The state of health care and adult social care in England 2024/25
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Deprivation of Liberty Safeguards
The Deprivation of Liberty Safeguards (DoLS) form an important part of the Mental Capacity Act 2005.
DoLS can be applied in care homes and hospitals where a person aged 18 or over does not have the mental capacity to consent to the arrangements made for their care or treatment, and they need to be deprived of their liberty. The safeguards are designed to protect people’s human rights, aiming to make sure that any restrictions are necessary to prevent harm, are proportionate and in the person’s best interests.
If a person is deprived of their liberty, they are not free to leave the premises on a permanent basis, for example to live where and with whom they choose to, and they are subject to continuous supervision and control. This means they are monitored or supervised for significant periods of the day, and they are not allowed to make important decisions about their own life.
We have raised serious concerns about the safeguards and the need for system-wide reform for a number of years. Applications to authorise the deprivation of a person’s liberty have continued to increase significantly over the last decade – far beyond the levels expected when the safeguards were designed. This puts pressure on local authorities, who are responsible for authorising standard DoLS applications, and often results in lengthy delays in processing applications. In turn, it affects health and care staff, who need to balance keeping people safe with protecting their rights while waiting for an application to be granted.
People in need of a DoLS authorisation are often among those least likely to have their voices heard. In a system struggling to cope, many people subject to DoLS authorisations are not having their rights upheld in the way that the system intended. In our last State of Care report, we called for urgent action to ensure that the system does not fail people in the future. We remain concerned that the current system is not effectively protecting the rights of many people who use health and social care services. Added to this, the level of understanding among staff of how and when to apply the safeguards, and the need to review restrictions regularly to ensure they remain relevant, continues to vary across both adult social care and hospital settings.
People at the heart of the system
Longstanding issues with the DoLS system can significantly affect people who are assessed as needing to be deprived of their liberty, their family, friends and carers. While DoLS aim to offer important safeguards, many of the issues we raise risk infringing people’s rights or even contributing to abuses of individuals’ rights. For example, this includes people being deprived of their liberty without legal protection while waiting for an authorisation. To better understand the experiences of staff using DoLS in hospitals, this year we surveyed Mental Capacity Act leads for hospitals and heard from staff at over 40 NHS trusts. One hospital provider told us:
DoLS is resource/admin heavy and as a result, we have created a system that rather than protecting people's human rights, leaves them vulnerable to unlawful deprivations and no recourse to public funds to challenge. Those that work within the world of DoLS are demoralised working in a broken system that no-one has the appetite to fix.
It can be particularly challenging for families and carers in situations where people may feel distressed and do not understand the restrictions placed on them. We heard some positive examples from hospital providers, where working closely and maintaining good communication with family members enabled staff to respect people’s choices while keeping them physically safe. Another provider noted how positive engagement with a family helped to minimise risk for a patient who was found to lack capacity to consent to being admitted.
However, a small number of providers commented on families’ lack of understanding of the DoLS process, which can result in stress, a lack of trust in the clinical team and complaints. The Mental Capacity Act Code of Practice is clear that for standard DoLS applications, staff at hospitals and care homes should tell the relevant person’s family, friends, carers and advocates about applying for an authorisation, unless there are valid reasons for not doing so. Anyone engaged in caring for the person or interested in their welfare should have opportunities to input their views.
Jane’s experience highlights the need for good communication about DoLS.
A personal story: The need for good communication
Jane’s husband, Andrew, experienced memory problems for around 3 years but initially did not want to see a doctor. When Jane convinced him to see the GP, he was referred for an urgent MRI scan. The following week, Andrew woke up early with no idea where he was, searching for the couple’s children, who were all in the house. Jane took him to A&E immediately.
At the hospital, Andrew’s state of confusion continued. A CT scan revealed he had a cyst on his brain, but Jane and Andrew were then left waiting in A&E for a further 11 hours. Jane described the constant battle to keep Andrew in A&E as he did not know where he was and wanted to return home. By the early hours of the following morning, Jane spoke to staff, and Andrew was admitted to an observation area.
At this point, DoLS was mentioned for the first time as Andrew was found not to have the mental capacity to consent to being in hospital. Staff did not explain the process to Jane or outline what it meant for her husband’s rights. Although the observation area was behind closed doors, Jane received a call early the next morning to say her husband had gone missing. Jane felt that the urgent DoLS authorisation did nothing to safeguard him.
While the hospital security team watched CCTV footage to try to track Andrew’s movements, it was Jane who eventually located him using the ‘find my phone’ app. Jane described a dangerous situation where he crossed a dual carriageway opposite the hospital, thinking he was on his way to work. She insisted someone from the hospital should meet him to ensure he returned to hospital safely. During his hospital stay, Andrew would try to leave the hospital with Jane every time she went home, and she received distressed phone calls from him every night.
Doctors at the hospital carried out a general cognitive assessment, asking Andrew questions about his name, the date and the people around him. Jane recalled a doctor making a blanket statement about her husband no longer having capacity, who added that they were “taking that away from him”.
[It is important to clarify that, legally, there is no such thing as 'taking away' a person's capacity. The starting point must always be to support individuals to make their own decisions. If they are still unable to make a decision even after all practicable steps have been taken, then the Mental Capacity Act is there to ensure that any decisions are made in the person’s best interests. This potential miscommunication may have added to Jane’s confusion about the process.]
Andrew was then moved between numerous wards over the following 5 days. Jane felt she needed to talk to staff on each ward about her husband’s mental capacity, as it was not always mentioned in handovers and she worried for his safety if staff were not aware. He was moved to a high dependency ward for people with dementia, with specialist staff who were better equipped to meet his needs. Jane felt this ward was safer as he was unable to leave.
Andrew was waiting for a bed to become available at a different hospital, and Jane mentioned being told by staff that they were “babysitting” him and there was no further treatment they could offer. It was only when Andrew was discharged that Jane found more information about DoLS in discharge notes. During his time in hospital, she had not seen any paperwork such as a formal urgent authorisation, and there was no explanation about the legal framework to keep him safe, nor any communication about her husband’s wishes or feelings.
Jane said an occupational therapist put together a helpful pack with some information about care at home and phone numbers to call for support, but the overall lack of information about DoLS meant she was unsure if the authorisation remained in place at home. She told us that the experience could have been significantly improved for both her and her husband if staff had explained their choices and rights. Ultimately, she does not feel the DoLS authorisation kept her husband safe.
Interview with member of the public
We expect providers to deliver person-centred, rights-respecting care. All providers have a duty to ensure that they provide care and treatment with the consent of the relevant person, and when a person lacks mental capacity to make an informed decision or give consent, staff should act in line with the requirements of the Mental Capacity Act 2005. Providers also have a duty to ensure people are not deprived of their liberty for the purpose of receiving care and treatment without lawful authority. We are also clear that care that does not respect and promote human rights is neither safe nor high-quality.
We were encouraged to hear examples of services supporting people to take part in decisions about their daily routines and care plans from some hospital providers. A number of NHS trust staff who responded to our survey also acknowledged that a DoLS authorisation does not remove a person's right to have a voice or to object. While there was recognition of the need to document and respect such objections, a few staff expressed mixed feelings when these objections conflicted with what was deemed to be in the individual's best interests. In some cases, this led to a sense of tension or conflict as staff navigated the fine balance between respecting individual autonomy and ensuring safety and appropriate care.
We continue to hear how issues with the DoLS system may disproportionately affect certain groups of people. Last year, we heard from a local authority national DoLS lead that while some people with a learning disability or living with dementia meet the requirements for a DoLS authorisation, the use of screening tools means their applications often do not meet the prioritisation criteria.
This year, several respondents in our survey specifically mentioned older people, including those with dementia. One respondent noted that because of the nature of their care needs, certain groups of people such as older people and people with dementia are more likely to require a DoLS authorisation. As a result, they may be disproportionally affected by the current DoLS processing times and the delays to the implementation of the LPS. Another suggested that local authorities do not always regard older people as a priority if they have complex care needs, including a dual diagnosis. We also heard from a respondent in a different trust that ‘most patients’ are never assessed by their local authority partners, and that patients either regain their capacity, are discharged or die before they are assessed.
Sarah’s story demonstrates how, when implemented correctly, a DoLS authorisation can benefit people with dementia and their families.
A personal story: DoLS as a safeguard during transitions
Sarah’s father, Michael, had been living with dementia for around 5 years when she started to see a noticeable deterioration in his health. Michael was usually well dressed when leaving the house and people may not recognise that he has dementia, but he would go for walks and not remember where he was going. On one occasion, Sarah had to share a post on Facebook asking friends to look out for her father.
A few weeks later, in the early hours of the morning, Sarah received a call from a paramedic to say Michael had been found in a large park on the other side of town, confused about where he was. Along with dementia, Michael also has some physical health conditions. He was taken to hospital and given a full assessment.
Michael was assigned a social worker, and after a mental capacity assessment they concluded that he lacked capacity to make decisions about where he lived and that it was not in his best interests to continue living independently. He had to wait in hospital for a suitable care home placement. During this time, his dementia became worse and the hospital staff told Sarah they were going to apply for DoLS authorisation to keep him in hospital. Sarah said the hospital and local authority worked effectively together and kept her well-informed. They explained what it meant to have a DoLS authorisation, how they came to the decision to apply and the process for an authorisation. Sarah became her father’s representative, which enabled her to represent his wishes. She explained that although the situation was “daunting and upsetting”, the family felt relieved that the DoLS was in place to keep her father safe.
Eventually, the social worker informed the family that an appropriate care home had been found. Sarah was able to talk to staff at the home about what they could offer Michael and ask questions. The family agreed that the home would be suitable and Michael moved in. Having support from the hospital and the care home meant the move went very smoothly. The home worked with the local authority to put a new DoLS authorisation in place. The assessments took place promptly and as her father’s representative, Sarah was involved in this process and was also given information in writing. The authorisation is reviewed regularly, with Sarah and her sister invited to attend meetings and provide input.
Reflecting on her experience of the DoLS process, Sarah said, “I have zero complaints about how the DoLS was put in place. They’ve given him his dignity, looked at his preferences. They have put his best interests first and made sure he’s safe.”
Interview with member of the public
Processing DoLS applications
Applications to deprive a person of their liberty must be authorised by a ‘supervisory body’. In England, the role of a supervisory body is undertaken by local authorities, who are responsible for arranging assessments to make sure that a deprivation of liberty is only authorised if certain requirements are met. Standard authorisations can last for up to a year. Where a care home or hospital has made a request for a standard authorisation (or is required to make a request to the supervisory body for a standard authorisation), but believes that the need for a person to be deprived of their liberty has now become so urgent that a DoLS authorisation needs to begin before the request is dealt with by the supervisory body, they may grant an urgent DoLS authorisation. These can last up to 7 days and can be extended for a further 7 days if necessary, but not beyond this.
Providers are required to formally notify CQC when they know the outcome of an application for a deprivation of liberty, including withdrawn applications. This must be done without delay for applications made to both the Court of Protection and under DoLS. It includes when an authorisation has not been granted, or the application has been withdrawn. Since April 2020, we have seen year-on-year increases in the number of notifications we receive.
In 2024/25, we received over 185,000 notifications, a 15% increase on the previous year.
Last year, we reported on the wide variation in how local authorities were managing DoLS applications. In 2024/25, our assessments of local authorities show a similar picture. While some local authorities reported not having any DoLS backlogs, others were struggling to meet demand and a few hospital providers told us that local authorities were not completing timely assessments or providing adequate feedback on the application process. According to the Association of Directors of Adult Social Services (ADASS) Spring Survey, directors have the least confidence that their adult social care budgets will be sufficient to meet their legal duties in relation to DoLS in 2025/26, compared with other legal duties. Local authorities with no waiting lists for DoLS applications or renewals told us about investing resources to cover the increase in applications in recent years and ensure levels of Best Interest Assessors were sufficient.
In our last report, we also highlighted that many local authorities cited the ADASS screening tool as a way of helping to prioritise DoLS applications. This year, we continued to see local authorities adopting risk-based approaches to triage and prioritise applications, and some local authorities had processes in place to regularly review their waiting lists.
While tools can help to identify applications that need urgent attention, local authorities have a statutory 21-day timeframe to process all standard applications. Unfortunately, many people face significant waits for DoLS authorisations, far beyond the statutory timeframe. For example, staff at one local authority outlined that lower risk assessments could take 2 to 3 years to complete. This poses a significant risk of people being unlawfully deprived of their liberty while they wait years for an authorisation. It may also increase inequalities for people who are more likely to be deemed lower risk, such as people with a learning disability or those living with dementia, as we highlighted in our 2023/24 report.
Several hospital providers cited this issue when responding to our survey. One described the “anxiety” felt by clinical staff when patients do not have a standard DoLS authorisation in place and an urgent authorisation lapses, meaning people are kept in hospital in their best interests without a legal framework in place. A different provider said their “biggest concern” is “patients being unlawfully deprived of their liberty because [local authorities] are unable to meet their legal obligations.”
We also heard how a lack of consistency in how local authorities process DoLS applications can be difficult for providers to navigate. In our survey, one hospital provider expressed frustration about the different formats and platforms that local authorities use, while another described the challenge of having to use 11 different local authority portals, which are all different. This can cause uncertainty about the correct procedure, resulting in staff being less confident in making applications and following up on them. However, some providers reported productive working relationships with local authorities, explaining how regular contact enabled them to check the status of referrals and highlight more urgent cases.
Staff understanding and application of DoLS
Another issue we have raised consistently in many State of Care reports is the variation in the way staff understand and apply the safeguards. This year, we continued to find examples of staff not properly understanding when DoLS is needed or failing to recognise and review restrictions appropriately.
Many respondents to our survey of Mental Capacity Act Leads raised the need for improved training to enhance understanding of the Mental Capacity Act, and therefore protect people’s rights. One noted the “poor application of knowledge to practice” even when this training forms part of the provider’s mandate for all staff. Examples like this one show that training alone is not enough, and it is important that staff can demonstrate that they understand what the requirements of the Mental Capacity Act and DoLS mean for the people they are caring for and are confident in applying this learning in their role. We have also found evidence of these challenges in our inspection activity.
These issues manifest in a variety of ways, and we continue to see examples in our inspection activity of providers not reviewing restrictions regularly to check if these remain proportionate. This could mean that people receive overly restrictive care or may remain deprived of their liberty for longer than they need to. Reviews could also show that a person needs enhanced safeguards. Not only does this represent a missed opportunity to improve care, but it also contradicts the principles of the Mental Capacity Act and means people’s human rights may be affected. However, when we analysed a small sample of our DoLS notifications from providers, many mentioned the need to regularly review the care arrangements to ensure they remain responsive to people’s changing needs and emphasised the need to inform the local authority if there is a change in circumstances that could require a review of the DoLS authorisation.
A standard authorisation can last for a maximum of 12 months. When providers review people’s care arrangements, they may find that a DoLS authorisation is still needed. To ensure that people are not restricted without the required safeguards in place, we expect providers to apply for renewals in a timely way using the correct process, but we continue to find examples in our inspection activity of this not happening. On the other hand, when responding to our Mental Capacity Act Leads survey, some hospital providers expressed frustration about the time it takes for their local authority to process renewals. Again, this risks people being deprived of their liberty without the appropriate legal framework in place while waiting for a renewal authorisation.
We have also seen cases where staff did not always recognise restrictions, such as locked bedroom doors or people not being able to leave where they live without support from staff. When services stop recognising restrictions there is a risk that they become part of the culture. At one adult social care service, we observed staff applying restrictions on multiple residents without lawful justification:
One person was walking with purpose and appeared content when they were repeatedly physically redirected to sit in a chair. There were no supporting assessments, consent forms, or best interest decisions in their care records to justify this practice. Multiple people were routinely kept in bed throughout the day and night with no recorded rationale or any indication this was people’s own choice. Two members of staff and multiple relatives told us they had raised these concerns with the registered manager, but no action was taken.
At the service, while some members of staff demonstrated a sound understanding of DoLS, others were unable to explain what this means for people in their service. One member of staff simply said “I don’t know” when asked about DoLS. In this assessment, inspectors identified multiple areas of concern and issued 6 Warning Notices for improvements to be made in areas including the need for consent.
At another service, inspectors found that staff and the manager lacked adequate knowledge of the Mental Capacity Act and DoLS. We were concerned that some people were subject to control or restraint that may not have been proportionate to the risk of harm. For example, one resident’s clothes were locked in a cupboard outside of their bedroom, with no evidence that this decision had been consented to or made in their best interest following a mental capacity assessment.
The wider policy landscape
The wider policy landscape in health and social care is changing, and this could have implications for the DoLS system. The Mental Health Bill is currently progressing through parliament and will bring about important safeguards for people who are detained under the Mental Health Act (MHA). This could have a knock-on effect on the DoLS system.
In our recent Monitoring the Mental Health Act report, we raised concerns about autistic people and people with a learning disability staying in hospital for prolonged periods when this does not meet their needs. We welcome the ambition to change this situation, which is reflected in the proposals of the Bill to exclude being autistic or having a learning disability from the scope of civil detention under the MHA. This means that being autistic or having a learning disability alone cannot be a reason to detain a person for longer than 28 days.
However, without suitable community-based alternatives, there is still a risk that people may be detained under other legal frameworks, such as DoLS, placing additional pressure on an already struggling system that is not always effectively protecting people’s rights.
Another pending area for change is the move from DoLS to Liberty Protection Safeguards (LPS). Introduced through the Mental Capacity (Amendment) Act 2019, LPS were intended to replace DoLS. They were designed to be more streamlined than DoLS, operating alongside care planning. It was intended to ensure that people could access key legal protections more quickly. It also extended to 16 and 17-year-olds and those deprived of their liberty in settings other than care homes and hospitals.
The implementation of LPS has been postponed multiple times: first in 2020 because of the COVID-19 pandemic, and again in 2023 it was paused without giving a reason. In successive State of Care reports, we have expressed concerns about implementation delays and uncertainty around the future of the LPS.
Chronic, longstanding issues with the current DoLS system mean many people are still not getting the important safeguards they need, and many of the issues we raise in this report are not new. We welcome the government’s recent announcement that it intends to take forward the consultation on LPS. We recognise that the sector will need time, resources and support to prepare for the introduction of the new system, and we will work with key stakeholders as part of this process. We look forward to the publication of an updated Code of Practice, as clear guidance will help health and social care staff with the practical application of the MCA and is essential to support the implementation of the reforms. During this process, it will be vital that the human rights of people affected by the current DoLS system remain a focus.