Health and Adult Social Services
THE DEPRIVATION OF LIBERTY SAFEGUARDS
INTER-AGENCY POLICY AND PROCEDURES
The Deprivation of Liberty Safeguards Inter-Agency Policy and Procedures 1.1 October 2009
Category:
Mental Capacity Act
Version Control:
1.1
Date of Creation:
September 2008
Implementation Date:
April 2009
Last Modified:
October 2009
Review Date
October 2010
EIA Assessment:
January 2009
Approving Body
NCC-DMT
NHS Northamptonshire- Governance Committee
Date of Approval
March 2009
Document author (s)/Key
Contributors including
department
Rosa Hannaford, Policy Team, Strategic Planning and Commissioning, Health
and Adult Social Services, NCC
Contact Person
(Responsible person) and
department:
Scott Parker ([email protected]), Deprivation of Liberty
Safeguards Lead, Safeguarding Adults, NCC
Either
OR
For public access online
(internet) (tick as
appropriate)
For staff access only (intranet)? (tick as appropriate)
Yes
Yes
No
No
PLEASE NOTE: The shaded boxes throughout this document tell you which standard Department of Health (DH) forms / letters
to use
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The Deprivation of Liberty Safeguards Inter-Agency Policy and Procedures 1.1 October 2009
CONTENTS
1
INTRODUCTION
2
RATIONALE AND PURPOSE
3
DEFINITIONS
4
5
7
7
8
3.1 Managing Authority
8
3.2 Supervisory Body
8
3.3 Dols Service
8
3.4 Signatory
8
3.5 Deprivation Of Liberty
8
3.6 Restraint
9
3.7 Relevant Person
9
3.8 Standard Authorisation
9
3.9 Urgent Authorisation
9
3.10 Capacity
9
3.11 Registered Care Home
9
3.12 Code Of Practice
9
3.13 Independent Mental Capacity Advocate (IMCA)
9
3.14 BIA
10
3.15 Mental Health Assessor
10
SCOPE
10
4.1 Organisations, Services And Staff
10
4.2 Persons Who Meet Following Criteria
11
4.3 What The Policy Does Not Cover?
11
POLICY STATEMENT
12
5.1 Governing Principles
5.2 Key
Responsibilities
Of Northamptonshire
Northamptonshire In Their Role As Supervisory Body:
12
County
Council
And
NHS
13
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5.2.1
Key Responsibilities Of Supervisory Body .......................................... 13
5.2.2
Key Responsibilities Of Dols Service.................................................. 14
5.2.3
Key Responsibilities Of Managing Authorities: Care Homes & Hospitals . 15
PROCEDURES AND GUIDANCE
17
6.1 The Deprivation Of Liberty Safeguards Service
18
6.2 Applying For A Standard Authorisation (Procedure For The Managing Authority)
19
6.2.1
Information To Be Provided To DoLS Service By Managing Authority..... 20
6.3 Receiving A Request For Assessment For Standard Authorisation (Procedure For
The DoLS Service)
6.3.1
21
Instructing An IMCA ....................................................................... 23
6.4 Assessment Process For A Standard Authorisation (Procedure For The DoLS
Service)
6.4.1
2 Stages In The Assessment Process ................................................ 24
6.4.2
Stage 1: Preliminary Assessments .................................................... 25
6.4.3
Stage 2: Full Assessments ............................................................... 26
6.4.4
Additional Duties During The Assessment Process .............................. 28
6.5 Process For Urgent Authorisations (Procedure For The Managing Authority And
DoLS Service).
6.5.1
Managing Authority Responsibilities .................................................. 29
6.5.2
Dols Service Responsibilities ............................................................ 30
6.5.3
Terminating An Urgent Authorisation ................................................ 31
6.5.4
Extending The Urgent Authorisation.................................................. 31
24
29
6.6 Third Party Requests – Unauthorised Deprivation Of Liberty (Procedure For The
DoLS Service)
32
6.7 Assessment Outcomes – Granting Or Declining An Authorisation (Procedure For
The DoLS Service, Supervisory Body And Managing Authority)
34
6.7.1
The Assessor’s Reports ................................................................... 34
6.8 Declining The Authorisation
35
6.9 Granting The Authorisation
35
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6.10 Recording And Notifying Relevant Parties Of The Decision
37
6.10.1
Actions To Be Undertaken By The Supervisory Body And Managing
Authority Where Liberty Is Being Deprived But The Requirements For
Authorisation Are Not Met........................................................................... 38
6.10.2
Responsibilities Of The Managing Authority Once An Authorisation Has
Been Granted Or Declined .......................................................................... 41
6.11 Conveying
41
6.12 Reviews
42
6.12.1
Managing Authority Responsibilities ............................................... 43
6.12.2
DoLS Service Responsibilities ........................................................ 43
6.13 Terminating A Standard Authorisation
45
6.14 Appeals And Court Of Protection
46
7
6.14.1
Managing Authority Appeals ......................................................... 46
6.14.2
Court Of Protection ...................................................................... 46
Information Governance
47
7.1 Transferring Personally Identifiable Information
47
7.2 Storing Personally Identifiable Information:
48
8
Policy Review
9
Related Policies, Procedures And Forms
10
Website Address For This Policy 50
11
Appendices
49
49
50
11.1 Appendix 1: List Of All DH Forms And Letters For The Deprivation Of Liberty
Safeguards
51
11.2 Appendix 2: Quick Reference Guide To The Interagency Policy And Procedures,
The Code Of Practice, And The DH Forms And Letters
52
11.3 Appendix 3: DH Guidance Document: What Should A Managing Authority Consider
Before Applying For Authorisation Of Deprivation Of Liberty (Extracted From The Code
Of Practice)
53
11.4 Appendix 4: DoLS Service Assessment Checklist
54
11.5 Appendix 5: DoLS Service Checklist For Dols Lead For The Appointment Of Best
Interests Assessors And Mental Health Assessors
55
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11.6 Appendix 6: Flowchart For Standard Authorisation Process
56
11.7 Appendix 7: Flowchart For Urgent Authorisation Process
57
11.8 Appendix 8: Flowchart For Third Party Request Process
58
11.9 Appendix 9: Standard Authorisation Review Process Flowchart
59
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The Deprivation of Liberty Safeguards Inter-Agency Policy and Procedures 1.1 October 2009
1
INTRODUCTION
The Deprivation of Liberty Safeguards 2008 are an amendment to the Mental Capacity Act
2005. They provide a legal framework to protect those who may lack the capacity to consent
to the arrangements for their treatment or care and where levels of restriction or restraint
used in delivering that care are so extensive as to potentially be depriving the person of their
liberty. The safeguards apply where that person’s care is being delivered in a registered
care home or hospital and has not been authorised under the Mental Health Act 1983.
These safeguards will prevent arbitrary decisions to deprive a person of their liberty and
provide a robust and transparent framework in which to challenge deprivation of liberty
authorisations. The safeguards therefore protect the rights of vulnerable individuals.
The safeguards come into force in April 2009 and from this point onwards a Managing
Authority (see definitions below) must seek authorisation from a Supervisory Body in order to
lawfully deprive a person of their liberty. Where a request for a Standard Authorisation for
deprivation of liberty is made, the Supervisory Body is responsible for conducting a number
of assessments to determine whether the authorisation is to be granted. Where any
assessment is negative, the authorisation cannot be granted.
2
RATIONALE AND PURPOSE
This document provides a local framework for the implementation of the Deprivation of
Liberty Safeguards within Northamptonshire and aims to set out the processes and
procedures that must be followed by those that have a duty of care towards a person who is,
or may become deprived of their liberty. This includes both Managing Authorities and the
Supervisory Bodies.
The Supervisory Bodies will deliver the duties required by the Deprivation of Liberty
Safeguards through a combined service (jointly managed by Northamptonshire County
Council and Northamptonshire Teaching Primary Care Trust) in order to deliver a single
pathway.
The Deprivation of Liberty Safeguards (DoLS) Code of Practice, published under sections 42
and 43 of the Mental Capacity Act 2005, provides extensive guidance and information about
the Act and how it works in practice and should remain the main point of reference for staff
working with deprivation of liberty issues.
This document does not replace the DOLS Code of Practice or seek to repeat the content or
guidance contained within it. This document is intended to clearly outline the key
responsibilities and procedures related to the implementation of the legislation within
Northamptonshire. The document aims to highlight the processes involved with requesting,
assessing, granting and reviewing Standard Authorisations for deprivation of liberty from the
perspective of both the Managing Authorities applying for the authorisation, and the
Supervisory Body who assess and grant the authorisation.
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3
3.1
DEFINITIONS
Managing Authority
The person or body with management responsibility for the hospital or care home in which a
person is, or may become deprived of their liberty.
3.2
Supervi sory Body
A primary care trust, local authority, Welsh Ministers or a local health board that is
responsible for considering a deprivation of liberty request, commissioning the assessments
and, where all the assessments agree, authorising deprivation of liberty. Within
Northamptonshire the Supervisory Bodies are Northamptonshire County Council (NCC) and
NHS Northamptonshire. Throughout the policy the term Supervisory Body is used to mean
either NCC or NHS Northamptonshire depending on whether the authorisation is for a care
home or hospital.
3.3
DoLS Servic e
The DoLS Service is a service managed by NCC and accountable to NCC and NHS
Northamptonshire. The DoLS Service undertake the work associated with deprivation of
liberty on behalf of the Supervisory Body, including responding to requests, conducting
assessments, specifying timescales and conditions for the authorisations and conducting
reviews. The Supervisory Body maintains overall responsibility for granting authorisations.
3.4
Signatory
The signatory is the relevant Senior Manager from the Supervisory Body who has overall
responsibility for granting the Standard Authorisation, attaching any conditions recommended
by the BIA during the assessment process and also setting the period for which the
authorisation will be in force.
3.5
Deprivation of Liberty
Deprivation of Liberty is a term used in the European Court of Human Rights about
circumstances when a person’s freedom is taken away. A distinction is drawn between the
deprivation of liberty of an individual (which is unlawful unless authorised) and restrictions on
the liberty of movement of an individual. This distinction is one of degree and intensity, not
nature or substance. Determining whether deprivation of liberty is taking place should always
be situation specific for the individual concerned and should take into account factors such
as the type, duration, effects and manner of implementation of the care or treatment in
question. Chapter 2 of the Code of Practice contains guidance on where restriction and
restraint may become deprivation if liberty.
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3.6
Restraint
The use or threat of force to help do an act which the person resists, or the restriction of the
person’s liberty of movement, whether or not they resist. Restraint may only be used where it
is necessary to protect the person from harm and is proportionate to the risk of harm.
3.7
Rel evant Person
A person who is, or may become, deprived of their liberty in a hospital or care home.
3.8
Standard Authorisati on
An authorisation given by the Supervisory Body after completion of the statutory assessment
process, giving lawful authority to deprive a relevant person of their liberty in the relevant
hospital or care home.
3.9
Urgent Authorisation
An authorisation given by a Managing Authority for a maximum of seven days, which may be
extended by a maximum of a further seven days by a Supervisory Body. The Urgent
Authorisation gives the Managing Authority lawful authority to deprive a person of their liberty
while the Standard Authorisation process is undertaken.
3.10 Capacity
Mental capacity is always referred to as time and situation specific. Where the term ‘lack of
capacity’ is used throughout this document it refers specifically to the capacity to decide
whether or not to consent to care or treatment that involves circumstances that amount to
deprivation of liberty at the time at which that decision needs to be made.
3.11 Regi stered Care Hom e
This includes both residential and nursing homes that can be managed by the county council
or privately owned.
3.12 Code of Practice
This refers to the Deprivation of Liberty Safeguards Code of Practice which supplements the
main Mental Capacity Act 2005 Code of Practice.
3.13 Independent Ment al Capacity Advoc ate ( IMCA)
This is someone who provides support and representation for a person who lacks capacity to
make specific decisions, where the person has no-one else to support them. An IMCA is not
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the same as an ordinary advocate. The IMCA service was established by the Mental
Capacity Act 2005.
3.14 BIA
Best Interest Assessor – This refers to the assessor responsible for conducting a range of
assessments to ascertain whether an authorisation for deprivation of liberty will be granted
(see section 6.4 below for the different assessments that can be conducted by the BIA). The
best interest assessors are appointed by the Supervisory Body and work within the DoLS
Service.
3.15 Mental Health Assessor
This is a separate assessor to the BIA, who is responsible for undertaking some of the
assessments at stage 2 of the assessment process that relate to the mental health of the
relevant person. The mental health assessor must conduct the mental health assessment,
but may also be responsible for the eligibility assessment and mental capacity assessment
where appropriate. The mental health assessor must be a doctor who is either approved
under section 12 of the Mental Health Act 1983 or is a registered medical practitioner with at
least 3 years post-registration experience in the diagnosis or treatment of mental disorder.
The Mental Health Assessor is appointed by the Supervisory Body.
4
SCOPE
The policy applies to the following:
4.1
Organisati ons, Servic es and Staff
I.
Northamptonshire County Council (Supervisory Body), including the interagency
DoLS service and other relevant departments such as Safeguarding Adults;
Commissioning and Contracts; Care Management.
II.
NHS Northamptonshire (Supervisory Body), including the interagency DoLS service
and associated directorates such as:
Commissioning directorates of Strategy and Systems; Quality Standards and
Learning; Corporate Services; IM&T; Public Health and Medical.
Provider services within localities and Continuing Health Care.
III.
The Managing Authorities: All local authority, NHS, independent and voluntary sector
hospitals and registered care homes in the county.
IV.
Managing Authorities in care homes and hospitals out of county for whom the
Northamptonshire Supervisory Bodies are responsible.
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V.
4.2
The Relevant Person: Anybody being treated or cared for in a local authority, NHS,
independent or voluntary sector hospital or registered care home in the county,
irrespective of whether they are publicly or privately funded.
Persons W ho Meet Following Criteria
The Deprivation of Liberty Safeguards and the processes contained within this policy
document apply to all persons that meet the following criteria:
Where they are over the age of 18 and
Where they are lacking the capacity to consent to the arrangements for their care
or treatment and
Where they are receiving care or treatment within a hospital or care home and
Where they are receiving care where levels of restriction and restraint are so high
that they constitute a deprivation of liberty and
Where detention is not already authorised under the Mental Health Act
4.3
Appendix 3
W hat The Policy Does Not Cover?
I.
The policy does not replace the Deprivation of Liberty Safeguards Code of Practice
2008, the Mental Capacity Act 2005 or any policies on the use of restraint that are in
use by Northamptonshire County Council, NHS Northamptonshire, independent care
homes or hospital units. All organisations should refer to their own restraint policies
and use them in conjunction with this document.
II.
The policy does not cover procedures for Managing Authorities to identify deprivation
of liberty or any procedures prior to the submission of a request for a Standard
Authorisation. These procedures will need to be produced internally for each care
home or hospital unit. (Managing Authorities may find it useful to refer to the
document ‘What should a Managing Authority consider before applying for
authorisation of deprivation of liberty?’ contained in appendix 3 when producing the
above mentioned procedure documents).
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5
5.1
POLICY STATEMENT
Governing Principles
The following principles will be adhered to by all those with a duty of care towards an
individual who is, or may be deprived of their liberty. This includes the Managing Authority
and Supervisory Body:
Staff will carry out their duty to ensure optimum care for customers and patients that
meets the needs of the individual and protects their Human Rights.
The dignity and well-being of the relevant person will be paramount at all times.
Staff at all levels will work collaboratively with colleagues across organisations, to
ensure efficient and consistent working practices, to ensure timely and effective
communication and information sharing and to maximise efficiency of resources by
avoiding duplication.
Staff will adhere both to the principles of the Mental Capacity Act 2005 and the
Deprivation of Liberty Safeguards 2008 at all times and refer to both Acts and their
Codes of Practice whenever capacity, best interest and deprivation of liberty issues
arise.
Every effort will be made by those with a duty of care towards an individual to prevent
deprivation of liberty. This includes both commissioners and providers of care.
Staff will work in accordance with the principles of the Data Protection Act and in
accordance with the information governance guidance included in section 7 of this
document, sharing and recording only that data which is necessary.
Staff will seek to engage anyone involved in caring for a person, anyone named by
them as a person to consult and anyone with an interest in the person’s welfare, and
ensure they are consulted in decision-making.
Every effort should be made to resolve disputes surrounding a decision to deprive a
person of their liberty locally and informally. Both the Managing Authority and
Supervisory Body should be willing to engage in constructive discussion.
Those involved with the relevant person’s care planning and delivery will maintain
responsibility for this throughout the assessment process. The DoLS assessment
process is undertaken where necessary in addition to the individuals care planning
and delivery.
All organisations and services involved with deprivation of liberty should seek to
develop good practice by monitoring and reviewing their processes as part of the
organisation’s governance structure.
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5.2
Key Responsibilities of Northam ptonshire County
Northam ptonshire In Their Role As Supervisory Body :
Council
and
NHS
In Northamptonshire, the statutory duties of the Supervisory Bodies are discharged through a
partnership arrangement governed by a contract Agreement. The partnership arrangements
will provide a service to meet the requirements of the Deprivation of Liberty Safeguards.
The statutory duties of the Supervisory Bodies cannot be delegated; however, functions of
the duties may be sub-contracted where it is clear that the agent is acting on the Supervisory
Body’s behalf. Within this agreement the Deprivation of Liberty Safeguards Service will be
acting on behalf of NHS Northamptonshire in arranging and managing the assessment and
review processes required by the Act.
The responsibility for granting an authorisation, setting the period of authorisation and
attaching any conditions to the authorisation cannot be delegated under this arrangement
and will therefore remain the responsibility of the relevant Supervisory Body, not the DoLS
Service.
5.2.1 Key Responsibilities Of Supervisory Body
The key responsibilities of the Supervisory Body are:
To co-ordinate a dedicated interagency Deprivation of Liberty Safeguards Service to
undertake the work related to deprivation of liberty.
To ensure there is a clear referral pathway for all Managing Authorities.
To recruit assessors that have the necessary skills, qualifications and experience as
outlined in the Code of Practice.
To ensure there are sufficient numbers of assessors to undertake the volume of
assessments required.
To ensure all staff working as assessors or in any capacity within the DoLS Service
receive adequate training to perform their role, including training in equality and
diversity issues.
To coordinate and deliver training to those services with statutory responsibilities for
the safeguards and advise on integrating the requirements across other relevant
service provision.
To ensure consistency and equality of access to, and outcomes from, Deprivation of
Liberty Safeguards services.
To have overall responsibility for granting or refusing authorisations for deprivation of
liberty and to be responsible for signing authorisations.
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When giving authorisation for deprivation of liberty, to specify the duration of the
deprivation of liberty, which cannot exceed 12 months and should be for the shortest
possible practicable time.
To attach appropriate conditions to the authorisation and make recommendations
based on the best interests of the relevant person.
To make this document available to all local authority and independent care homes,
hospitals and relevant staff from the Supervisory Body and to ensure information
pertaining to the procedures and processes contained within this document is
communicated in a timely and effective manner.
To record management information and use it to measure the effectiveness of the
process outlined within this document and to assess the nature of the authorisations
both granted and refused in light of the local population of Northamptonshire.
To use management information and reviews to develop good practice and
communicate this information to relevant departments, such as those involved with
commissioning care and support services.
To collect equalities monitoring information for deprivation of liberty cases and use
this information to monitor any differential impact on particular groups and enhance
anti-discriminatory practices.
To enhance contract monitoring of care homes and hospitals through combined
intelligent information and intelligence (not personal data) arising from assessments
of care plans and levels of restrictive practices.
5.2.2 Key Responsibilities Of DoLS Service
The key responsibilities of the DoLS Service are:
To provide Managing Authorities with standard forms for use when requesting a
Standard Authorisation of deprivation of liberty and to ensure referral processes are
effective, secure and safe.
To receive applications from Managing Authorities for Standard Authorisations of
deprivation of liberty and to respond to applications within the timescales specified
within the procedures section of this document.
To appoint assessors, IMCA’s and relevant person’s representatives.
To facilitate and conduct the six necessary assessments of the relevant person to
ascertain whether or not they meet the qualifying requirements for a Standard
Authorisation to be given.
To give notice of the decision in writing to the requisite people and to other persons
entitled to notice by the most appropriate means.
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To access relevant resources that will enhance the quality of the assessment process
e.g. specialist opinion; interpreters etc.
To respond to requests to review an authorisation for deprivation of liberty. To record
assessment information and outcomes in accordance with statutory requirements and
to complete necessary information for management monitoring purposes.
5.2.3 Key Responsibilities Of Managing Authorities: Care Hom es & Hospitals
The following are the key responsibilities of care homes and hospitals in their role as
Managing Authorities:
To deliver care in as least restrictive means as viable that is proportionate and
necessary to prevent harm to that individual.
To adapt care planning processes to ensure consideration is given to whether a
person has the capacity to consent to the services which are to be provided and
whether their actions are likely to result in a deprivation of liberty.
To ensure clear and robust procedures are in place for staff to offer guidance and
clarity on when a request for a Standard Authorisation would be required, and the
procedures that should be followed in order to make an application to the Supervisory
Body. This requires clear policy and guidance relating to the use of restraint and
restrictive practices.
To ensure that no person is deprived of their liberty except where i) an Urgent
Authorisation is in place, ii) a Standard Authorisation is in place or iii) their liberty has
been deprived through other legal means e.g. under the Mental Health Act 1983.
To grant themselves Urgent Authorisation where deprivation of liberty needs to
commence before a Standard Authorisation can be obtained.
To obtain Standard Authorisation from the Supervisory Body in advance of the
deprivation of liberty, except in urgent circumstances where an Urgent Authorisation
is already in place, in which case authorisation must be obtained from the
Supervisory Body within seven calendar days of the start of the deprivation of liberty.
To comply with any conditions attached to the authorisation as imposed by the
Supervisory Body.
To ensure that applications for authorisation are not made as standard for all
admissions to hospitals and care homes simply because the relevant person lacks
the capacity to decide whether to be admitted, or where lower levels of restriction or
restraint are used that are permissible within the meaning of section 5 & 6 of the
Mental Capacity Act 2005. The referral process should be used appropriately and
when levels of restriction and restraint are significant it is genuinely necessary for a
person to be deprived of their liberty in their best interests.
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To ensure that the relevant person and their representative understands the effects of
an authorisation once it is granted and that they understand their rights and have
knowledge of complaints procedures.
To make alternative arrangements for care where an authorisation is refused and to
undertake urgent action to prevent unlawful deprivation of liberty.
To accommodate visits from the relevant person’s representative, recording details of
visits and informing the Supervisory Body if the representative is not maintaining
appropriate contact.
To maintain records and ensure that all relevant staff are made aware of whether an
authorisation is granted or refused.
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6
Appendix 6,
7, 8 and 9
PROCEDURES AND GUIDANCE
This section of the document outlines the key processes involved in the Deprivation of
Liberty Safeguards. Different aspects of the procedures are the responsibility of the
Managing Authority, the DoLS Service or the Supervisory Body and there are a number of
key timescales that all staff need to be aware of and adhere to. For clarity, the summary box
below highlights these key timescales. Staff may also find it useful to refer to the Process
Flowcharts included in appendix 6, 7, 8 and 9.
Standard Authorisations (sections 6.2, 6.3 and 6.4) – for use where it is anticipated that
deprivation of liberty will occur
Managing Authorities can apply for a Standard Authorisation up to 28 days in advance
of the anticipated deprivation of liberty.
The DoLS Service will acknowledge receipt of a request within 24 hours (or the next
working day if the form is received on a Friday or bank holiday)
The DoLS Service will inform the Managing Authority, in writing, that it is pursuing the
request and of it’s intended date for the BIA to commence assessments within 48
hours of the date of receipt of the original request (or within 48 hours of the next
working day if the request is received on a Friday or bank holiday).
The DoLS Service will appoint an IMCA if needed within 48 hours of the date that it
wrote to the Managing Authority to confirm it is pursuing the request.
The DoLS Service will have 21 days in total from the date of receipt of the original
request in which to complete all assessments and respond to the Managing Authority
with a decision.
From the date that all stage 1 assessments are concluded by the BIA, the Mental
Health Assessor will have 96 hours in which to complete the Mental Health
Assessment at stage 2.
Urgent Authorisations (section 6.5) – for use where the person is already being deprived of
their liberty or will be in the immediate future
The Managing Authority can issue itself an Urgent Authorisation for up to 7 days.
The Managing Authority must request a Standard Authorisation at the same time as
issuing itself an Urgent Authorisation.
The DoLS Service will inform the Managing Authority, in writing, of its intended date for
the BIA to commence assessments within 1 working day of the date of receipt of the
original request.
The DoLS Service must complete all assessments and respond to the Managing
Authority with a decision within the period of the Urgent Authorisation. The Mental
Health Assessment must be complete within 48 hours of the end of Stage 1.
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The DoLS Service
can extend the Urgent Authorisation for a maximum of a further 7
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days (only in exceptional circumstances).
The Deprivation of Liberty Safeguards Inter-Agency Policy and Procedures 1.1 October 2009
Third Party Requests (section 6.6)
Where a 3rd Party requests that the Managing Authority applies for an authorisation, the
Managing Authority must respond to the 3rd Party within 24 hours.
The DoLS Service will have 7 days from the date that the 3rd Party request was received
in order to ascertain whether an unauthorised deprivation of liberty is occurring.
If the DoLS Service find that an unauthorised deprivation of liberty is occurring, it will
have 21 days in which to complete all assessments as per a Standard Authorisation.
After the assessment process (section 6.10)
If the DoLS Service declines an authorisation because one or more of the requirements
are not met, but the BIA decides deprivation of liberty is occurring, the BIA will need to
arrange for a planning meeting to take place within 48 hours of notifying the Managing
Authority of its decision.
Within 7 days of the planning meeting taking place, an appropriate solution must have
been effected and the care plan must have been amended to ensure an unlawful
deprivation of liberty does not continue.
Any failure to meet the timeframes as outlined above must be reported to the relevant
Supervisory Body via their incident reporting procedures
6.1
The Deprivati on of Liberty Safeguards Servic e
Northamptonshire County Council and NHS Northamptonshire have developed an integrated
service model for the implementation of the Deprivation of Liberty Safeguards and have
appointed a specialist DoLS Service to respond to requests for Standard Authorisations from
Managing Authorities.
The DoLS Service is located within the Safeguarding Adults Team at Northamptonshire
County Council and the team will be managed by NCC on behalf of NHS Northamptonshire.
The contact details for the DoLS Service are as follows:
DoLS Service
Safeguarding Adults Team
Northamptonshire County Council
Floor 2, Oxford House
Wellingborough
NN8 4JR
Telephone: 01933 220724/ Safe Haven Fax: 01933 201057
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The core team consists of the following roles:
Team Manager (who is also the DoLS Lead). This key role has a duty to ensure
compliance with the regulations.
Senior Administrator
Best Interest Assessors employed within the DoLS Service
Best Interest Assessors contracted from other services
Supplementary BIA’s contracted and paid per assessment and required to undertake
a minimum of 3 assessments per annum.
The core service will also employ, when necessary, Paid Representatives, IMCA’s
and Mental Health Assessors.
6.2
Applying For A Standard Authorisati on (Proc edure For The Managing
Authority)
I.
Managing Authorities will need to ensure they have workable internal procedures in
place to identify if authorisation for deprivation of liberty is required, or if it is
necessary in exceptional circumstances to issue an Urgent Authorisation (see section
6.5 below). Procedures should clearly identify who is responsible for taking action at
this stage.
Managing Authorities should seek advice if necessary from the DoLS Service at this
stage.
II.
Managing Authorities will need to ensure every effort has been made to avoid
deprivation of liberty and care is being provided within the provisions of the Mental
Capacity Act.
III.
If the relevant person is already subject to a DoLS authorisation and a move is
planned to another care home or hospital and their liberty may be deprived, the
Managing Authority must apply to the DoLS Service for a new authorisation following
the procedures outlined in this section. An authorisation applies to the person in a
particular environment and an authorisation only applies to that hospital or care
home.
IV.
Where it is decided that an authorisation is required, the appropriate member of staff
identified in the internal procedures should complete the standard form- Form 4:
Managing Authority request for a Standard Authorisation. This can be done up to 28
days in advance of the anticipated deprivation of liberty occurring.
Form 4
The request form should be sent by fax to the DoLS Service using the following Safe
Haven Fax number: 01933 201057
V.
Managing Authorities must make every effort to send their request to the correct
Supervisory Body (please see paragraph 6.3 below for information on who
Supervisory Bodies have responsibility for)
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VI.
Where the Managing Authority needs to send requests for Standard Authorisations
for more than one relevant person, these should be sent individually on a case-bycase basis.
6.2.1 Inform ation to Be Provided To DoLS Servic e by Managing Authority
The Managing Authority is required to provide the following information to the DoLS Service
at this stage:
Relevant person’s information (including name, gender, age, address)
The name, address and telephone number of the Managing Authority (and a named
contact)
The purpose for which the authorisation is requested
The date from which the authorisation is sought
Whether the Managing Authority has given an Urgent Authorisation and the date of
expiry.
6.2.1.1 Additional Information
The request for a Standard Authorisation must also include, if available, the following
information:
Medical information relating to the relevant person
The diagnosis of the mental disorder from which the relevant person is suffering
Any relevant care plans / assessments
The racial, ethnic or national origins of the relevant person
Details of the proposed restrictions on liberty
Whether there is an existing Standard Authorisation in force in relation to the relevant
person, and date of expiry.
Whether or not an IMCA is required (an IMCA would be required if the relevant
person does not have somebody not engaged in providing their care or treatment in a
professional capacity or for remuneration to support them)
Contact details of anyone engaged in caring for the person or who have been named
by the relevant person as someone to consult.
Information about any legislative considerations, such as:
Lasting Power of Attorney
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Advance Decision to Refuse Treatment
Mental Health Act requirements
VII.
Once the request form has been sent to the DoLS Service, the Managing Authority
should, if judged appropriate/practicable, inform the family and carers of the relevant
person that an application for a Standard Authorisation has been made. The
Managing Authority should also keep a copy of the request form and clear written
records of the reasons for the request.
VIII.
If a Managing Authority receives a request from a third party to apply for an
authorisation, or to change the care regime, the Managing Authority must respond to
this request within 24 hours.
Where the Managing Authority has been unable to resolve the 3 rd party request, i.e.
where they have not been able to satisfy the 3rd party that no deprivation of liberty is
occurring, they must submit an application to the DoLS Service following the
procedures outlined above. Where the Managing Authority has failed to make an
application, the Supervisory Body will accept a referral from the 3rd party. In such
circumstances, the Care Quality Commission will be notified.
IX.
6.3
I.
Where the Supervisory Body and the Managing Authority are the same organisation,
it can act in both capacities. However, in such a situation, the BIA cannot be an
employee of the Supervisory Body/Managing Authority, or provide services to it.
Rec eiving a Request for Assessm ent
(Procedure For The DoLS Service)
For
Standard
Authorisation
Northamptonshire DoLS Service has duties as a Supervisory Body towards Managing
Authorities where:
For registered care homes
The relevant person is ordinarily resident within Northamptonshire or
The relevant person is not ordinarily resident in England or Wales or
The relevant person has no fixed abode or
The relevant person is funding their own care
For hospitals
NHS Northamptonshire has commissioned the relevant person’s care or
The hospital is within Northamptonshire and the relevant person has self-funded
their care
Managing Authorities must make every effort to send their application to the correct
Supervisory Body. In the event that the Northamptonshire DoLS Service receives a
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referral that is the responsibility of a Supervisory Body in another area, the DoLS Service
will inform the Managing Authority of this and redirect the form to the Supervisory Body of
the correct authority. In the event that that Supervisory Body requests assistance from
the Northamptonshire DoLS Service in undertaking the assessments, the ADASS
Protocol for the Inter-Authority Management of Deprivation of Liberty Safeguards
Applications will be applied.
II.
Upon receipt of a request for a Standard Authorisation, the DoLS Service Senior
Administrator will initially acknowledge receipt of the referral form within 24 hours (or the
next working day if the form is received on a Friday or bank holiday) by sending a secure
fax to the Managing Authority.
III.
The DoLS Service will consider whether the application is appropriate, complete or
whether any additional information is required from the Managing Authority.
If the request form (Form 4) is incomplete/invalid, the DoLS Service will refer back
to the Managing Authority for further information/necessary action. The
application process will be restarted on receipt of the revised request
form/information.
If the DoLS Service considers that the request has been made too far in advance
of expiry of an existing authorisation, this should be resolved with the Managing
Authority and the application process stopped until another request form is
received at a more appropriate time.
If the request form is both complete and valid, within 48 hours of receipt of the
original application (or within 48 hours of the next working day if the form is
received on a Friday or bank holiday) the DoLS Service will inform the Managing
Authority, in writing, of its intended date for sending a BIA to commence the
assessment process.
IV.
From the date of receipt of the original application, the DoLS Service will have 21 days in
total in which to complete all assessments and respond to the Managing Authority’s
request.
V.
The Northamptonshire DoLS Service has divided the assessment process into two
stages, stage 1 for preliminary assessments and stage 2 for full assessments. The
assessments at stage 1 are conducted by a Best Interest Assessor. Once all stage 1
assessments are complete and this is recorded on the checklist, the Mental Health
Assessors will have 96 hours in which to complete the mental health assessment at
stage 2 of the process. The Best Interest Assessor will complete assessment
requirements within stage 2 of the assessment process. (see section 6.4 below for full
details of the assessment process).
VI.
The Senior Administrator will need to begin the DoLS Service Assessment Checklist
included in Appendix 4 of this document, recording the date of receipt of the form, the
Appendix 4
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intended date for the BIA to commence assessment and any reasons for appointing a
particular BIA (if there are any).
6.3.1 Instructing An IMCA
I.
The relevant person must have someone who can provide support to them
throughout the assessment process, such as a family member, friend or carer. This
person cannot be someone who provides care or treatment in a professional capacity
or for remuneration. If the relevant person does not have somebody available to
support them, then the DoLS Service will need to instruct an Independent Mental
Capacity Advocate (IMCA). In doing so, the DoLS Service will take account of the
relevant person’s cultural background, including their race, ethnicity, religious beliefs
and sexuality.
II.
There is a standard referral form available for the DoLS Service to use when
instructing an IMCA (Form 30: Supervisory Body instructs an IMCA to represent a
person who is, or may become, subject to a deprivation of liberty authorisation). This
form requires the DoLS Service to identify the purpose of the IMCA and under which
section of the Mental Capacity Act they are being instructed. The DoLS Service
should provide as much detail as possible when instructing an IMCA.
III.
The date the IMCA was instructed should be recorded on the DoLS checklist by the
senior administrator. In the case of applications for Standard Authorisations, this will
be done within 48 hours of confirming that the application should be pursued, or
within 24 hours or next working day for Urgent Authorisations.
Form 30
There is a standard form available for the IMCA to use to provide their report to the
Supervisory Body (Form 31: IMCA Report to the Supervisory Body).
Form 31
The Supervisory Body with responsibility for the contract with the IMCA Service will
need to ensure that the IMCA Service is pro-active in it’s recruitment of advocates
from a diverse range of cultural backgrounds.
IV.
Where a request for an authorisation is received for a care home placement that is
being funded by Continuing Health Care, the BIA should inform the head of
Continuing Health Care or their deputy, prior to the assessments being conducted,
that a request for an authorisation has been made and that the BIA will be
commencing the assessment process. (See item 6.4.4 (IV) below for further
requirements relating to authorisations for CHC funded placements).
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6.4
Assessm ent Process for A Standard Authorisation (Proc edure For The
DoLS Servic e)
I.
Once a request form has been received and the DoLS Service have confirmed
receipt and informed the Managing Authority of its intended date for commencing the
assessment, the BIA Lead is then responsible for appointing the duty BIA to
commence the assessment process. The choice of BIA will be determined by:
ensuring compliance with conflict regulations
the skills and experience required for that specific assessment. This may
include experience of working with a particular disability or service group and
also knowledge of the persons cultural background
expedient use of resources
II.
A form is available for the DoLS Lead to use when appointing assessors. This is a
checklist to ensure assessors meet all the regulations and that there are no conflicts
of interest. The form can be used for both BIA’s and Mental Health Assessors and
includes a space for any additional reason for appointing a particular assessor to a
particular case. This form is included in appendix 5.
III.
There are also standard referral forms available for the DoLS Service to use when
appointing suitably qualified Best Interests Assessors and Mental Health Assessors.
The forms allow the DoLS Service to identify which assessments it wants the
assessors to undertake.
Appendix 5
Form 28 &
Form 29
6.4.1 2 Stages in the Assessm ent Process
Northamptonshire DoLS Service will undertake the assessment process in 2 stages:
1. Stage 1: Preliminary stage
2. Stage 2: Four full assessments
I.
The Senior Administrator is responsible for ensuring the BIA has access to any
resources required to undertake the assessments, such as interpreters or speech
therapists, which may support the relevant person or anyone with an interest in their
care or treatment. The Senior Administrator should also make provision to ensure
information is available in other languages and formats as and when required.
II.
The Managing Authority must provide the BIA conducting assessments with any
relevant assessments or care plans and enable access to and copies of any records
held that assessors or IMCA may consider relevant.
III.
Staff should refer to section 4 of the Code of Practice for full guidance on each of the
assessments, their purpose and how they should be conducted.
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Assessors are personally accountable for their decisions and Managing Authorities
and Supervisory Bodies must not dictate or seek to influence their decisions. However
the Supervisory Body retains liability for the assessment process.
6.4.2 Stage 1: Prelim inary Assessm ents
At this stage the BIA commences the initial assessments. The purpose of these assessments
is to determine whether the BIA and Mental Health Assessor will need to undertake the full
Best Interests Assessment and full Mental Health Assessment at Stage 2. Where any
requirement is not met at this stage, the assessment process ceases immediately (see
paragraph 6.4.2.5 (III) below).
Throughout both stages of assessment, the assessors will need to use the standard form s
issued by the Department of Health. The forms for the assessments are numbered 5 to 11.
(see the list of all DH forms and letters included in appendix 1). Staff will need to be aware of
any additional information/requirements included in the document Deprivation of Liberty
Safeguards Forms and Record Keeping.
Form 5
6.4.2.1 Confirm Age Assessment
This assessment is to establish if the relevant person is aged 18 or over.
The BIA will undertake this assessment.
6.4.2.2 Identify If Liberty Is Being Deprived
This establishes whether deprivation of liberty is occurring or if it is going to occur.
The BIA will undertake this assessment.
Form 8
6.4.2.3 Confirm No Refusals Assessment
This establishes whether an authorisation for deprivation of liberty would conflict with other
existing authority for decision making for that person, such as a valid and applicable Advance
Decision to Refuse Treatment (ADRT) or a refusal by an attorney or deputy.
The BIA will undertake this assessment.
Form 7
6.4.2.4 Preliminary Mental Capacity Assessment
This is a preliminary assessment of the relevant person’s mental capacity to consent to the
arrangements for their care i.e. the levels of restriction or restraint used. Unless it is evident
that the person has capacity, (in which case all assessments end immediately), this
assessment may be concluded at stage 2 by the mental health assessor or BIA.
The BIA will undertake this assessment.
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6.4.2.5 Preliminary Eligibility Assessment
I.
This is a preliminary assessment that establishes whether the relevant person is
subject to a requirement under the Mental Health Act 1983 that may conflict with an
authorisation under DoLS or whether their care should be provided under the Mental
Health Act.
II.
This preliminary assessment will be undertaken by the BIA. Where the BIA is also an
AMHP this assessment can be completed at stage 1, otherwise the Mental Health
Assessor will need to undertake the full assessment at stage 2. If it is clear that this
requirement is not met, all assessments end. Where further consideration is required,
this assessment will be concluded in stage 2. (Please see paragraph 6.4.3.3 for
further information about the eligibility assessments).
III.
If any requirement is not met at this stage, the assessment process is
immediately ceased and the Managing Authority is informed, in writing of the
decision that the Standard Authorisation is refused and the reasons for this.
The BIA will need to complete Form 13 – Supervisory Body declines a request
for a Standard Authorisation (See section 6.7 below for procedures related to
the outcomes of the assessment).
IV.
All assessments should be recorded on the standard forms issued by the Department
of Health and the DoLS Service Assessment Checklist should be updated. Where
preliminary assessments indicate a need for stage 2, the Mental Health Assessor will
be notified and time of request noted. The Mental Health Assessors have 96 hours in
which to complete the mental health assessment at stage 2.
Form 9
Form 13
Appendix 4
V.
At this point, the BIA can be changed if the preliminary stage 1 assessments highlight
any issues that a different BIA with specialist skills may be better suited to assessing.
For instance, different assessors may have experience of working with particular
service user groups, experience of working with people from particular cultural
backgrounds or have specific communication skills which would be of benefit to
assessment process.
VI.
Where a change of BIA occurs, it is essential that there is good communication
between them and that any reasons for changing the BIA are recorded.
6.4.3 Stage 2: Full Assessments
6.4.3.1 Mental Health Assessment
Form 6
This assessment must be conducted by a Mental Health Assessor. The purpose is to
establish whether the relevant person is suffering from a mental disorder within the meaning
of the Mental Health Act 1983.
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The DoLS team leader will be responsible for appointing the Mental Health Assessor. The
choice of assessor will be governed by
ensuring compliance with regulations
knowledge of the relevant person
skills and specialist knowledge for the relevant persons needs
expedience of resources
Reasons for appointing the Mental Health Assessor will be recorded.
6.4.3.2 Mental Capacity Assessment
Form 7
This establishes whether the relevant person lacks the capacity to consent to the
arrangements proposed for their care or treatment. This will be conducted by the BIA unless
the relevant person is already known to the Mental Health Assessor, in which case, the
Mental Health Assessor will conduct this assessment.
6.4.3.3 Eligibility Assessment
Form 9
This establishes whether the relevant person is subject to a requirement under the Mental
Health Act 1983 that may conflict with an authorisation under DoLS or whether their care
should be provided under the Mental Health Act. This will be conducted by the BIA, unless
the BIA is not an AMHP, in which case the assessment will be conducted by the Mental
Health Assessor who must be approved under section 12 of the Mental Health Act 1983 to
undertake this assessment.
Where the eligibility assessment is not conducted by the BIA, the Mental Health Assessor will
need to ask the BIA for any information about whether the person is subject to guardianship
under the Mental Health Act 1983 or if they meet the criteria for being detained under section
2 or 3 of that Act.
6.4.3.4 Best Interests Assessment
Form 10
This assessment establishes whether the proposed deprivation of liberty is in the relevant
person’s best interests, is necessary to prevent harm to themselves and that the deprivation
of liberty is proportionate to the likelihood and seriousness of the harm. This assessment
must consider all circumstances of the case including how issues of equality and human
rights are addressed. This assessment must be conducted by the BIA.
6.4.3.5 Equivalent Assessments
Form 11
The Act allows equivalent assessments to be relied upon instead of obtaining fresh
assessments. Within Northamptonshire, the use of equivalent assessments will be restricted
to:
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Eligibility Assessment: A mental health assessment can be use if it has occurred
within the last 2 months, if no significant changes have occurred in the relevant
person’s mental health and the DoLS Lead is satisfied that there is no reason why the
assessment may no longer be accurate.
Age Assessment: Where age has been recorded within a formal assessment process
having occurred within the last 12 months
If an equivalent assessment is used, the BIA will need to complete Form 11.
6.4.4 Additional Duties during the Assessm ent Proc ess
I.
The BIA should at this stage initiate identifying a Relevant Person’s Representative,
although this person will not actually be appointed until an authorisation is approved
and confirmed in writing.
The role of the Relevant Person’s Representative is to maintain contact with the
relevant person and to provide independent representation and support to the
relevant person in all matters relating to the Deprivation of Liberty Safeguards,
including triggering a review.
The code of practice provides eligibility criteria for who can be the Relevant Person’s
Representative. At the assessment stage the BIA must identify if there is anyone they
would recommend to become the relevant person’s representative, and discuss the
representative’s role with the people interviewed during the assessment process
(even though some of these assessments may not lead to an authorisation being
granted).The standard form, Form 24: Best interests assessor action in respect of the
selection of a relevant persons representative should be completed at this point.
Form 24
If the relevant person does not have anyone who could act as his or her
representative, the BIA should consider appointing a paid representative.
The responsibility for ensuring a Relevant Person’s Representative is appointed at
the point of an authorisation being granted rests with the DoLS Lead.
The Code of Practice provides detailed guidance on how the BIA should go about
selecting the Relevant Person’s Representative and this should be done with due
regard to the personal attributes and cultural background of the relevant person.
The appointment of the Relevant Person’s Representative needs to be officially
signed by the Signatory for the relevant Supervisory Body (see para 6.9 (VI) below)
II.
The BIA should, throughout the assessment stage, identify and attempt to resolve
any disagreements with the IMCA or those supporting the relevant person.
III.
The BIA should attempt, wherever possible, to discuss with the Managing Authority
any possible recommendations they intend to make in their report to ensure early
remedial action in the event of an authorisation not being granted.
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IV.
Where the authorisation is for a care home placement being funded by another
commissioner of care, such as Continuing Health Care, the BIA will need to ensure
that the Head of Service or their deputy is consulted regarding any conditions that
they are considering attaching to the authorisation, especially if these conditions may
require additional resources. This consultation must take place prior to the
authorisation being signed off by Signatory from the Supervisory Body.
V.
The BIA will need to refer to the Safeguarding Adults Team and Interagency
Safeguarding Adults Procedure when the BIA considers practices to be abusive
within the meaning of those procedures including where deprivation of liberty is
affecting a number of people within a home or ward. This will include consideration of
referral to the Care Quality Commission in line with those procedures.
VI.
The checklist should be completed by the BIA throughout the assessment process to
ensure the DoLS Lead is able to track progress of the assessment and to allow clear
communication with the Managing Authority regarding the progress of each
assessment toward timely conclusion.
6.5
Process for Urgent Authorisations (Proc edure for The Managing Authority
And DoLS Service).
6.5.1 Managing Authority Responsibilities
Form 1
Form 4
In exceptional circumstances, where deprivation of liberty needs to commence before a
Standard Authorisation can be obtained, the Managing Authority can issue itself an Urgent
Authorisation which makes deprivation of liberty lawful for a short period of time. A request
for a Standard Authorisation must be made simultaneously with the issuing of an Urgent
Authorisation. The Managing Authority will need to complete the following forms at the same
time: Form 1: For the giving of an Urgent Authorisation by a Managing Authority and Form 4:
Managing Authority request for a Standard Authorisation. Form 4 must be forwarded to the
DoLS Service as per the process for Standard Authorisation requests as outlined in section
6.2 above.
The DoLS Service will need to undertake the same assessment process as for a Standard
Authorisation, but within shorter timescales.
Where the Managing Authority is considering granting an Urgent Authorisation prior to an
urgent move to alternative accommodation, they must consider the likely effect the move
may have on the person’s mental health and how this may distort the subsequent
assessment.
I.
Managing Authorities should have a procedure in place giving clear guidance to staff
about the actions, responsibilities and timescales required for issuing Urgent
Authorisations.
II.
Managing Authorities should refer to the Code of Practice for clear guidance
governing the circumstances in which an Urgent Authorisation can and cannot be
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issued. Any care or treatment provided under an Urgent Authorisation must comply
with Section 6 of the Mental Capacity Act 2005 and the relevant people must be
consulted before granting an Urgent Authorisation (this includes anyone engaged in
caring for the person or who has an interest in their welfare).
III.
The Managing Authority will need to keep records of Urgent Authorisations issued
and give written copies to the relevant person and any IMCA instructed. The relevant
person’s family, friends and carers should be notified and the relevant person should
be helped to understand their rights.
IV.
The Urgent Authorisation ends upon conclusion of the Standard Authorisation or
upon expiry of the Urgent Authorisation, whichever is the earlier. The DoLS Service,
on behalf of the Supervisory Body, will inform the relevant person and any IMCA
appointed that the Urgent Authorisation has ended. This may be combined with the
outcome form for the Standard Authorisation.
6.5.2 DoLS Servic e Responsibilities
I.
Upon receipt of the Standard Authorisation request form, the DoLS Service will need
to undertake the same assessment process as for a Standard Authorisation, but with
a different set of timescales:
The DoLS Service will need to inform the Managing Authority of its intended
date for sending a BIA to conduct assessments within 1 working day of receipt
of the referral.
From the end of Stage 1, the Mental Health Assessor will have 48 hours to
complete the mental health assessment.
All assessments will need to be complete and an outcome report issued with a
decision on whether the authorisation will be granted within the time period of
the original Urgent Authorisation (unless this is extended)
The DoLS Service must ensure good communication and coordination, taking
particular care where the expiry date coincides with weekends or bank
holidays.
II.
Once the assessment process is complete for the Standard Authorisation, the DoLS
Service will need to make a decision to either grant the authorisation or decline the
request for a Standard Authorisation and follow the same processes outlined in
Section 6.7 below. The DoLS Service will need to inform the Managing Authority of
the need to terminate the Urgent Authorisation where requirements for Standard
Authorisation are not met.
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6.5.3 Term inating an Urgent Authorisation
I.
The Managing Authority must terminate the Urgent Authorisation at the end of the 7
day period for which it was issued (unless the Managing Authority has applied to the
DoLS Service to extend the Urgent Authorisation – see para 6.5.4 below).
II.
The Urgent Authorisation would also terminate if the Standard Authorisation applied
for is granted by the Supervisory Body, or if it is not granted as this would constitute
an unlawful deprivation of liberty.
III.
The DoLS Service must inform the relevant person and any IMCA instructed that the
Urgent Authorisation has terminated. If possible, this notification should be combined
with the notification of the outcome of the assessment process for the Standard
Authorisation.
6.5.4 Extending the Urgent Authorisation
I.
In exceptional circumstances where the Standard Authorisation cannot be dealt with
within the period of the Urgent Authorisation, the Managing Authority can apply to
extend the period of the Urgent Authorisation for a maximum of a further 7 days. The
standard form, Form 2: Managing Authority request for an extension in the duration of
an Urgent Authorisation must be sent to the DoLS Service.
II.
The Managing Authority must keep a written record of the reason for the request and
notify the relevant person in writing. In such circumstances, the DoLS Service Lead
will consult with the Signatory from the relevant Supervisory Body before determining
whether to grant an extension and keep a record of any discussions that take place.
The reasons for granting or declining an extension will be recorded in writing.
III.
The DoLS Service will need to determine whether or not to extend this Urgent
Authorisation, and inform the Managing Authority of its decision, giving reasons and
keeping written records. The standard form, Form 3: Supervisory Body’s decision
regarding request for an extension of an Urgent Authorisation should be used.
IV.
Where the DoLS Service agrees to extend the period of Urgent Authorisation, the
Managing Authority is responsible for informing the relevant person and any IMCA
instructed of the extension, both orally and in writing and inform them of their rights
and assist their understanding. The relevant person and IMCA must also be informed
where a request to extend an Urgent Authorisation is declined.
V.
Both the Managing Authority and DoLS Service must ensure that the use of Urgent
Authorisations is recorded, monitored and audited as part of the organisation’s
governance procedures.
Form 2
Form 3
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6.6
Third Party Requests – Unauthorised Deprivation of Liberty (Procedure For
The DoLS Service)
I.
The DoLS Service may receive referrals from a third party regarding an unauthorised
deprivation of liberty. Standard letters are available for 3rd parties to write to either the
Managing Authority (letter 1) or Supervisory Body (letter 2). The 3 rd party should
always contact the Managing Authority in the first instance.
Letters 1 & 2
Form 16
II.
Form 17
The DoLS Service should keep a written record of the request and ascertain whether
the 3rd party has requested that the Managing Authority apply for an authorisation.
(Where this is the case the Managing Authority is required to respond to the 3 rd party
within 24 hours). If the 3rd party has not yet done this, the matter should be referred
back to the 3 rd party to approach the Managing Authority. The DoLS Service will
consider what support the 3rd party may require to approach the Managing Authority
and enable this process. The standard form, Form 16: Record of Supervisory Body
action on receipt of notification of a possible unauthorised deprivation of liberty should
be used by the DoLS Service at this point.
If the 3rd party has previously approached the Managing Authority, the DoLS service
will either:
Appoint a BIA to ascertain whether or not there is an unauthorised deprivation of
liberty. This assessment must be completed within 7 days. At this stage an
IMCA will be instructed if required (see item 6.3.6 above) and the DoLS
Assessment Checklist will be started by the Senior Administrator. The standard
form, Form 17: Unauthorised deprivation of liberty assessor’s report should be
completed.
The 3rd party, the relevant person, the Managing Authority and any IMCA will be
notified of the decision to investigate the matter and the BIA that has been
appointed to undertake the assessment.
The DoLS Service will consider any additional services required in order to
support the assessment process, such as an interpreter or other communication
support needs.
Or, if the request is considered either vexatious or frivolous, or if it has already
been decided that no deprivation is occurring, the DoLS Service will notify the 3rd
party, the relevant person, any IMCA instructed and the Managing Authority that
the DoLS service has been asked to decide whether or not there is an
unauthorised deprivation of liberty occurring, but that the matter is not to be
pursued.
III.
If the assessment finds that no deprivation of liberty is occurring, the DoLS Service
will notify the 3rd party, the relevant person, the Managing Authority and any IMCA of
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Form 18
IV.
Form 18
V.
Form 18
Form 4
Form 1
the outcome. This will be recorded by the DoLS Service. The DoLS Service will need
to complete standard form, Form 18: Supervisory Body’s decision following the
receipt of an unauthorised deprivation of liberty report.
If the assessment finds that deprivation of liberty is occurring, the BIA will need to
ascertain whether this has already been authorised. If the deprivation of liberty has
already been authorised, the DoLS Service will notify the 3rd party, the relevant
person, the Managing Authority and any IMCA of the outcome. The DoLS Service will
need to complete standard form, Form 18: Supervisory Body’s decision following the
receipt of an unauthorised deprivation of liberty report.
If the deprivation of liberty is not already authorised, the Managing Authority is
deemed to have requested a Standard Authorisation in relation to the relevant
person. The DoLS Service will need to complete standard form, Form 18: Supervisory
Body’s decision following the receipt of an unauthorised deprivation of liberty. In such
circumstances, the DoLS Service will notify the relevant regulatory body of the
Managing Authority.
The Managing Authority will need to provide the DoLS Service with the information
required for a Standard Authorisation as per section 6.4 above and must complete
Form 4: Managing Authority request for a Standard Authorisation and send it to the
DoLS Service. The DoLS Service will notify the 3 rd party, the relevant person, the
Managing Authority and any IMCA that the DoLS Service will commence assessments
as per a Standard Authorisation for deprivation of liberty and the procedures outlined in
this document will be followed.
The present care and/or treatment of the relevant person that has been found to
amount to deprivation of liberty must be discontinued while the Standard Authorisation
process is undertaken, unless the Managing Authority considers it necessary to
continue with the care/treatment, in which case it must grant itself an Urgent
Authorisation and complete Form 1: For the giving of an Urgent Authorisation for a
Managing Authority.
If the Managing Authority grants itself an Urgent Authorisation, the DoLS Service will
need to conduct the assessments within the timescales for Urgent Authorisation as set
out in section 6.5 above.
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6.7
Assessm ent Outcom es – Granting or Declining an Authorisation (Procedure
for the DoLS Servic e, Supervisory Body And Managing Authority)
6.7.1 The Assessor’s Reports
Form 10
I.
The assessors are responsible for recording the outcomes and completing the
standard forms relevant to the assessments they are responsible for as outlined in
section 6.4 above.
II.
There are particular requirements for the best interests assessment form (form 10:
best interest assessment form for completion by assessor). For the best interests
assessment the BIA must explain the reasons for their conclusions.
Where the best interests assessment does not support the deprivation of liberty, the
BIA will provide guidance for commissioners and care providers on future actions and
alternative care / treatment. This information should be communicated to the
managing authority at the earliest possible stage during the assessment process to
enable timely alternative care planning.
Where the best interests assessment supports the authorisation, the BIA will specify
the following on the best interest assessment form:
The reasons concerning whether or not the care/treatment amounts to deprivation
of liberty, whether this is in the person’s best interests, whether it is necessary to
prevent harm to that person and whether it is a proportionate response to the
likelihood of the person suffering harm.
Any conditions related to the deprivation of liberty authorisation and how to avoid
deprivation of liberty in the future. The BIA should not specify any conditions that
do not relate directly to the deprivation of liberty.
Recommend the length of authorisation
The BIA is responsible for pulling together each assessment report and completing the
relevant outcome form that details the BIA’s decision as to whether the authorisation should
be granted or declined.
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6.8
DECLINING THE AUTHORISATION
I.
Where any assessment concludes the requirement is not met, all assessments
end and the authorisation will be declined.
The BIA will need to communicate this to the other assessors and complete Form 13:
Supervisory Body Declines A Request For A Standard Authorisation.
Form 13
The BIA will complete Form 10 up to section D5
The BIA is required to give details on this form as to why the relevant person failed to meet
one or more of the requirements.
The form will need to be forwarded to the DoLS lead for signing. Where the authorisation is
declined, the relevant supervisory body will need to be informed but it is not necessary for
the form to be forwarded to a senior manager of the supervisory body for signature.
The DoLS lead is responsible for ensuring due process is followed and notifying all the
relevant parties as detailed in para 6.10 below.
Where it is deemed that deprivation of liberty is occurring, the DoLS lead is responsible for
instigating the procedure as detailed in para 6.9 below.
6.9
I.
GRANTING THE AUTHORI SATION
Where all assessment requirements are met, the authorisation will be granted.
The BIA will need to complete form 12: supervisory body gives a standard
authorisation. The BIA needs to include the following information on the form:
Form 12
The date on which the authorisation comes into force and the period for which it is
set.
The purpose for which the authorisation is given
Any conditions to be attached to the authorisation
The reasons why each qualifying requirement is met
II.
Once form 12 has been completed, the BIA will need to forward it, along with copies
of all the assessment forms, to the DoLS lead in the first instance for validation. The
minimum number of copies should be made and where the BIA is forwarding more
than one case to the DoLS lead, these should be sent separately on a case-by-case
basis.
III.
The DoLS lead will then need to forward the form and copies of all assessments to
the relevant supervisory body (NCC or NHS Northamptonshire). The relevant
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supervisory body has responsibility for signing the authorisation and this responsibility
will rest with a senior manager from the relevant supervisory body.
IV.
The Senior Managers From The Relevant Supervisory Body That Will Act As
Signatory Are:
For authorisations for care homes: Hass Service Managers
For authorisations for hospitals: Designated Senior Managers within the
NHS Northamptonshire contacted through NHS Northamptonshire
headquarters.
V.
The signatory of the relevant supervisory body is responsible for ensuring due
process has been followed and all assessments have been completed correctly and
fully.
The signatory cannot overturn the decision of the BIA to grant the authorisation, but
can highlight where re-assessment may be necessary.
Where the supervisory body and managing authority are the same organisation, such
as where the care home involved is managed by NCC, the senior manager acting as
signatory should not be directly involved in the management of that service. An
alternative senior manager from a different service area of the relevant supervisory
body should act as signatory in these circumstances.
The key responsibilities of the signatory are:
Grant the authorisation where all requirements are met as prescribed by the
Act.
Consider whether to attach conditions as recommended by the BIA.
o
The signatory for the Supervisory Body will need to consider the
implications of the conditions attached to the authorisation as
recommended by the BIA, particularly with regard to potentially
sanctioning additional resources on behalf of their organisations
commissioners.
o
Where the Supervisory Body does not attach the conditions as
recommended by the BIA or deviates from the BIA’s recommendations,
they must discuss this with the BIA in case this would significantly affect
the conclusions reached by the BIA in their assessment (unless the BIA
has specified on Form 12 that failure to attach the conditions would not
have affected their decision).
o
The BIA must be available for the signatory to consult with prior to signing
the authorisation. Wherever possible this should be face-to-face
consultation.
Set the period of authorisation.
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o
The signatory for the Supervisory Body cannot extend the period of
authorisation as recommended by the BIA. However, they can discuss
with the BIA if they consider the timescale should be shortened.
Officially appointing the Relevant Person’s Representative (see para 6.10
(VI) below)
VI.
Once the signatory for the supervisory body has signed form 12, the form will need to
be sent back to the DoLS service. The DoLS lead will then have responsibility for
ensuring due process is followed and notifying all the relevant parties as detailed in
section 6.10 below.
6.10 Rec ording and Notifying Relevant Parties of The Decision
Once the DoLS service has completed the form stating it’s decision to either grant or refuse
the authorisation, and the form has been signed by the appropriate person, the DoLS lead is
responsible for ensuring the following are undertaken:
I.
A copy of the outcome form (form 12 or 13) is kept and filed
II.
A copy of form 30 is completed and filed
III.
The outcome is recorded on the careFirst database including the date and time
the outcome report is signed and including alerts for reviews and expiry of
authorisation.
IV.
Written copies of the outcome form (with copies of all assessments attached) are
sent to the following:
The managing authority;
The relevant person;
The relevant person’s representative;
The IMCA (if instructed);
Any other persons consulted by the BIA and named in the best interests
assessment report as an interested person.
Form 24
V.
Any information or documentation for the relevant person, anyone consulted
throughout the assessment process or with an interest in their care or treatment
should be made available in other languages and formats as and when required.
VI.
Appointing the Relevant Person’s Representative
Where an authorisation is granted, a Relevant Person’s Representative is appointed
based on the BIA’s recommendations. The Relevant Person’s Representative will be
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required to sign and return Form 24 within a two week period to ensure compliance with
the appointment process.
Form 25
The DoLS Service will need to complete Form 25: Supervisory Body action in respect of
the appointment of a relevant person’s representative and forward this to the Signatory
for the relevant Supervisory Body along with Form 12. The Signatory will need to sign
Form 25 to officially appoint the Relevant Person’s Representative.
Once Form 25 has been signed by the relevant Supervisory Body, it should be sent to the
following: The Managing Authority; the relevant person; the Relevant Person’s
Representative; the IMCA (if required); any other persons consulted by the BIA.
The Representative must be given information and support to assist them in their role
and be provided with the means to contact an IMCA.
The relevant commissioning service of the supervisory body is informed of the
outcome.
The relevant person and their representative have information regarding how to
appeal against a decision and how to access the court of protection.
The managing authority has information regarding the relevant complaints
procedures of the supervisory body and how to appeal against the assessments
process.
o
NCC Complaints Procedure
http://www.northamptonshire.gov.uk/en/councilservices/Council/fee
dback/Pages/default.aspx
o
NHS Northamptonshire Complaints Procedure
http://www.northamptonshire.nhs.uk/talk-to-us/index.php
Appendix 4
The DoLS Service Assessment Checklist is completed and recorded.
6.10.1 Actions to Be Undertaken By The Supervisory Body And Managing
Authority W here Liberty Is Being Deprived But The Requirem ents For
Authorisation Are Not Met
Where the DoLS Service refuses authorisation for deprivation of liberty because one of the
requirements are not met, but agrees that deprivation of liberty is occurring, depending on
which of the 6 requirements are not met the Managing Authority, along with the Supervisory
Body will need to take appropriate alternative action.
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6.10.1.1
Planning Meetings
In certain circumstances (see options for different assessments below) it will be necessary
for the supervisory body and managing authority to have a planning meeting to discuss the
required action in light of the refusal of authorisation. Where a planning meeting is required, it
should take place within, at the latest, 48 hours of the managing authority being informed
that the authorisation will not be granted (or the following working day if the managing
authority is informed of the refusal on a Friday). The DoLS lead will have responsibility for
calling the planning meeting once the authorisation has been returned to the DoLS service
by the signatory from the supervisory body.
The required attendees at the planning meeting will include the BIA, a representative from
the relevant commissioning department of the supervisory body, an advocate for the relevant
person (where involved), a senior representative from the managing authority and the
relevant person’s lead professional (such as a care manager, continuing health care
assessor or ward key worker).
In circumstances where the relevant person is a self-funder, care planning will need to
include those who manage the relevant person’s funds.
The purpose of the planning meeting will be to review the care or treatment currently in place
and agree a plan to ensure no unlawful deprivation of liberty continues, assessing any risks
as a means of reducing restriction and safeguarding issues. The plan must consider how
issues of equality and human rights are addressed in delivering care. The planning meeting
can also consider any additional resource requirements of the managing authority resulting
from the recommendations of the BIA to amend the care plan.
Within 7 days of the planning meeting taking place, an appropriate solution needs to have
been effected and the care plan will need to have been amended.
Two months after this planning meeting, the individual responsible for the relevant person’s
care (such as the care manager) will review the care provided to ensure that the care regime
has not reverted back into unlawful deprivation of liberty. This should be recorded and kept in
the relevant person’s records.
All outcomes from the planning meetings and dates for review should be recorded by the
supervisory body. Depending upon the circumstances of the case, the supervisory body may
also need to consider whether referral to the relevant regulatory body or safeguarding adults
team is required.
6.10.1.2
Age Assessment
If this assessment does not meet the requirements for authorisation because the relevant
person is under the age of 18, the managing authority will need to refer the case to the
relevant children’s services and use of the children act 1989 or mental health act 1983 may
be considered.
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6.10.1.3
Mental Health Assessment
If this assessment does not meet the requirement for authorisation because the relevant
person does not have a mental disorder as defined by the mental health act 1983, the
managing authority cannot legally detain the relevant person without their permission.
A planning meeting will need to be scheduled within at the latest 48 hours of the managing
authority being notified of the refusal in order to consider how to modify the care plan to
avoid a deprivation of liberty.
6.10.1.4
Mental Capacity Assessment
If this assessment does not meet the requirement for authorisation and it is found that the
person does have the mental capacity to make decisions about their care, it is unlawful to
deprive them of their liberty against their will.
A planning meeting will need to be scheduled within 48 hours of the managing authority
being notified of the refusal in order to consider how to best support the person to meet their
needs.
6.10.1.5
Best Interests Assessment
Where this assessment does not meet the requirement for authorisation because deprivation
of liberty is deemed not to be in the relevant person’s best interests, the care plan will need
to be amended to avoid unlawful deprivation of liberty.
A planning meeting will need to be scheduled within 48 hours of the managing authority
being notified of the refusal in order to consider alternative arrangements for care or
treatment.
6.10.1.6
Eligibility Assessment
If this assessment does not meet the requirement for authorisation because the relevant
person was identified as needing to be subject to the mental health act 1983 instead of the
deprivation of liberty safeguards, an assessment will need to be made under the mental
health act 1983. a referral should be made to the AMPH service. (refer to sections 4.55 to
4.57 of the DoLS code of practice for further information on what to do if a person is
assessed as ineligible).
6.10.1.7
No Refusals Assessment
Where this assessment does not meet the requirement for authorisation because there is a
valid refusal from a donee or deputy or where an applicable and valid ADRT is in place,
alternative arrangements for care or treatment will need to be made. This may include
application to the court of protection if there is a question about the refusal.
A planning meeting will need to be scheduled within 48 hours of the managing authority
being notified of the refusal in order to consider alternative arrangements.
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Responsibilities for implementing alternative care will rest with the managing authority and
those responsible for care, e.g. care manager, care programme coordinator, key worker etc.
6.10.2 Responsibilities of the Managing Authority Onc e an Authorisation Has
Been Granted Or Declined
I.
If the managing authority receives notification from the DoLS service that the
authorisation has been granted, it must take all practical and possible steps to ensure
that the relevant person understands the effects of the authorisation, their rights, and
the complaints procedures and consider any specific communication needs.
Information should be provided to the relevant person, and to their representative,
both orally and in writing.
II.
Whether the authorisation is granted or not, the outcome form must be included in the
relevant person’s records and be made known to all relevant staff.
III.
The managing authority must make alternative arrangements for care where
authorisation is not granted, based on the recommendations made in the outcome
form and ensuring urgent action to prevent unlawful deprivation of liberty. The
managing authority must comply with the supervisory body where a planning meeting
is required to discuss where deprivation of liberty is occurring but not authorised (see
section 6.10.1 above)
IV.
Visits by the relevant person’s representative must be accommodated and details of
visits are to be recorded in the relevant person’s records.
V.
Inform the DoLS service if the relevant person’s representative is not maintaining
appropriate contact.
VI.
Inform the DoLS service where the relevant person, or their representative, requests
an IMCA.
6.11 CONVEYING
I.
It is the responsibility of those involved in the delivery of the relevant person’s care or
treatment to convey the relevant person to the accommodation where the
authorisation is to take effect.
The wider provisions of the mental capacity act must be met when conveying the
relevant person. Therefore:
It must be in the person’s best interests, and
Any restraint used must be proportionate and necessary to prevent harm to that
person.
II.
Consideration must be given to the best means of conveying the relevant person and
who should be asked to support this, for instance, whether family/carers and the
ambulance service will aide the process to achieve the best outcome for the person.
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III.
In exceptional circumstances, where the police are required to assist in the
conveying, this must be carefully considered, coordinated and planned to ensure the
person’s dignity and safety are paramount at all times.
IV.
In exceptional circumstances where a journey may involve sustained period requiring
high levels of restraint, it may be necessary to seek an order from the court of
protection to ensure this is lawful. Legal advice should be sought in these
circumstances.
6.12 REVIEW S
A standard authorisation can be reviewed at any time and will be undertaken by the DoLS
service on behalf of the supervisory body.
Reviews will be conducted where any of the statutory grounds for review as stated in the
Code of Practice are met, or where the Managing Authority, the relevant person or their
representative requests a review. Standard forms and letters are available for the following to
use to request a review:
Form 19
The Managing Authority should use Form 19: Request for a review of a Standard
Authorisation from the Managing Authority to the Supervisory Body.
Letter 3
The relevant person should use Letter 3: Letter to a Supervisory Body from a
person subject to a Standard Authorisation requesting a review of a Standard
Authorisation.
Letter 4
The Relevant Person’s Representative should use Letter 4: Letter to a
Supervisory Body from a person subject to a Standard Authorisation’s
representative requesting a review of a Standard Authorisation.
Deprivation of Liberty can end before a formal review. An authorisation only permits
deprivation of liberty; it does not mean that the person must be deprived where a
change of circumstance no longer necessitates it.
Throughout the period in which the authorisation is in force, those with responsibility for
arranging and reviewing the relevant person’s care (such as the care manager, care
programme coordinator, key worker) will need to maintain active involvement. For
instance, where the relevant person is resident in a care home, the NCC care manager
will need to maintain involvement with the person to ensure that care is provided by the
least restrictive means possible, that conditions are adhered to and that the Managing
Authority requests reviews at appropriate times.
The responsible worker will communicate any issues to the DoLS Service including
whether an IMCA may be required to support the relevant person’s representative to
exercise their rights.
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6.12.1 Managing Authority Responsibilities
The Managing Authority must inform the DoLS Service of any of the following events:
Where the deprivation of liberty is no longer necessary and the authorisation
will be ended
Where any circumstances have changed that may require a review
Form 14
Form 15
Where any circumstances have changed that may require review of the
eligibility assessment and short term suspension of the authorisation (such as
admission under the Mental Health Act 1983). Under these circumstances the
Supervisory Body can suspend the authorisation. The Managing Authority
must complete Form 14: Managing Authority notifies the Supervisory Body
that a Standard Authorisation should be suspended because the eligibility
criteria is no longer being met and forward this to the DoLS Service.
Where the relevant person becomes eligible again within 28 days following a
suspension. Under these circumstances the Supervisory Body will remove the
suspension, unless no notice is given in 28 days and the authorisation will be
terminated. The Managing Authority should complete Form 15: Managing
Authority notifies the Supervisory Body that the eligibility requirement is again
met and the suspension of the Standard Authorisation is lifted and forward this
to the DoLS Service.
Where the Managing Authority identifies that the relevant person has regained
capacity on a long-term basis and the authorisation will need to be terminated.
Where the deprivation of liberty may need to continue after expiry of the
authorisation.
6.12.2 DoLS Servic e Responsibilities
I.
The DoLS service must be aware of the statutory grounds for conducting reviews as
stated in the code of practice. if the statutory grounds are met, the DoLS service must
carry out a review.
II.
The DoLS service must also conduct a review where it has been requested by the
managing authority, the relevant person or the relevant person’s representative.
III.
Where a managing authority applies to the DoLS service again for re-assessment
due to the imminent expiry of the current standard authorisation, the DoLS service will
need to re-instigate the assessment process as outlined in sections 6.3, 6.4 and 6.7
above.
IV.
Once a request for a review has been received, the DoLS service should
acknowledge receipt of the request, in writing, within 24 hours at the latest of the
request being received. The DoLS service will need to inform the relevant person,
Form 20
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their representative and the managing authority of their intention to conduct a review
and should use the standard form, form 20: supervisory body notifies relevant
interested parties that a review is to be carried out.
V.
Form 21
DoLS service will need to determine which of the requirements needs to be reviewed
and whether any further action is required. The DoLS service will need to complete
form 21: supervisory body records it’s decision as to whether any qualifying
requirements are reviewable. The DoLS service will need to inform the managing
authority within 48 hours of receipt of the request for the review, of its intended date
for commencing the review, which requirements are to be reviewed and the name of
the BIA or mental health assessor appointed to conduct this.
The review will consider any change of circumstances and conduct re-assessment of
criteria where required
VI.
In general, the reviews should follow the same process as the standard authorisation
for each of the qualifying requirements that need to be reviewed. The DoLS service
will have 21 days in total in which to complete the review.
VII.
Following a review, the BIA will need to complete form 22: supervisory body’s
decision following receipt of review assessments, detailing the outcome of the
reviews and the required actions. This may include:
Form 22
Varying the conditions attached to the authorisation
Terminating the authorisation where deprivation of liberty is no longer required or
where any requirement is no longer met.
The BIA will need to forward the Form 22 to the DoLS Lead. If the BIA recommends varying
the conditions attached to the authorisation, the DoLS Lead will then need to forward it to the
relevant Service Manager or Associate Director of the Supervisory Body for signing as per
the procedure outlined in section 6.7 above.
A copy of the form will need to be sent to the Managing Authority, the relevant person, their
representative, any IMCA instructed and any other persons consulted during the review.
VIII.
Form 14
Form 15
IX.
The supervisory body is responsible for suspending the authorisation where there has
been a change in the eligibility requirement (such as admission under the mental
health act 1983). The supervisory body is also responsible for lifting this suspension
where the relevant person becomes eligible again within 28 days following the
suspension. If no notice is given within 28 days the authorisation will be terminated.
There are standard forms available which should be used by managing authorities to
inform the supervisory body that a suspension of authorisation is required or needs t o
be lifted.
The DoLS service will keep records of any information received by the managing
authority relating to the review and record any outcomes of the review in the relevant
person’s records.
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6.13 TERMINATING A STANDARD AUTHORISA TION
I.
Form 23
II.
When a standard authorisation ceases to be in force, the DoLS service will need to
record this using form 23: supervisory body gives notice that a standard authorisation
has ceased to be in force.
A standard authorisation will cease to be in force in the following circumstances:
Where the managing authority gave notice to the DoLS service that this person
has ceased to meet the eligibility requirement and 28 days have elapsed since
that notice was given without the suspension being lifted. This will include
circumstances where capacity has been regained.
The standard authorisation has expired.
A review of the standard authorisation has been completed and the review
concluded that the person no longer meets the requirements for being deprived of
their liberty.
Following a change in the place where the person is deprived of their liberty, the
standard authorisation has been replaced with a new authorisation for the new
place and therefore ceases to have effect.
The court of protection or another court has made an order that the standard
authorisation is invalid or that it shall no longer have effect.
The person has died.
III.
Form 4
When an authorisation expires, the managing authority cannot lawfully continue to
deprive the person of their liberty.
Where the managing authority considers that the relevant person will continue to
need to be deprived of their liberty once the standard authorisation has expired, they
will need to request a new standard authorisation to take effect immediately after the
expiry of the existing authorisation. The managing authority will need to complete
form 4: managing authority request for a standard authorisation and send this to the
DoLS service. The DoLS service will follow the same process for assessments as for
an original standard authorisation as outlined above.
There is no statutory time limit on how far in advance the managing authority can
request a renewal of an authorisation, however it will need to be far enough in
advance for the renewal to take effect before the existing authorisation expires, but
not so far in advance that the relevant person’s needs could not be reasonably
predicted. The DoLS service will endeavour to contact the managing authority 30
days prior to an authorisation expiring to avoid unlawful deprivation of liberty
occurring.
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IV.
The DoLS service will need to inform in writing the following interested parties when a
standard authorisation expires:
The relevant person
The relevant person’s representative
The managing authority
Every interested person named by the BIA in their report as somebody they have
consulted in carrying out their assessment.
6.14 Appeals and Court Of Protection
6.14.1 Managing Authority Appeals
Once an authorisation has been granted or refused by the supervisory body, the managing
authority itself cannot appeal against the decision. However, the managing authority can
appeal against the assessment process if it believes there was a fault in the assessment
process or negligence on the part of the assessor, or whether a change in the condition of
the person requires a re-assessment.
The dispute will be investigated by the senior manager of the relevant supervisory body
responsible for the authorisation and will be resolved through the relevant supervisory
bodies’ complaints procedures.
Where the investigation finds that there was a fault in the assessment process or negligence
on the part of the assessor, the particular assessment in question will be conducted again
and the process for either granting or declining the authorisation will be followed depending
on the outcome.
Where the appeal is not upheld, the Managing Authority will be informed that the original
decision to grant or decline the authorisation remains in force.
6.14.2 Court Of Protection
The mental capacity act 2005 enables anyone deprived of their liberty to make speedy
application to the court of protection to review the lawfulness of their deprivation.
It is the responsibility of the managing authority to ensure that the relevant person and their
representative is aware of their rights to apply to the court both before and after the
authorisation is granted and that they have the information required in order to make a
referral to the court. The relevant person and their representative should be made aware of
the types of questions/issues they can take to the court as highlighted in the code of practice.
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The managing authority and the supervisory body should endeavour to resolve any concerns
through mediation or their own complaints procedures before the relevant person or their
representative refer the matter to the court.
The managing authority and supervisory body are required to comply with any conditions
imposed by the court following a hearing.
7
INFORM ATION GOVERNANCE
Due to the nature of the Deprivation of Liberty Safeguards, the information that will need to
be transferred and stored will be highly confidential and personally-identifiable. Therefore, all
staff should work to strict procedures relating to confidentiality and the safe and secure
transfer and storage of information.
Specific procedures apply where the Managing Authority is a hospital setting and where
information is being transferred between these settings and the DoLS Service. Staff from
these services will need to adhere to information governance procedures imposed by NHS
Northamptonshire (see below).
All staff should adhere to the Eight Principles of the Data Protection Act and also the Six
Caldicott Principles, particularly:
Transferring the minimum amount of information necessary:
o
Requesting only that information that is required during the assessment
process and keeping paper copies to a minimum
Ensuring access is on a need to know basis:
o
While many people will need to be consulted during the DoLS assessment
process, personally identifiable information should only be transferred
between those with statutory duties for undertaking DoLS work
The data obtained for Deprivation of Liberty work should be used only for that
purpose
7.1
Transferring Pers onally Identifiable Inform ation
Where information pertaining to deprivation of liberty is being transferred between the DoLS
service and a managing authority that is a hospital setting, staff from both services must
adhere to the guidance published in the following documents:
Safe Haven Policy for the Exchange of Patient Identifiable Information (NHS
Northamptonshire)
Sharing Personally Identifiable Information: Northamptonshire Interagency Protocol
(NHS Northamptonshire). NCC policy is currently being developed.
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Where information pertaining to Deprivation of Liberty is being transferred between the DoLS
Service and a Managing Authority that is a care home, they should endeavour to comply with
Safe Haven good practice, in particular:
Locating the fax machine in a secure environment and removing faxes from
the machine upon receipt
Taking care in dialing the correct number
Phone the intended recipient to say that a confidential fax is being sent and
ask the recipient to confirm the fax has arrived
Never leaving confidential faxes lying around
Sending the minimum amount of personally identifiable information
Always including a front-sheet with a confidentiality clause
Fax machines should be password protected
Personally-identifiable information sent by post should be sealed securely,
marked private and confidential and clearly labelled to a named individual.
Incoming mail should be opened away from public areas
Email is not a secure system for transferring personally identifiable information
and should not be used unless there is provision to send encrypted email.
7.2
Storing Personally Identifiable Inform ation:
Where information pertaining to Deprivation of Liberty is being stored by a Managing
Authority that is a hospital setting, staff must adhere to the guidance published in the
following document:
Records Management Policy (NHS Northamptonshire). NCC Records Management
policy is being revised.
Where information pertaining to Deprivation of Liberty is being stored by the DoLS Service or
a Managing Authority that is a care home, they should endeavour to comply with good record
keeping practice, in particular:
Storing paper records containing personally-identifiable information in locked cabinets
that are clearly labelled
Using booking out procedures to track the whereabouts of files and records
Arranging records so they can be found urgently if required
Keeping records closed when not in use so information cannot be seen
Where information is stored electronically ensuring files are clearly labelled, computer
screens are locked when unattended and ensuring passwords are not shared
Ensuring staff do not take manual records home
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8
POLICY REVIEW
This policy document and the procedures contained within it will be reviewed on an annual
basis.
The review will incorporate the following:
A full audit of the service
Analysis of information from any complaints or incidents that have been reported
Analysis of equality monitoring data that has been collected and an analysis of the
authorisations granted and declined in comparison with the local population.
9
RELATED POLICIES, PROCEDURES AND FORMS
Staff in all organisations undertaking any work related to the Deprivation of Liberty
Safeguards on a daily basis will need to refer to the following 3 documents, each of which
have a different purpose and should be used in conjunction with each other:
The Deprivation of Liberty Safeguards Code of Practice – This document provides
information on the requirements of the law
This Deprivation of Liberty Safeguards Interagency Policy and Procedures This document provides information on how the safeguards are being implemented
locally in Northamptonshire and the procedures that will need to be followed
The Deprivation of Liberty Safeguards Forms and Record Keeping - This
document contains all the standard forms and letters issued by the Department of
Health for the processes involved in the Safeguards. Staff will need to be aware of
any additional requirements included in this document that relate to the
completion/submission of these forms.
Interagency Safeguarding Adults Procedures
Mental Capacity Act 2005
Safe Haven Policy for the Exchange of Patient Identifiable Information (NHS
Northamptonshire)
Sharing Personally Identifiable Information: Northamptonshire Interagency Protocol
(NHS Northamptonshire)
Records Management Policy (NHS Northamptonshire)
ADASS Protocol for the Inter-Authority Management of Deprivation of Liberty
Safeguards Applications
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10 WEBSITE ADDRESS FOR THIS POLICY
NCC Intranet
http://intranet.northamptonshire.gov.uk/services/hass/service/pap/pages/policylibrary.
aspx
NCC Internet
http://www.northamptonshire.gov.uk/en/councilservices/asc/services/va/Pages/dols.a
spx
NHS Northamptonshire
www.foi.northants.nhs.uk/Content/Policies_and_procedures/Quality%2c_Standards_
%26_Learning/index.jsp
11 APPENDICES
Appendix 1:
List of all DH forms and letters for the Deprivation of Liberty Safeguards
Appendix 2:
Quick reference guide to the Interagency Policy and Procedures, the Code of
Practice and the DH forms and letters.
Appendix 3:
DH Guidance document: What should a Managing Authority consider before
applying for authorisation of deprivation of liberty (Extracted from the Code of
Practice)
Appendix 4:
DoLS Service Assessment Checklist (Draft)
Appendix 5:
DoLS Service Checklist for DoLS Lead for the Appointment of Best Interests
Assessors and Mental Health Assessors (Draft)
Appendix 6:
Flowchart for Standard Authorisation Process (Draft)
Appendix 7:
Flowchart for Urgent Authorisation Process (Draft)
Appendix 8:
Flowchart for Third Party Request Process (Draft)
Appendix 9:
Standard Authorisation Review Process Flowchart (Extracted from the Code
of Practice)
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11.1 Appendi x 1: List of All DH Form s And Letters For The Deprivation Of
Liberty Safeguards
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List of all Department of Health standard letters and forms for the
Deprivation of Liberty Safeguards
Form /
letter
number
Title
Who should
complete the
letter / form?
Form 1
For the giving of an urgent authorisation by a
managing authority
Managing
Authority
Form 2
Managing authority request for an extension in the
duration of an urgent authorisation
Managing
Authority
Form 3
Supervisory body’s decision regarding request for an
extension of an urgent authorisation
Supervisory Body
(DoLS Service)
Form 4
Managing authority request for a standard
authorisation
Managing
Authority
Form 5
Age assessment form for completion by assessor
Supervisory Body
(DoLS Service)
Form 6
Mental health assessment form for completion by
assessor
Supervisory Body
(DoLS Service)
Form 7
Mental capacity assessment form for completion by
assessor
Supervisory Body
(DoLS Service)
Form 8
No refusals assessment form for completion by
assessor
Supervisory Body
(DoLS Service)
Form 9
Eligibility assessment form for completion by assessor
Supervisory Body
(DoLS Service)
Form 10
Best interests assessment form for completion by
assessor
Supervisory Body
(DoLS Service)
Form 11
Record by supervisory body that an equivalent
assessment is being used
Supervisory Body
(DoLS Service)
Form 12
Supervisory Body gives a standard authorisation
Supervisory Body
(DoLS Service)
Form 13
Supervisory body declines a request for a standard
authorisation
Supervisory Body
(DoLS Service)
Form 14
Managing authority notifies the supervisory body that
a standard authorisation should be suspended
because the eligibility requirement is no longer being
met
Managing
Authority
Form 15
Managing authority notifies the supervisory body that
the eligibility requirement is again met and the
suspension of the standard authorisation is lifted
Managing
Authority
Urgent Authorisations
Requests for a Standard Authorisation
Suspension of a Standard Authorisation
Unauthorised Deprivation of Liberty (Third Party Requests)
Letter 1
Letter for a person to send to a managing authority
concerning a possible unauthorised deprivation of
liberty
Third Party
Letter 2
Letter for a person to send to a supervisory body
concerning a possible unauthorised deprivation of
liberty
Third Party
Form 16
Record of supervisory body action on receipt of
notification of a possible unauthorised deprivation of
liberty
Supervisory Body
(DoLS Service)
Form 17
Unauthorised deprivation of liberty assessor’s report
Supervisory Body
(DoLS Service)
Form 18
Supervisory body’s decision following the receipt of an
unauthorised deprivation of liberty report
Supervisory Body
(DoLS Service)
Letter 3
Letter to a supervisory body from a person subject to
a standard authorisation requesting a review of the
standard authorisation
Relevant Person
Letter 4
Letter to a supervisory body from a person subject to
a standard authorisation’s representative requesting a
review of the standard authorisation
Relevant
Person’s
Representative
Form 19
Request for a review of a standard authorisation from
the managing authority to the supervisory body
Managing
Authority
Form 20
Supervisory body notifies relevant interested parties
that a review is to be carried out
Supervisory Body
(DoLS Service)
Form 21
Supervisory body records it’s decision as to whether
any qualifying requirements are reviewable
Supervisory Body
(DoLS Service)
Form 22
Supervisory body’s decision following receipt of
review assessments
Supervisory Body
(DoLS Service)
Review of a Standard Authorisation
Standard Authorisation Ceased to be in Force
Form 23
Supervisory body gives notice that a standard
authorisation has ceased to be in force
Supervisory Body
(DoLS Service)
Relevant Person’s Representative
Form 24
Best interests assessor action in respect of the
selection of a relevant person’s representative
Supervisory Body
(DoLS Service)
Form 25
Supervisory body action in respect of the appointment
of a relevant persons representative
Supervisory Body
(DoLS Service)
Form 26
Supervisory body gives a relevant person’s
representative notice of the pending termination of
their appointment
Supervisory Body
(DoLS Service)
Form 27
Supervisory body terminates a relevant person’s
representative’s appointment
Supervisory Body
(DoLS Service)
Mental Health Assessor and Best Interest Assessor Referral Forms
Form 28
Best Interest Assessor Referral Form
Supervisory Body
(DoLS Service)
Form 29
Mental Health Assessor Referral Form
Supervisory Body
(DoLS Service)
IMCA Referral and Report Forms
Form 30
IMCA Referral Form
Supervisory Body
(DoLS Service)
Form 31
IMCA Report Form
IMCA
Record of Deprivation of Liberty Safeguards Activity
Form 32
Record of Assessments, Authorisations and Reviews
Supervisory Body
(DoLS Service)
The Deprivation of Liberty Safeguards Inter-Agency Policy and Procedures 1.1 October 2009
11.2 Appendi x 2: Quick Reference Guide to The Interagency Policy And
Procedures, The Code Of Practice, And The Dh Form s And Letters
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Quick reference Guide to the Interagency Policy and Procedures, the
Code of Practice and the DoH Forms and Letters
This document lists frequently asked questions for the different services,
organisations and individuals that are involved with the Deprivation of Liberty
Safeguards.
For each question, the relevant reference number from the Interagency Policy
and Procedures is given and, where appropriate, a reference to the Code of
Practice and the relevant DoH standard form is also listed.
FAQ
Interagency
Policy Ref
Code of
Practice Ref
DoH
Form
For Managing Authorities
What are my key responsibilities with
5.3
regard to the DoLS legislation?
3.1
How do I request a standard authorisation?
6.2
3.7 - 3.10
Where do I send the request for
authorisation?
6.2.4
3.11 – 3.14
What information do I need to include with
the request for standard authorisation?
6.2.5
3.8
What happens if an authorisation is
refused, but the relevant person is being
deprived of their liberty?
6.7.6
5.24
What do I need to do once the DoLS
Service have granted / refused my request
for a standard authorisation?
6.7.7
5.20 – 5.23
What do I need to do if I receive a third
party request to apply for a standard
authorisation?
6.2.7 / 6.6
9.1 – 9.2
What do I need to do if an assessment
undertaken in response to a third party
request finds that unauthorised deprivation
of liberty is occurring?
6.6.5
9.12 – 9.13
Form 4
Form 1
What should I do if deprivation of liberty
needs to commence before a standard
authorisation is granted?
6.5.1
6.1 – 6.6
Form 1
Form 4
How do I extend the period of the urgent
authorisation?
6.5.8
6.20 – 6.28
Form 2
Form 4
Form 4
When does an urgent authorisation end?
6.5.7
6.16
How do I request a review of a standard
authorisation?
6.9
Form 19
What do I do if the relevant person no
longer meets the eligibility requirement and
I need to suspend the authorisation?
6.9.1
8.2
8.3
8.5
8.19 – 8.21
How do I appeal against the assessment
process?
6.11.1
What do I need to do if the relevant person
will need to be deprived of their liberty once
the authorisation has expired?
6.10.3
8.25 – 8.29
Form 4
For the DoLS Service
What are my key responsibilities with
5.2
regard to the DoLS legislation?
Form 14
Form 15
3.3
What happens if the Managing Authority
and the Supervisory Body are the same
organisation?
6.2.8
3.21
What does the DoLS Service need to do
once a request for standard authorisation
has been received?
6.3.2 / 6.3.3
3.17
What are the timescales for a standard
authorisation?
6.3.2 – 6.3.5
4.9 – 4.12
When does an IMCA need to be
instructed?
6.3.7
3.22 – 3.28
How does the DoLS Lead appoint a BIA to
undertake the assessments?
6.4.1
How will the assessments be conducted?
6.4.2 –
6.4.7.5
4.1 – 4.3
4.19 – 4.61
Who is eligible to undertake the
assessments?
6.4.6.1 –
6.4.6.5 and
6.4.7.1 –
6.4.7.4
Can an equivalent assessment be used?
6.4.7.5
4.24
4.28
4.31 - 4.32
4.35 - 4.36
4.62 - 4.54
4.60
4.4 – 4.8
Form 11
What happens when one or more of the
requirements are not met and the
authorisation is to be declined?
6.4.6.6
6.7.2
5.18 – 5.19
Form 13
4.13 – 4.17
Forms
5,6,7,8,9
& 10
What happens when all the requirements
are met and the authorisation is to be
granted?
6.7.3
Who is responsible for signing the form
when an authorisation is granted?
6.7.3.3 –
6.7.3.4
Who needs to be notified of the decision to
grant / refuse an authorisation?
6.7.5
5.1 - 5.8
Form 12
Form 12
5.7
What needs to happen when an
6.7.6
authorisation is refused but the assessment
determines that deprivation if liberty is
occurring?
5.24
When should a relevant person’s
representative be appointed?
6.4.8.1
6.7.5
7.9 – 7.11
7.22 – 7.24
What is the process for an urgent
authorisation?
6.5.6.1
6.1 – 6.7
6.16 – 6.19
What do I need to do if the MA requests an
extension to the urgent authorisation?
6.5.8.2 –
6.5.8.3
6.20 – 6.28
Form 3
What do I need to do when I receive a third
party request for standard authorisation?
6.6.1
9.3 – 9.7
Form 16
What assessment needs to be undertaken
if the DoLS Service decides to pursue a
third party request?
6.6.2
9.8 – 9.9
Form 17
What happens if an assessment
undertaken in response to a third party
request finds that deprivation of liberty is
occurring?
6.6.3 – 6.6.5
9.12
Form 18
How do I respond to a request for a
review?
6.9.2.4 –
6.9.2.6
8.6 – 8.16
Form 20
Form 21
How do I record my decision following a
review of a standard authorisation?
6.9.2.7
8.17 – 8.18
Form 22
8.29
Form 23
How do I record that a standard
6.10.1
authorisation ceases to be in force and who 6.10.4
do I need to inform?
For the Supervisory Body
What are my key responsibilities with
5.2
regard to the DoLS legislation?
3.3
Form 24
Form 25
When will I be asked to act as signatory for
a standard authorisation?
Who has responsibility for acting as
Signatory?
6.7.3.3
Can I amend the conditions attached to the
authorisation as recommended by the BIA?
6.7.3.5
5.5
Form 12
Can I extend / shorten the period of the
authorisation as set by the BIA?
6.7.3.5
5.3
Form 12
9.1
Letter 1
Letter 2
6.7.3.4
For a Third Party
How do I request that the managing
6.6.1
authority should apply for a standard
authorisation because an unauthorised
deprivation of liberty is occurring?
How will the DoLS Service respond to my
request?
6.6.2
What will happen if the DoLS Service finds 6.6.3 – 6.6.5
that an unauthorised deprivation of liberty is
/ isn’t occurring?
When will I be informed of the outcome of
my request?
Form12
9.4 – 9.7
9.10 – 9.14
6.6.3 to 6.6.5 9.11
For the Relevant Person and/or their Representative
How do I request a review of a standard
6.9
8.2
authorisation?
How can I apply to the Court of Protection
6.11.2
to review the lawfulness of the deprivation
of liberty?
General
How is the work related to the Deprivation
5.2
of Liberty Safeguards being undertaken in
6.1
Northamptonshire?
What other documents should staff refer to
when undertaking DoLS work?
4.5
How should the relevant person be
conveyed to the accommodation where the
authorisation is to take effect?
6.8
10.1 – 10.3
10.7 – 10.9
2.14 – 2.15
Letter 3
Letter 4
The Deprivation of Liberty Safeguards Inter-Agency Policy and Procedures 1.1 October 2009
11.3 Appendi x 3: DH Guidance Docum ent: W hat Should A Managing Authority
Consider Before Applying For Authorisation Of Deprivation Of Liberty
(Extracted From The Code Of Practice)
Please note this flowchart document continues on to a second page
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11.4 Appendi x 4: DoLS Servic e Assessm ent Checklist
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DoLS Service Assessment Checklist
Staff should use this checklist to track the assessment process. Please refer to the
Deprivation of Liberty Safeguards Interagency Policy and Procedures for guidance
relating to the procedures and timescales for standard authorisations, urgent
authorisations and 3rd Party Requests.
Relevant person:
__________________________________
Managing Authority:
__________________________________
careFirst ID number:
__________________________________
Section 1: Referral Process
Standard Authorisations: Initial referral
(please see separate sections for 3rd party requests and urgent authorisations)
Request for standard authorisation received
Date: _______________________
Main contact (from Managing Authority)
_____________________________
Receipt Acknowledged
Date: _______________________
Form referred back to Managing Authority  Date: _______________________
(if incomplete/invalid/too far in advance of expiry of existing authorisation)
Urgent Authorisations: Initial referral
Urgent Authorisation received
Date: _______________________
Date of expiry of urgent authorisation
Date: _______________________
Request for standard authorisation received from Managing Authority:

Date: _______________________
Main contact (from Managing Authority)
_____________________________
Managing Authority notified of intended date for BIA to commence assessment:
Date: _______________________
3rd Party Requests: Initial request
3rd party request received
Date: _______________________
Name of 3rd Party
_____________________________
Referred back to 3rd Party? Yes  No

Is the matter to be pursued? Yes  No
Date: _______________________

If no, Inform: 3rd party
Relevant Person
IMCA
Managing Authority




If yes, BIA appointed to determine if DoL occurring Date:_______________________
Name of BIA
______________________________
IMCA instructed?
Yes  No
Assessment Complete


Name:_________________________
Date: ________________________
Outcome:
DoL is Occurring

DoL already authorised?
Yes Cease process
No
 Commence assessment
process as per standard
authorisation
DoL is not occurring

3rd party
Inform relevant parties of outcome:
Relevant Person
IMCA
Managing Authority




All Referrals
Intended date of commencement for BIA
Date:_________________________
Name BIA appointed for Stage 1 assessments
______________________________
Brief reasons for appointment of BIA
______________________________
______________________________
______________________________
IMCA instructed?
Yes  No

Name:_________________________
Notification sent to Managing Authority of intended date for commencement and BIA
appointed
Date:_________________________
Section 2: Assessment Process
Stage 1 Assessment
Date
Completed
Completed By
Requirement Met
Yes
No
Confirm age
assessment
Identify if liberty is
being deprived
Confirm no refusals
assessment
Preliminary mental
capacity assessment
Preliminary eligibility
assessment
Assessment process to proceed to Stage 2?
Yes 
No

(Proceed to Section 3 and complete outcome process)
Stage 2 Assessment
Name of BIA appointed (if different to Stage 1 BIA)
___________________________
Brief reasons for appointment of BIA at Stage 2
___________________________
___________________________
___________________________
___________________________
Name of Mental Health Assessor appointed
___________________________
Date
Completed
Mental Health
Assessment
Mental Capacity
Assessment
Eligibility Assessment
Best Interest
Assessment
Completed By
Requirement Met
Yes
No
Section 3: Outcome process
Outcome:
Authorisation Granted
Authorisation Refused



Date: _____________________
Outcome Report given to Supervisory Body

for approval where authorisation is to be granted
Date: _____________________
Outcome Report given to DoLS Lead
Name of Service Manager / Associate Director responsible for approval
__________________________________
Outcome Recorded on careFirst Database

Date: _____________________
Relevant Person’s Representative Appointed:
Name:
Date:
________________________
________________________
Outcome Report sent to:
Managing Authority
Relevant Person
Relevant Person’s Representative
IMCA
Commissioning Service
Other Persons Consulted






Date: _______________________
Date: _______________________
Date: _______________________
Date: _______________________
Date: _______________________
Date: _______________________
Information given to relevant person / representative about Court of Protection

Date: __________________________
Information given to Managing Authority about Appeals process

Date: __________________________
Planning Meeting Required?
Yes No Date: __________________________
For urgent authorisations only:
Application to extend received:
Yes No Date: __________________________
Authorisation extended by ____ days (enter 0 if refused)
New date of expiry of urgent authorisation
__________________________
Managing Authority informed of decision Date:
__________________________
The Deprivation of Liberty Safeguards Inter-Agency Policy and Procedures 1.1 October 2009
11.5 Appendi x 5: DoLS Servic e Checklist for DoLS Lead for The Appointm ent Of
Best Interests Assessors And Mental Health Assessors
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DoLS Service Checklist for DoLS Lead for the Appointment of Best
Interests Assessors and Mental Health Assessors
Name of potential BIA/MHA
Name of Managing Authority
Name of Supervisory Body
Name of Relevant Person
__________________________________
__________________________________
__________________________________
__________________________________
Section 1: Best Interests Assessor
You must be able to tick all of the following to appoint this person as a
best interest assessor (BIA).
Requirement
The BIA is not involved in the care or treatment of the person they are
assessing nor in decisions about their care
The BIA is not in a line management relationship with the professional
proposing the deprivation of liberty or the mental health assessor
The BIA does not have a financial interest in the case of the person they are
assessing (a person is considered to have a financial interest in a case where that person is
a partner, director, other office-holder or major shareholder of the managing authority that has
made the application for a standard authorisation)
The BIA is not the same person as the mental health assessor
The BIA is not a relative of the person being assessed or a relative of a
person with a financial interest in the person’s care (see Code of Practice
paragraph 4.13 for the definition of ‘relative’)
Where undertaking the eligibility assessment, the BIA is authorised as an
AMHP
Where the managing authority and supervisory body are the same body, the
BIA is not employed by the body or providing services to it
There are no other conflict of interest situations that might bring into question
the objectivity of an assessment
Tick all
that
apply
Section 2: Mental Health Assessor
You must be able to tick all of the following to appoint this person as a
mental health assessor (MHA).
Requirement
Tick all
that
apply
The MHA is not the same person as the BIA
The MHA is a doctor
The MHA is approved under section 12 of the Mental Health Act 1983 or is a
registered medical practitioner with at least 3 years’ post-registration
experience in the diagnosis or treatment of mental disorder. (To undertake
the eligibility assessment MHA’s must be section 12 approved)
The MHA has completed the standard training for deprivation of liberty
mental health assessors (If the MHA completed the standard training more than 12
months ago – they must have also undertaken further training relevant to their role as mental
health assessor in the 12 month period prior to selection)
The MHA does not have a financial interest in the case of the person they are
assessing (a person is considered to have a financial interest in a case where that person is
a partner, director, other office-holder or major shareholder of the managing authority that has
made the application for a standard authorisation)
The MHA is not a relative of the person being assessed or a relative of a
person with a financial interest in the person’s care (see Code of Practice
paragraph 4.13 for the definition of ‘relative’)
There are no other conflict of interest situations that might bring into question
the objectivity of an assessment
Section 3: Additional Information
Please use the space below to record any other relevant information or
reasons for appointing this person as a BIA/MHA for this particular
case:
(You may want to consider the following:
The reason for the proposed deprivation of liberty
Whether the potential assessor has experience of working with a particular service
group
Whether the potential assessor has experience of working with people from the
cultural background of the person being assessed
For the mental capacity / mental health assessments, would an assessor who already
knows the relevant person be of benefit?
Any other specific needs of the person being assessed, e.g. communication needs)
The Deprivation of Liberty Safeguards Inter-Agency Policy and Procedures 1.1 October 2009
11.6 Appendi x 6: Flowchart for Standard Authorisation Process
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The Deprivation of Liberty Safeguards: Flowchart for Standard Authorisation Process (Draft)
MA complete FORM 4: Request for a Standard Authorisation and
send to the DS. MA inform family and carers of relevant person.
MA use internal procedures to determine
if DoL is required, seeking advice from
the DS where necessary
Abbreviations Used:
MA
SB
DS
BIA
DOL
DS acknowledge receipt of Form 4 within 24 hours
DS begins DoLS Service Checklist
Managing Authority
Supervisory Body
DoLS Service
Best Interest’s Assessor
Deprivation of Liberty
No
Refer back to the MA for necessary
action / further information. Restart
application process on receipt of revised
application
Is the Request for a Standard
Authorisation both valid and
complete?
Yes
DS will inform the MA in writing of it’s
intended date for the BIA to commence
assessment process within 48 hours of
receipt of Form 4
Does the relevant person have
somebody not engaged in providing care
or treatment in a professional capacity or
for remuneration to support them?
Yes
No
DS must instruct section 39A IMCA
Is an urgent authorisation in force
Yes
Assessments must be completed within
the period of the urgent authorisation
See Urgent Authorisation Flowchart
No
Assessments must be completed within 21 days from the date the DS receives
Form 4 from the MA
Appointed BIA commences the six qualifying assessments using Forms 5,6,7,8,9,10. (Form 11 should be used where a valid equivalent
assessment can be used.)
The DS has divided the assessment process into 2 stages – Stage 1 for preliminary assessments and Stage 2 for full assessments. If all
Stage 1 assessments are positive, a Mental Health Assessor is appointed who will have 96 hours in which to complete the Mental Health
Assessment at Stage 2.
The BIA initiates identification of a Relevant Person’s Representative.
Are any assessments negative at either Stage 1 or Stage 2?
Yes
Assessment Process ceases immediately
BIA completes Form 13: Supervisory Body Declines a
Request for a Standard Authorisation
No
If all assessments are positive BIA completes Form 12:
Supervisory Body Gives a Standard Authorisation
BIA recommends conditions to attach to the authorisation
and specifies the period of authorisation
BIA sends Form 13 to the appropriate Associate Director /
Service Manager of the relevant SB for signature
BIA sends Form 12 to the appropriate Associate Director /
Service Manager of the relevant SB for signing.
DS notify the MA, relevant person, relevant person’s
representative (if already identified), IMCA (if required)
and any other person’s consulted by the BIA.
SB considers the conditions recommended and consults
with BIA
The relevant commissioning service of the SB is informed.
The MA is given information about the relevant complaints
procedures for the SB
Is liberty being deprived although the requirements for
authorisation are not met?
Yes
BIA completes Form 24: Best Interest’s Assessor Action
In Respect of the Selection of Relevant Person’s
Representative
DS completes Form 25: Supervisory Body Action in
Respect of the Appointment of a Relevant Person’s
Representative
No
DS notify the MA, the relevant person, their
representative, IMCA (if required) and any other
person’s consulted by the BIA
No further action required
In certain circumstances a
planning meeting between
the SB and the MA will be
necessary to discuss the
required action needed in
light of the refusal of the
authorisation.
The meeting should take
place within 48 hours of
the issuing of the refusal
and should review the
care or treatment currently
in place to ensure DoL
does not continue.
DS ensure the following:
Written records of the authorisation are kept
DoLS Checklist is completed and recorded
The relevant commissioning service are informed
The outcome is recorded on the careFirst database
The relevant person and their representative have information about
the Court of Protection
The MA is given information about the relevant complaints
procedures for the SB
REVIEW – See Review Process Flowchart
If the Standard Authorisation needs to be
suspended once it has been granted, the MA
should complete Form 14: Managing Authority
Notifies the Supervisory Body that a Standard
Authorisation Should Be Suspended
If the Standard Authorisation comes into use
again following a suspension, the MA should
complete Form 15: Managing Authority
Notifies the Supervisory Body that the
Eligibility Requirement is Again Met and the
Suspension of the Standard Authorisation is
Lifted
The Deprivation of Liberty Safeguards Inter-Agency Policy and Procedures 1.1 October 2009
11.7 Appendi x 7: Flowchart for Urgent Authorisation Process
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The Deprivation of Liberty Safeguards: Flowchart for Urgent Authorisation Process (Draft)
Abbreviations Used:
MA use internal
procedures to
determine if DoL is
required, seeking
advice from the DS
where necessary
Where deprivation of liberty needs to commence before a
standard authorisation can be obtained, the MA must issue
itself an urgent authorisation for up to 7 days. The MA must
complete Form 1: For the giving of an urgent authorisation
by the Managing Authority
At the same time as the MA issues itself an urgent authorisation, it must also
request a standard authorisation and complete Form 4: Managing Authority
request for a standard authorisation, sending this form to the DoLS Service
The DS will confirm receipt of Form 4 within 1 working day and notify the MA of
it’s intended date for sending a BIA to commence the assessment process.
The DS will have to complete all assessments and reach a decision within the
period of the urgent authorisation
(see Standard Authorisation Flowchart for assessment process)
From the end of the Stage 1 assessments, the MHA will have
48 hours to complete the mental health assessment
Can the assessments be carried out within the period of the
urgent authorisation?
No
Yes
The DS will need to notify the MA of
their decision as per the process for
standard authorisation and terminate
the urgent authorisation
The MA can apply to extend the
period of urgent authorisation by a
maximum of a further 7 days.
The MA must complete Form 2:
Managing Authority request for an
extension in the duration of an
urgent authorisation
The DS will need to determine whether or not to extend the urgent
authorisation and issue Form 3: Supervisory Body’s decision
regarding request for an extension of an urgent authorisation
Extension is granted
Extension is refused
All assessments must be carried out
within the period of the extension of the
urgent authorisation
The deprivation of liberty must cease
while the DS undertake the process
for a standard authorisation
The DS will need to notify the MA of
their decision as per the process for
standard authorisation and terminate the
urgent authorisation
MA
SB
DS
BIA
MHA
DOL
Managing Authority
Supervisory Body
DoLS Service
Best Interest’s Assessor
Mental Health Assessor
Deprivation of Liberty
The Deprivation of Liberty Safeguards Inter-Agency Policy and Procedures 1.1 October 2009
11.8 Appendi x 8: Flowchart for Third Party Request Process
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A third party feels that an
un-authorised deprivation of
liberty is occurring
The third party write to the MA requesting that the MA applies for a standard
authorisation.
Abbreviations Used:
The third party should complete Letter 1: Letter for a person to send to a
managing authority concerning a possible unauthorised deprivation of
liberty
MA
SB
DS
BIA
MHA
DOL
The MA must respond to the third party within 24 hours
Managing Authority
Supervisory Body
DoLS Service
Best Interest’s Assessor
Mental Health Assessor
Deprivation of Liberty
If the MA does not request a standard authorisation following the receipt of Letter1 from the third party,
but the third party still believes an unauthorised DoL is occurring, the third party can send the following
to the DS - Letter 2: Letter for a person to send to a supervisory body concerning a possible
unauthorised deprivation of liberty
Upon receipt of Letter 2, the DS will need to determine whether the MA has
already applied for a standard authorisation
Yes
No
Standard authorisation process applies. Third party
is informed.
The DS will need to consider Is the request vexatious or frivolous, or has it already been
determined that no DoL is occurring with no subsequent change in circumstances?
The DS must complete Form 16: Record of
supervisory body action on receipt of
notification of a possible unauthorised
deprivation of liberty
No
Yes
The DS will notify the third party, the relevant
person, any IMCA instructed and the MA that
the DS has been asked to decide whether or not
an unauthorised DoL is occurring, but that the
matter is not to be pursued.
The DS will complete Form 16: Record of
supervisory body action on receipt of
notification of a possible unauthorised
deprivation of liberty
The DS will pursue the request. The DS will complete Form 16: Record of supervisory
body action on receipt of notification of a possible unauthorised deprivation of
liberty
The DS will notify all relevant parties (the third party, the relevant person, the Managing
Authority and an IMCA if instructed) of the decision to pursue the matter
Does the relevant person have somebody not engaged in
providing care or treatment in a professional capacity or for
remuneration to support them?
No
The DS must appoint a section 39A
IMCA
Yes
The DS will appoint a BIA to undertake an assessment to ascertain whether an unauthorised DoL is occurring.
This must be completed within 7 days.
The DS will complete Form 17: Unauthorised deprivation of liberty assessor’s report
Does the BIA’s assessment determine that an unauthorised DoL is occurring?
No
Yes
The DS will notify all relevant parties that the BIA has determined that no DoL is
occurring.
Has this DoL already been
authorised
Yes
The DS will notify all relevant
parties that the DoL has already
been authorised.
The DS will complete Form 18:
Supervisory Body’s decision
following the receipt of an
unauthorised deprivation of
liberty report
The DS will complete Form 18: Supervisory Body’s decision following the
receipt of an unauthorised deprivation of liberty report
No
The MA is deemed to have
requested a standard authorisation
in respect of the relevant person.
The DS will complete Form 18:
Supervisory Body’s decision
following the receipt of an
unauthorised deprivation of
liberty report
The MA will need to complete Form 4: Managing
Authority request for a standard authorisation and
provide the DS with the relevant information.
The MA must discontinue the care/treatment that amounts
to DoL until the standard authorisation is granted
Process commences as per standard authorisation
If the MA considers it necessary to continue with the care/
treatment that amounts to DoL, it must grant itself an
urgent authorisation.
The MA must simultaneously complete Form 1: For the
giving of an urgent authorisation for a managing
authority and Form 4: Managing Authority request for a
standard authorisation.
Process commences as per urgent authorisation
The Deprivation of Liberty Safeguards Inter-Agency Policy and Procedures 1.1 October 2009
11.9 Appendi x 9: Standard Authorisation Review Process Flowchart
Please note this document is extracted from the DoLS Code of Practice and continues onto a
second page
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