Purpose
To ensure decisions are made lawfully, that capacity is presumed and that any restriction on liberty is necessary, proportionate and authorised.
Scope
All staff involved in care planning, consent and decision making.
The five statutory principles
Presume capacity; support decision making; unwise decisions are permitted; act in best interests; choose the least restrictive option.
Assessment and best interests
Capacity is assessed decision-specific and time-specific, recorded with the evidence for the conclusion.
Best-interests decisions record who was consulted, the person's past and present wishes, beliefs and values, and the options considered.
An IMCA is instructed where the person has no appropriate representative for serious decisions.
Deprivation of liberty
Any continuous supervision and control with a lack of freedom to leave is referred for authorisation, with conditions monitored and expiry dates tracked.
Training and competency
All staff receive induction training on this policy before working unsupervised, refreshed at least annually or sooner following incident learning or a change in guidance.
Competency is confirmed through observation of practice, supervision discussion and reflective questioning — not attendance records alone.
Training records are maintained centrally and gaps are reviewed monthly against the training matrix.
Governance, monitoring and accountability
The registered manager holds overall accountability for this policy. Day-to-day implementation is delegated to named leads recorded in the service's accountability matrix.
Compliance is monitored through the service audit calendar, with findings reported to the monthly governance review and escalated to the provider board where risk is rated high.
Every audit finding is converted into an entry on the improvement action tracker with a named owner, priority rating, target date and evidence of completion.
Learning is shared with the whole team through team meetings, supervision and reflective practice sessions. Where a theme recurs, the policy itself is reviewed rather than the individual blamed.
- Central DoLS tracker with application, authorisation and expiry dates reviewed monthly.
- Audit of capacity assessments for decision-specificity and quality.
- Restrictive practice register reviewed monthly with a reduction target for each entry.
- Immediate review where a restriction is applied without authorisation.
- Additional support and accessible formats are provided so that people with communication or cognitive difficulties can participate in decisions about their own lives.
- Cultural and religious beliefs are actively sought when determining best interests.
Evidence of compliance
- Capacity assessments
- Best-interests records
- DoLS tracker
- Restrictive practice register
Suggested review cycle: Annually.