

The best-interests process must include consideration of:

• all relevant circumstances;
• the person’s past and present wishes and feelings;
• the beliefs and values that would be likely to influence their decision;
• the person’s ability to participate in the decision;
• the views of anyone the Mental Capacity Act requires or permits to be consulted; and
• whether the objective can be achieved effectively in a less restrictive way.

Family members or next of kin must not be treated as having automatic legal authority to consent to a restriction on the person’s behalf. They should be consulted where appropriate as part of the best-interests process, but they may make the decision on the person’s behalf only where they hold the relevant legal authority, such as an applicable Lasting Power of Attorney or deputyship and the decision falls within the scope of that authority.

Where required by the Mental Capacity Act 2005, an Independent Mental Capacity Advocate must be instructed.

Restraint

Where an act amounts to restraint and is undertaken in reliance on the Mental Capacity Act 2005, staff must be able to demonstrate that:

• the person lacks capacity in relation to the relevant matter;
• the act is in the person’s best interests;
• restraint is necessary to prevent harm to the person; and
• the restraint is proportionate to the likelihood and seriousness of the harm.

The least restrictive effective alternative must always be considered.

Deprivation of Liberty

The service must consider the person’s complete care arrangements rather than looking at a locked door in isolation when determining whether those arrangements may amount to a deprivation of liberty.

Assessment of deprivation of liberty must be undertaken in accordance with current Article 5 case law, including the Supreme Court judgment in A Reference by the Attorney General for Northern Ireland [2026] UKSC 16, and current CQC and Government guidance.

Where the circumstances amount to a deprivation of liberty and the applicable legal framework requires authorisation, the Registered Manager must ensure that the appropriate lawful authority is sought without avoidable delay. For a person accommodated in a care home within the scope of the Deprivation of Liberty Safeguards, this will normally require the appropriate DoLS process unless another legal route applies.

The service must not assume that an application awaiting determination provides unlimited authority for restrictive practices. Any restrictions used whilst an application is pending must themselves have a lawful basis and must remain necessary, proportionate and as least restrictive as reasonably practicable.

Where there is uncertainty about the legal effect of the person’s wishes and feelings, their ability to consent for Article 5 purposes, or whether the arrangements amount to a deprivation of liberty following current case law, the Registered Manager must obtain appropriate professional or legal advice.

7. Handling Conflicts and Concerns

Where a Service User With Capacity Refuses a Proposed Locking Arrangement

If a service user has capacity to make the relevant decision and refuses to have their door locked or refuses another proposed restriction, staff must not impose the restriction solely because they believe it would reduce risk.

Staff must:

• explain the identified risks and proposed risk-reduction measures in a way the person can understand;
• listen to and record the person’s wishes, concerns and preferred alternatives;
• consider less restrictive measures;
• review the care plan and risk assessment;
• involve appropriate professionals where necessary; and
• respect the person’s decision unless a separate lawful authority permits or requires intervention.

Family members may be involved with the person’s agreement or where another lawful basis permits involvement, but they must not be asked to override the valid decision of an adult who has capacity.

Where a Service User Wishes to Lock Their Door and Staff Have Safety Concerns

Staff must discuss the concern with the person and seek an arrangement that protects their privacy and autonomy whilst managing identified risks.

Possible measures may include:

• an appropriate emergency-access mechanism;
• assistive technology;
• an agreed call-bell arrangement;
• agreed and proportionate welfare checks;
• changes to the locking mechanism; or
• other individually assessed measures.

Any monitoring arrangement must be proportionate and must not unnecessarily interfere with the person’s privacy.

Where a Person Lacks Capacity

Where the person lacks capacity for the relevant decision, staff must follow the requirements set out in Section 6 of this policy.

Disagreement between family members, representatives or professionals must not be resolved by imposing an unrecorded or informal restriction. Where significant disagreement remains about a serious restriction or deprivation of liberty, the Registered Manager must seek appropriate professional or legal advice and consider whether an application to the Court of Protection is required.

8. Staff Training and Responsibilities

All staff whose duties may involve door security, room access or restrictive practices must receive information, instruction and training appropriate to their role.

Training and competency must include, where relevant:

• service users’ rights to privacy, dignity and autonomy;
• the Mental Capacity Act 2005 and its statutory principles;
• decision-specific capacity assessment;
• consent and refusal;
• best-interests decision-making;
• the legal requirements governing restraint;
• deprivation of liberty and applicable authorisation procedures;
• recognising when a restriction may amount to or contribute to a deprivation of liberty;
• current CQC requirements concerning restrictive practices;
• safeguarding responsibilities;
• emergency access arrangements;
• safe use and control of keys, master keys and override systems; and
• relevant fire-safety and evacuation procedures.

Staff must:

• follow the service user’s care plan, risk assessment and any lawful authorisation;
• respect the person’s privacy and preferences;
• use the least restrictive lawful approach;
• never impose a restriction for staff convenience;
• check that any applicable conditions attached to an authorisation are followed;
• immediately report any restriction that appears unauthorised, unnecessary, disproportionate or inconsistent with the care plan;
• report any failure of a lock, emergency-access mechanism or other security equipment that may place a person at risk; and
• accurately record relevant decisions, interventions and incidents.

The Registered Manager must ensure that restrictive door arrangements are subject to appropriate management oversight and that staff are competent to implement them lawfully.

9. Documentation and Record-Keeping

The service must maintain accurate, complete and contemporaneous records sufficient to demonstrate the lawful basis for and appropriate oversight of any door-locking or restrictive arrangement.

Care Plans and Risk Assessments

Where relevant, the person’s records must include:

• their wishes and preferences concerning locking their door and staff access;
• identified risks and agreed risk-management measures;
• any relevant capacity assessment;
• evidence of consent where the person has capacity;
• any best-interests decision where the person lacks capacity;
• alternatives and less restrictive measures considered;
• the reason a restriction is considered necessary;
• the legal basis relied upon;
• details of any DoLS authorisation, Court of Protection order or other applicable authority;
• any conditions attached to an authorisation;
• emergency-access arrangements; and
• the date and outcome of reviews.

Records must distinguish clearly between a service user choosing to lock their own door and staff imposing or controlling a restriction.

Incidents and Unplanned Restrictions

Staff must record and report incidents including:

• inability to gain access during an emergency;
• failure or malfunction of a lock, master key or override system where safety may have been affected;
• a person being inadvertently or unlawfully locked in or prevented from leaving;
• use of an unplanned restrictive intervention;
• breach of a DoLS condition or other legal authorisation; and
• any concern that a person’s liberty has been restricted without lawful authority.

Where an incident raises a safeguarding concern, it must also be managed under the service’s safeguarding procedures and referred to the appropriate safeguarding authority where required.

CQC Notifications Relating to Deprivation of Liberty

The Registered Manager must ensure that CQC is notified in accordance with the Care Quality Commission (Registration) Regulations 2009 and current CQC notification requirements.

For deprivation-of-liberty applications, the service must notify CQC of the outcome of the application when that outcome is known, in accordance with current CQC requirements. This includes applicable outcomes such as an authorisation being granted, an application not being authorised, or an application being withdrawn.

The policy must not state that CQC must automatically be notified merely because a standard DoLS application has been submitted.

The service must retain evidence of required notifications and must have an effective system for monitoring:

• applications submitted;
• applications awaiting determination;
• urgent authorisations where applicable;
• authorised applications;
• start and expiry dates;
• conditions attached to authorisations;
• reviews and renewals; and
• required CQC notifications.

10. Fire Safety and Door-Locking Arrangements

All locking arrangements must be consistent with the service’s current fire risk assessment and emergency evacuation arrangements.

Before a new locking mechanism is installed or an existing arrangement is materially changed, an appropriately competent person must consider its effect on:

• the service user’s ability to escape or be evacuated in an emergency;
• staff emergency access;
• the operation and integrity of any fire door;
• self-closing devices and other fire-safety equipment;
• the home’s evacuation strategy;
• any individual evacuation assistance required by the service user; and
• the safety of other service users, staff and visitors.

Locks, keys, override devices and associated equipment must be maintained in safe working order.

A service user must not be placed behind a lock that prevents their safe evacuation unless the arrangement is lawful, has been appropriately risk assessed and is compatible with the home’s fire-safety arrangements.

Staff must know how to obtain emergency access without avoidable delay and must understand the actions required in the event of fire or another emergency.

Any conflict between a proposed care restriction and fire-safety requirements must be escalated to the Registered Manager and the person responsible for fire safety before the arrangement is implemented.

11. Related Policies

• CH07-Person-Centred Care Policy
• CH08-Dignity and Respect Policy
• CH12-Safe Care and Treatment Policy
• CH18-Risk Management and Assessment Policy
• CH23-Lone Working and Staff Safety Policy
• CH39-Mental Capacity and Deprivation of Liberty Safeguards Policy

12. Policy Review

• This policy will be reviewed annually or sooner if changes in CQC regulations or legal guidance occur.
• Amendments will be made to ensure compliance with service user rights and best practices.
• Regular training and audits will be conducted to ensure adherence.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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