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This policy lays out the local processes for All Ashford and St Peters NHS Foundation Trust (The Trust) staff to carry out to meet the legal responsibility for Deprivation of Liberty Safeguards (DoLS) legislation (2009). This policy will ensure that staff are aware of the processes that need to be carried out in order to ensure that we are compliant with the legislation and the decisions are based on the best interest for the patient.

DoLs needs to be embedded within the organisation, with staff having a full understanding of the DoLS principles. Staff must adhere closely to the Mental Capacity Act Policy. Any staff working in inpatient areas caring for or providing treatment for people with dementia, mental health issues, a learning disability or an acquired brain injury should be familiar with the DoLS processes and procedures. DoLS applies to people over the age of 18.



Although DoLS applies to decision making with adult patients in relation to their care and/or treatment, all substantive and temporary staff who have contractual obligations to the Trust must be familiar with the policy and where to get help and advice. The Policy also covers all those working in a voluntary capacity within the organisation. Agency and contracted staff are expected to familiarise themselves with these procedures and to ensure that their practice is in line with the Trust. Staff that are not directly employed by the Trust should have appropriate training from their employer and the Trust will seek reassurance from contractors to assure themselves of this.



The purpose of this policy is to ensure that there are clear and robust processes for staff to follow and identify and escalate potential DoLS.

DoLS was introduced into the Mental Capacity Act 2005 by the Mental Health Act 1983 amended 2007 following the Bournewood case. DoLS are designed to provide a legal process that protects adults who lack mental capacity against decisions that deprive them of their liberty.


Policy Details

Download: PDF version
Compiled by: David Sills, Dementia & Admiral Nurse Lead
Sarah Hill, Safeguarding Adults Nurse
Ratified by: Trust Executive Committee
Date Ratified: August 2018
Date Issued: April 2020
Review Date: March 2021
Target Audience: All staff
Contact name: David Sills, Dementia & Admiral Nurse Lead
Sarah Hill, Safeguarding Adults Nurse


See also:

  • Safeguarding Adult Policy
  • Mental Capacity Policy
  • Consent Policy