Restrictions, DoLS and Least Restrictive Practice in Dementia Care: A Practical Governance Guide

January 23, 2026

In dementia care, restrictions often arrive quietly: “keep the door locked”, “don’t let her go out alone”, “only staff can hold the phone”, “hide the kettle”, “two staff for personal care”. Many of these steps are introduced with good intent, but they can become routine deprivation of liberty if they are not individually justified, time-limited, and reviewed. Strong services treat restriction management as a governance process, not a set of informal rules. This article sits within safeguarding, capacity, consent and human rights and links to operational controls used in dementia service models to keep practice least restrictive and defensible.

What counts as a restriction in dementia services

A restriction is any measure that limits a person’s freedom, choice, or privacy beyond what they would normally accept, or beyond what is necessary to meet a specific risk. Common examples include:

locked doors, keypad codes, or staff-only access areas
continuous supervision or “1:1” observation
preventing a person leaving, or physically guiding them back
limiting contact with family or friends
removing access to everyday items (phones, money, kitchen equipment)
covert administration of medication (in specific circumstances)

In practice, risk increases when restrictions are undocumented, applied as blanket rules, or left in place without review because “it’s always been done”.

Least restrictive practice: the operational test

Least restrictive practice is not “doing nothing”. It is choosing the option that meets the need while limiting liberty the least. Operationally, staff should be able to answer:

What risk are we managing? (specific and evidenced, not general anxiety)
What alternatives have we tried? (including environmental, relational, and routine changes)
What is the minimum control needed? (time-limited and reviewable)
How will we know we can reduce it? (clear outcomes and triggers)

Operational Example 1: Locked door introduced after repeated exit-seeking

Context: A resident repeatedly leaves the building to “go home”, becomes lost, and is found distressed. Staff lock the main door and tell everyone “no one goes out unless accompanied”.

Support approach: The manager reframes this from a blanket control to an individual plan. The service explores why the person is leaving (boredom, anxiety, searching for a routine), and introduces risk enablement alternatives: scheduled escorted walks, meaningful roles (posting letters, gardening), and reassurance routines at trigger times.

Day-to-day delivery detail: Staff implement a timed plan: (1) a daily “going out” slot with a familiar staff member; (2) quiet-time activities in late afternoon; (3) environmental cues (clear signage, a “home corner” with familiar items). If the door must remain locked for the wider setting, the service documents how the person’s liberty is enabled through planned access, and how staff avoid coercive responses when the person approaches the exit.

How effectiveness or change is evidenced: The service records frequency of exit attempts, distress levels, and successful supported outings. Review meetings assess whether the supervision level can reduce, whether the person can have partial independence (e.g., garden access), and what outcomes demonstrate safety.

Operational Example 2: Continuous observation introduced after falls and night-time wandering

Context: A resident has several falls at night while looking for the toilet. Staff initiate constant observation and consider bedrails. The person becomes agitated with staff presence and sleeps less.

Support approach: The service applies a “falls plus rights” approach: reduce risk through environment and routine first, rather than surveillance. They complete a falls review (medication, footwear, eyesight, continence), adjust lighting, introduce clear wayfinding, and consider sensor technology as a less restrictive option than continuous observation.

Day-to-day delivery detail: Staff implement a night plan: regular prompted toileting, motion-activated lighting, clutter-free route, and a low bed if indicated. If observation remains necessary short term, it is recorded as time-limited with a review date and a clear objective (e.g., “reduce night-time falls while implementing environmental changes”). Staff are trained to observe discreetly, avoid constant verbal prompting, and support sleep hygiene.

How effectiveness or change is evidenced: Evidence includes reduced falls, improved sleep patterns, and observation logs showing decreasing need. Governance review checks whether observation is stepped down (e.g., from 1:1 to intermittent checks) once controls are embedded.

Operational Example 3: Restricting contact due to distress and alleged coercion

Context: After visits from a relative, a resident becomes tearful, refuses meals, and appears fearful. Staff suspect coercion about money and consider stopping all contact.

Support approach: The manager balances safeguarding and rights. They explore the resident’s wishes using communication adjustments and involve advocacy where appropriate. They consider structured contact options: supervised visits, time limits, clear behaviour expectations, and alternative communication methods where face-to-face visits are destabilising.

Day-to-day delivery detail: Staff document each contact event objectively: what was said, how the resident responded, and what support was required after. If capacity to decide about contact is lacking, a best-interests pathway is used, with safeguarding input if exploitation is suspected. Any restriction is time-limited, proportionate, and includes a scheduled review and a clear route to relax restrictions if safe.

How effectiveness or change is evidenced: The service monitors distress indicators, eating patterns, and engagement after contact changes. Reviews consider whether the resident’s wellbeing improves and whether the restriction can reduce over time while maintaining safety.

DoLS and deprivation of liberty: what services need to be ready to evidence

Where restrictions amount to deprivation of liberty, services need to be able to evidence: the person’s care needs, why restrictions are necessary, why they are proportionate, and why less restrictive options are insufficient. In practice, “ready” means the service can quickly show:

the restriction(s) in place and the specific risks they address
capacity considerations and involvement of the person as far as possible
alternatives trialled and outcomes
review dates and evidence of stepping down restrictions when possible
staff understanding of day-to-day application (not just paperwork)

Commissioner expectation: a restriction governance system that reduces control over time

Commissioner expectation: Commissioners typically expect services to manage restrictions as a quality and risk system. They look for a restriction register, review meetings, clear escalation routes, and auditable evidence that restrictions do not remain “set and forget”. Practically, services should be able to demonstrate: why restrictions were introduced, what less restrictive options were tried, what outcomes were monitored, and how restrictions were reduced as risk reduced.

Regulator / Inspector expectation: least restrictive practice is visible in routines and staff language

Regulator / Inspector expectation (e.g. CQC): Inspectors commonly test whether restrictions are normalised. They will observe whether staff use coercive language (“you’re not allowed”), whether people can access outdoor space, whether privacy is respected, and whether supervision is proportionate. They also check staff understanding: can staff explain why a restriction exists, what the review date is, and what would allow reduction? Strong services show that restriction reduction is an active goal, not an afterthought.

Governance that prevents restriction creep

Restriction creep happens when controls remain because they feel safer for staff. Robust governance prevents this by forcing visibility and review:

Restriction register: live list of restrictions, rationale, start date, review date, and responsible lead.
Monthly least-restrictive panel: review top restrictions, test alternatives, and agree step-down plans.
Audit sampling: check records include alternatives tried, consultation, and outcome monitoring.
Competency checks: ensure staff can explain restrictions and apply them proportionately.
Learning from incidents: each incident review must include “how we reduce restriction next time”.

What “good” looks like day to day

Good restriction practice is calm, specific, and reviewable. Staff describe the risk, not the rule. They enable choice through routine, environment and relationships, and they record outcomes so restrictions reduce when safe. That is how services protect people, protect rights, and remain defensible when challenged.