Locked Door Policy in a Care Home

What a locked door policy actually has to decide

The question a home is really answering is narrow. A resident with dementia may walk towards a street, and the building has an exit. Between those two facts sit four decisions, and a policy that does not answer all four is a document that will be interpreted differently by each person on each shift.

• Which doors may be secured, named individually, and which may never be secured because they are an escape route.
• Who may hold a key, and who must carry one on every shift, including the night shift and the shift where the manager is off site.
• How a resident who wants to leave is supported, and how quickly a door can be opened by the person standing next to it.
• What was tried before the door was secured, and what would have to change for the door to be unlocked again.

What the Code of Practice asks for

Paragraph 12.9.2 of the Code of Practice for Residential Care Homes (Elderly Persons) asks each home to formulate effective guidelines to identify residents with wandering behaviour, and to provide appropriate facilities to prevent them leaving unnoticed or entering restricted areas. Paragraph 7.2.1 names the facilities it has in mind: window grills and openable window grill locks, closed-circuit television systems, digital door locks and sensory alarms, each kept in working order, inspected and maintained regularly, with records of that maintenance kept.

The Hong Kong Alzheimer's Disease Association's guidance on protecting a person from wandering sits beside that requirement and qualifies it. It advises installing deadbolt or slide-bolt locks on exterior doors and limiting access to dangerous areas, and in the same list it states plainly: never lock a person with dementia in a home without supervision.

Read together, the two documents describe a facility plus a person. The Code asks for the hardware, the guidelines and the maintenance record; the association's warning explains why the hardware without a staffed response is the thing to avoid. That is why a locked door policy is a staffing and documentation document before it is a building document.

Key control, shift by shift

Most of the operational risk in a locked door policy is not the lock. It is the key: who has it, where it is at 3am, and whether the person who needs it can reach it without leaving the resident alone. The table below is the level of detail a policy needs, written for the shifts a home actually runs.

Two rules make key control real rather than nominal. The first is that a key is signed out to a named person, not left in a drawer that everyone knows about; a key that is available to everyone is not controlled, and it also cannot be shown to an inspector. The second is that the handover includes the key, in the same way it includes the resident who is unwell. A night shift that begins without a key in the right pocket begins with a locked door and no way through it.

The alternatives to try first, in order

Securing a door is the last item on a list, not the first, and a policy that records the earlier items is a policy that can be defended. The order below runs from the least restrictive and cheapest to the most.

• Environmental: make the exit less interesting than the lounge — a visible, well-lit route back, a seating area at the end of the corridor, a door that looks like a door rather than a way out.
• Routine: a walk at the time the resident usually sets off, and the same walk at the same time each day.
• Signage: a sign on the exit that reads as a place, not a prohibition, and a clock or a calendar beside it.
• Supervision: a staffed position with a sightline to the exit at the hours the resident walks, which the incident record will tell you.
• Technology: a door contact or a sensory alarm that reports a crossing, understood as a report rather than a prevention.
• Restraint of the person: a decision that needs the process described in our note on restraint and the least restrictive alternative, not a door lock by another name.

Doors, fire and evacuation

A secured door and a fire exit are the same door in most buildings, and that is the tension the policy has to resolve in writing. Whatever the home does about wandering, an exit that cannot be opened from the inside in an emergency is a life-safety problem that outranks it, and the person who discovers it will be the person on the night shift with a trolley of residents.

The practical answer is that the door stays openable from the inside, the lock is on the outside face or is released by the fire alarm, and the key that opens it is carried by the person on the floor rather than stored in an office. The policy should say which of those three applies to each door, and the fire drill should test the door in the state it is actually kept in — a drill that assumes an unlocked door proves nothing about a night when it is locked.

What residents and families are told

A locked door is a restriction on a person's movement, and the record of it is a consent and information question before it is a clinical one. The family should be told which doors are secured, why, what was tried first, and what would have to change for the door to be opened again. The resident should be told in the way they can understand, and the care plan should say what that was.

This is also where a home's camera and sensor decisions meet the policy. A door contact reports a crossing; a camera at an exit raises the privacy questions described in our note on privacy-preserving vision, which is where the resident and family conversation belongs. The written record is the same document either way: which doors, which devices, who is told, and who reviews it.

Reviewing the policy after an incident

The policy earns its place in the file when something happens: a resident is found outside, a door is found propped open, a key is missing at handover. Each of those is an incident with its own record, and the review should ask three questions rather than one. Was the door in the state the policy says it should be in? Was the key where the policy says it should be? Was the person who could have opened it close enough to matter?

A home that answers those three questions after every event ends up with a policy that changes on evidence rather than on memory, and with a maintenance record that shows the door contacts and alarms were tested. That record is what turns a lock into a defensible decision, and our note on writing the incident record describes the fields that make it usable six months later.