Policy – Locked door
Suitable for adult residential social care or mental healthcare settings.
Note: this worked example policy is for illustrative information only. It may be used by an adult
social care or healthcare organisation as a basis upon which to develop their own policy but
should be fully customised and adapted to the specific needs of the organisation concerned.
Aim
The aim of this organisation is to ensure that users of this service are free from unlawful and
unjustified restrictions on their movements while protecting their safety and security.
Background
This organisation believes that respect for human rights and basic human freedoms is a
fundamental element in the ethical provision of care services. Such freedoms include freedom of
movement and freedom from unlawful restriction on movement and activities. However, at the
same time the organisation also recognises its duty of care to protect its service users from
unacceptable risks and to protect their security and the security of their belongings. Such an
‘unacceptable risk’ may include service users who are assessed as being in danger of leaving the
premises unobserved and harming themselves or coming to harm.
The organisation recognises the following relevant legislation and international conventions:

UN Declaration of Human Rights 1948

European Convention on Human Rights (ECHR)

Human Rights Act 1998

Equality Act 2010

Mental Health Act 1983 and the Mental Health Code of Practice 2015.
This policy is intended as a guide to good practice in what is often seen as a difficult area of care.
It should be followed by all staff, who should recognise the duty of the service under the above to
safeguard and respect the human rights of service users to come and go as they please and to
enjoy basic freedoms of movement and association free from unnecessary or unwarranted
restrictions. In particular, the organisation recognises the requirement under the Mental Health
Act 1983 Code of Practice to wherever possible ensure that the least restrictive care options are
employed and that so-called ‘blanket’ restrictions, where these are unjustified, should be avoided.
An example of such a blanket restriction is the locking of all doors to a health or social care
premises to maintain the safety of a few service users who are assessed as at risk of harm from
leaving the premises unobserved whereby the restriction applies to all of the other service users
in the premises unnecessarily.
In addition to the above, this organisation also recognises that respect for human rights is an
important part of compliance with the registration requirements of the Care Quality Commission
(CQC).
CQC regulatory requirements
All adult social care providers must comply with the regulatory requirements of the CQC in
order to maintain their registration.
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which include
the fundamental standards, apply to health and social care providers from April 2015.
Regulation 13: Safeguarding service users from abuse and improper treatment, states that
service users must be protected from abuse and improper treatment. According to Regulation
13, a service user must not be deprived of their liberty for the purpose of receiving care or
treatment without lawful authority, including restrictions to their movement.
Regulation 15: Premises and equipment states that premises must be secure and suitable for
the purpose for which they are used.
Guidance for providers on meeting the regulations, published by the CQC in March 2015,
includes prompts, described below, which service providers must take notice of.
As part of their induction, staff must receive training that is relevant to their role and at a
suitable level to make sure any control, restraint or restrictive practices are only used when
absolutely necessary, in line with current national guidance and good practice, and as a last
resort.
If using restraint, providers must make sure that restraint:

is only used when absolutely necessary

is proportionate in relation to the risk of harm and the seriousness of that harm to the
person using the service or another person

takes account of the assessment of the person’s needs and their capacity to consent to
such treatment

follows current legislation and guidance.
Providers and staff should regularly monitor and review the approach to, and use of, restraint
and restrictive practices.
Security arrangements must make sure that people are safe while receiving care, including:

protecting personal safety, which includes restrictive protection required in relation to the
Mental Capacity Act 2005 and Mental Health Act 1983 – this includes the use of window
restrictors or locks on doors, which are used in a way that protects people using the
service when lawful and necessary, but which does not restrict the liberty of other people
using the service

not inadvertently restricting people’s movements

providing appropriate information about access and entry when people who use the
service are unable to come and go freely and when people using a service move from the
premises as part of their care and treatment

using the appropriate level of security needed in relation to the services being delivered.
When a person lacks the mental capacity to consent to care and treatment, a best interests
process must be followed in accordance with the Mental Capacity Act 2005.
Policy
In this organisation:

All service users should have their needs assessed and any risks relating to their care
addressed in discussion with themselves and with their family, carers and representatives. In
some cases the risk assessment may identify a risk of self-harm or of coming to harm for a
service user leaving the premises on their own, or of moving from one part of the premises to
another unobserved where this may be deemed a risk. In the event of such an assessment
adequate intervention measures should be introduced to reduce the risks to an acceptable
level.

Assessments should be made with reference to the Mental Capacity Act 2005 where the
service user involved is suspected of lacking capacity. In such cases all decisions should be
made in the best interests of the service user and represent the least restrictive option.

Assessments which are properly made under the Mental Capacity Act deprivation of liberty
safeguards, and approved by a valid supervisory body, may include authorisation to deprive a
service user of their liberty in their best interests.

All risk assessments should be individualised as part of a person-centred care planning
process for each person.

In addition to individualised risk assessments, the premises itself should be subject to
regularly reviewed risk assessment focusing on the security of the premises. The aim of this
assessment will be to minimise the risk of theft and intrusion and to maintain the safety and
security of service users, staff and possessions and property.

The balance of freedom of movement and restrictions due to security policies should be
maintained by reference to good practice and by consideration of the principle of ‘least
restrictive’ care when conducting risk assessments. Managers and risk assessors should also
balance security with the maintenance of a welcoming environment.

Wherever possible, security and safety and the risks of service users leaving unobserved
should be managed by adequate staffing and by one-to-one care for at-risk individuals, not by
the use of locked doors.

Locking doors to restrict movement should never be used as a ‘blanket restriction’ to enable
easier care, to make up for short staff numbers or to reduce staff to service user ratios.

Security arrangements should always be appropriate and justified within the security policy –
security should never be used as a reason for locking doors and unnecessarily restricting the
movement of service users or their visitors.

Blanket restrictions are understood to be those restrictions which restrict a service user’s
liberty and other rights, which are routinely applied to all service users without individual risk
assessments to justify their application. Managers and staff should avoid the use of all such
restrictions unless they can be justified as necessary and proportionate responses to risks
identified for particular individuals.

Care must always be based on the principle of the ‘least restrictive option’ where
independence and autonomy are maximised and service users empowered, wherever
possible, to make their own decisions.

Effective governance arrangements will be in place which will include monitoring of human
rights standards, including freedom of movement within the premises.

All staff will work to eliminate discrimination by embedding equality through systems,
processes and outputs and ensuring that all forms of discrimination are prohibited, prevented
and eliminated. The locking of doors should never be used as a punishment or as a method
of discriminating against an individual or a group of service users.

All security arrangements and any use of locked doors should consider the access needs of
disabled service users and the access plan for the premises.

Any access restrictions should be marked with clear and adequate signage. All access
restrictions should be kept under review.
Management duties
Managers and supervisors in the organisation have a duty to:

regularly audit the use of this policy and the effectiveness of procedures to establish an
effective locked door policy

monitor complaints and compliments relating to locked doors or unnecessary restrictions on
movement, taking action as required and fully investigating any complaints.
Staff duties
Staff in this organisation have a duty to:

comply with all policies and procedures

always act in full compliance with the Equality Act 2010, the Mental Capacity Act 2005 and
the associated deprivation of liberty safeguards

attend appropriate training.
Training
In this organisation:

induction will include training and guidance on the locked door policy of the organisation, and
on managing security risks

all staff will be trained in the requirements of the Mental Capacity Act and with the associated
deprivation of liberty safeguards.
Applicability and scope
This policy applies to all staff and volunteers working in or for the organisation without exception.
All staff have responsibility for ensuring that they work within the remit of this policy and in the
manner in which they have been trained.
Associated policies and procedures

Safeguarding and whistleblowing policies

Mental Capacity Act policy

Deprivation of liberty safeguards policy

Missing service user policy

Risk assessment and care planning policies

Human rights policies.
Responsibilities
Responsibility for the implementation, monitoring and review of this policy lies with the service
provider.
Signed:
Dated:
Policy ref number and version:
Author:
Implementation date:
Next review date: