{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}


Locking Service Users’ Doors Policy

1. Purpose

This policy sets out the care home’s arrangements for the use and management of locks on individuals’ bedroom doors and on external doors and exits. Its purpose is to protect individuals’ rights to privacy, dignity, autonomy, safety and freedom of movement while ensuring appropriate security of the premises.

The service will comply with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, the Mental Capacity Act 2005 and its Code of Practice, the Deprivation of Liberty Safeguards where applicable, applicable human rights requirements, fire-safety legislation and relevant Welsh Government and Care Inspectorate Wales guidance.

The service recognises that the use of a lock is not automatically a restrictive practice. An individual with the relevant capacity may choose to lock their own bedroom door to protect their privacy, dignity or possessions. However, where a locked door or other security measure is imposed or operated by the service in a way that restricts an individual’s liberty of movement, it may amount to control, restraint or restrictive practice and must be individually assessed, necessary, proportionate, lawful and the least restrictive means of managing the identified risk.

Where arrangements may amount to a deprivation of liberty, the service will assess the individual’s actual circumstances in accordance with current law and guidance and will ensure that lawful authority is obtained where required. The service will not deprive an individual of their liberty for the purpose of receiving care and support without lawful authority.

2. Scope

3. Policy Statement and Principles

We are committed to protecting and promoting every individual’s privacy, dignity, autonomy, safety, human rights and freedom of movement. The following principles apply to all decisions concerning bedroom locks, external-door security and other arrangements that may restrict movement.

4. Bedroom Door Locking Guidelines

Bedroom-door arrangements must protect the individual’s privacy and dignity while ensuring that assessed care, support and safety needs can be met.

  1. Locking arrangements

Bedroom doors will have locking arrangements appropriate to the design of the premises, the individual’s needs and the service’s fire and safety arrangements. Where a lock is provided for an individual’s use, its design must take account of the individual’s physical, cognitive, sensory and communication needs.

Where necessary, an appropriate emergency override arrangement will enable authorised staff to gain access in circumstances where immediate entry is necessary to protect life or prevent serious harm.

  1. Individual access to keys or other locking devices

Individuals who wish to use their bedroom lock will be supported to do so where this can be done safely. Appropriate support or reasonable adjustments will be provided where required.

An individual’s diagnosis, disability or age must not, on its own, be used as a reason to withhold a key, fob, code or other means of operating their bedroom lock.

  1. Where independent use of the lock presents an identified risk

Where there is evidence that an individual’s use of a bedroom lock may create a significant risk, the service must complete an individual risk assessment.

If the individual has capacity to make the relevant decision, staff will explain the identified risks and available options and will respect the individual’s decision unless another lawful basis for intervention applies.

If there is reason to doubt the individual’s capacity to make the relevant decision, capacity must be assessed in accordance with the Mental Capacity Act 2005. Where the individual lacks capacity, any decision concerning their use of the lock must be made in their best interests and must be the least restrictive effective option.

An MDT recommendation may inform the assessment but does not, by itself, provide legal authority to override an individual’s capacitous decision, impose restraint or deprive an individual of liberty.

Alternatives must be considered before imposing a restriction. Depending upon the individual circumstances, alternatives may include:

  1. adapting the locking mechanism;
  2. providing additional support or prompting;
  3. providing secure storage for personal possessions;
  4. increased observation where individually justified;
  5. assistive technology or alert systems;
  6. environmental modifications; or
  7. changes to staffing support or routines.

Any restriction must be recorded in the individual’s personal plan and reviewed whenever circumstances change and at each relevant personal-plan review.

  1. Staff access to bedrooms

Staff must knock, identify themselves and allow sufficient time for the individual to respond before entering.

Where the door is locked, staff must not use a master key or override mechanism merely for convenience or routine access.

Non-emergency entry should take place with the individual’s agreement unless another lawful basis for entry has been established and documented.

Staff may use emergency access without prior consent where there is a reasonable and immediate concern for the individual’s safety or the safety of another person, including a medical emergency, fire, suspected serious injury or another situation requiring immediate intervention.

The reason for emergency or non-consensual access must be documented. Where entry forms part of, or results in, control, restraint or restrictive practice, the additional recording requirements in this policy apply.

  1. Privacy and planned checks

Individuals may choose to lock their bedroom door while they are inside their room.

Preferences concerning night-time checks, welfare observations and staff access must be discussed with the individual and recorded in the personal plan where relevant.

A clinical or safety risk, including falls risk, does not automatically authorise staff to override a capacitous individual’s wishes. Where additional access or observation is considered necessary, staff must consider consent, the individual’s capacity for the relevant decision, the identified risk, available alternatives and the least restrictive means of managing that risk.

Where the individual lacks capacity, any planned arrangement involving entry to the bedroom or restriction of their ability to lock the door must comply with the Mental Capacity Act 2005 and any other applicable legal authority.

  1. Lockable storage

Appropriate arrangements will be available for the secure storage of an individual’s money, valuables and personal possessions where required. Where possessions or valuables are handed to the service for safekeeping, the required records will be maintained.

Medicines must be stored and managed in accordance with the service’s medicines policy, the individual’s assessed needs and the applicable medicines-management requirements. An individual who self-administers medicines will be supported to do so only in accordance with their medicines assessment and personal plan.

5. External Door Locking and Building Security

The service will maintain premises that are secure from unauthorised access while ensuring that security arrangements do not unnecessarily restrict an individual’s freedom of movement, privacy, dignity, independence or human rights.

6. Safeguarding Considerations, Mental Capacity and Deprivation of Liberty

Door-locking and security arrangements can engage an individual’s fundamental rights and may constitute restrictive practice, control or restraint or, depending upon the individual’s circumstances, a deprivation of liberty. The following requirements therefore apply.

Relevant considerations may include:

No single factor is determinative. Where there is serious doubt about whether an individual is genuinely accepting of the arrangements, staff must not infer valid consent merely from an absence of active resistance.

7. Staff Responsibilities

All staff must understand and implement this policy consistently.

Training must be refreshed at appropriate intervals and following material changes to legislation, national guidance or CIW requirements.

8. Compliance and Quality Assurance

Compliance with this policy will form part of the service’s governance, monitoring and quality-assurance arrangements.

The Registered Manager and Responsible Individual will ensure that audits include, where relevant:

Any use of control or restraint must be recorded within 24 hours in accordance with Regulation 29. Records must contain sufficient information to support individual review and wider governance analysis.

The service will maintain the records required by the Regulations, including the date and circumstances of measures of control or restraint used in relation to an individual.

Records relating to control, restraint and restrictive practice will be reviewed as part of the service’s governance and quality-of-care arrangements. Trends will be considered to establish whether:

The service provider must notify Care Inspectorate Wales of any request to a supervisory body concerning the application of DoLS and must comply with any other applicable statutory notification requirements.

Any apparent unlawful restriction or deprivation of liberty will be escalated immediately to the Registered Manager. Immediate steps will be taken to safeguard the individual’s rights and welfare, review the arrangements and obtain appropriate professional or legal advice and lawful authority where required.

Where inappropriate restriction, abuse, neglect or improper treatment is alleged or suspected, the service’s safeguarding procedures and the Wales Safeguarding Procedures will be followed and appropriate referrals and notifications made.

Any breach of this policy will be investigated. Remedial measures may include immediate changes to an individual’s arrangements, safeguarding action, additional training or supervision, disciplinary action, revision of personal plans or risk assessments, regulatory notification and wider service improvement.

9. Policy Review

This policy will be reviewed at least annually and sooner where:

The service provider and Responsible Individual will ensure that the policy remains consistent with the service’s statement of purpose and with other relevant policies, including safeguarding, control and restraint/restrictive practice, Mental Capacity Act and DoLS, medicines management, fire safety, risk management and complaints policies.

Where policy changes affect individuals or their representatives, information will be communicated in an appropriate and accessible manner. Staff will be informed of revisions and provided with additional training where required.

References and legal framework

This policy must be read alongside the current versions of:

Regulation 31 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 requires that an individual must not be deprived of their liberty for the purpose of receiving care and support without lawful authority. The service will therefore ensure that door-locking and security arrangements are individually assessed, rights-based, lawful and regularly reviewed.


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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.

Leave a Reply

Your email address will not be published. Required fields are marked *