DEPRIVATION OF LIBERTY SAFEGUARDS (DoLS) Version: Final Ratified by (name of Committee): Date ratified: Provider Quality and Committee 28 September 2010 Date issued: October 2010 Expiry date: (Document is not valid after this date) Review date: September 2013 Lead Executive/Director: Vicky Preece, Lead Nurse for Provider Services Vicky Preece, Lead Nurse for Provider Services WPCT staff responsible for the referral for Deprivation of Liberty Safeguards Approvals. Name of originator/author: Target audience: Safety January 2013 If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on 01905 760020 or email [email protected] 1 CONTRIBUTION LIST Key individuals involved in developing the document Name Vicky Preece Debbie Hipkins Designation Lead Nurse for Provider Services Safeguarding Adults Learning Lead Circulated to the following individuals for comments Name Maria Wilday Sue Lahiff Debbie Narburgh Ginny Snape Lin Ingles Lisa Levy Della Lewis Designation Matron and Hospital Manager, POWCH Matron, Evesham Hospital Matron, GP Unit Kidderminster Matron, Tenbury Hospital Matron, Malvern Hospital Associate Director for Hospitals Clinical Governance Team Manager This policy was approved by WPCT Clinical Policies and Guidelines group on 22 September 2010. 2 Contents 1 2 3 4 5 6 7 8 9 10 11 Glossary of Terms Introduction Scope of the Policy 3.1 Exclusions Responsibility and Duties Definitions Policy detail 6.1 When can someone be deprived of their liberty 6.2 How can deprivation of liberty be identified 6.3 What practical steps can be taken to reduce the risk of deprivation of liberty occurring? Process to follow 7.1 What does a managing authority need to do? 7.2 Applying for standard authorisations 7.3 Applying for urgent authorisations 7.4 How does the assessment process work? 7.5 Providing support throughout the assessment process 7.6 What happens when an MCA DoLS authorisation is granted 7.7 What happens if a request for an authorisation is turned down? 7.8 Use of referral forms for DoLS Procedures to follow 8.1 When to use an urgent or standard referral for a DoLS 8.2 Procedure to follow by Matrons and Ward Managers Notifying the Care Quality Commission 9.1 Actions that must be undertaken Training and Awareness Monitoring compliance Appendix 1 – questions and answers on Dols Appendix 2 - DoLS checklist Appendix 3 – Delegation of duties Appendix 4 – DoLS Referral process Appendix 5 – Process for Requesting an extensions of an urgent DoLS and a review of a standard DoLS Appendix 6 – Actions checklist for DoLS referrals Appendix 7 – Ward Checklist and Record of visits Appendix 8 – DoLS Flowchart and procedure Appendix 9 – Requirement for recording DoLS Page Number 4 5 5 6 7 8 8 9 9 10 11 11 11 12 12 13 13 14 14 14 16 16 17 17 18 19 21 22 23 24 25 27 28 3 1. Glossary of Terms Term Meaning DOLS Deprivation of Liberty Safeguards. Managing Authority The Organisation responsible for managing inpatient beds – this is the PCT Provider Services. For the application of the DOLS procedures, each individual Community Hospital will be itself a Managing Authority. The Managing Authority is responsible for applying for authorisation under DOLS. This duty is delegated to the Ward Managers and Matrons. Relevant Person A patient who is subject to assessment and authorisation under DOLS. IMCA Independent Mental Capacity Advocate. Representative A person appointed by the Supervisory Body to support and represent the relevant person. Eligible Person Someone who can require the Supervisory Body to carry out a review: The relevant person, their representative or the managing authority. Best Interests Assessor The person who carries out the Best Interests Assessment (and up to 4 others). A professional, not a doctor, with special experience and training. Mental Health Assessor The person who carries out the Mental Health Assessment (and possible up to 2 others). A doctor with expertise in mental health. 4 2. Introduction The Mental Capacity Act (2005) provides a statutory framework for acting and making decisions on behalf of individuals who lack the mental capacity to do so for themselves. It introduced a number of principles to protect these individuals and ensure that they are given every chance to make decisions for themselves. The Act came into force in October 2007. The Government has added new provisions to the Act: the Deprivation of Liberty Safeguards. The safeguards focus on some of the most vulnerable people in our society: those who for their own safety and in their own best interests need to be accommodated under care and treatment regimes that may have the effect of depriving them of their liberty, but who lack the capacity to consent. The deprivation of a person’s liberty is a very serious matter and should not happen unless it is absolutely necessary, and in the best interests of the person concerned. That is why the safeguards have been created: to ensure that any decision to deprive someone of their liberty is made following defined processes and in consultation with specific authorities. Please refer to the Mental Capacity Act 2005 – Deprivation of Liberty Safeguards Code of Practice, (accessible through the PCT intranet) for more information and background. The Code of Practice helps to explain how to identify when a person is, or is at risk of being deprived of their liberty. The Code of Practice provides guidance to anyone working with and/or caring for adults who lack capacity, but it particularly focuses on those who have a ‘duty of care’ to a person who lacks capacity to consent to the care or treatment that is being provided, where that care or treatment may include the need to deprive the person of their liberty. Both this code and the main Mental Capacity Act have statutory force, which means that certain people are under a legal duty to have regard to them. These people would include all healthcare professionals who have a ‘duty of care’ to care or treat a person. 3. Scope of the Policy This Policy needs to be used in conjunction with the Mental Capacity Act 2005 – Code of Practice for Deprivation of Liberty Safeguards and Deprivation of Liberty Safeguards – A guide to hospitals and care homes. Both are accessible through the PCT intranet. This Policy applies to Worcestershire PCT Provider Services as a Managing Authority (Registered Care Homes or Hospitals) who during this process will require authorization from the Supervisory Bodies (PCTs and Local Authorities) because depriving someone of their liberty is illegal without authorisation. 5 This Policy covers the role of the Community Hospitals and their staff. It covers what staff should know, admission, application for authorisation, urgent authorisation and review. Further information is available in the DOLS Code of Practice. This policy applies to 18+ adults who:• • • Do not have the mental capacity to agree to arrangements for their accommodation, treatment and care. Have to have restrictions placed on them in order to keep them in a safe environment, therefore effectively depriving them of their liberty. Lack capacity to consent. Please note DOLS does not apply to people detained in hospital under a section of the Mental Health Act 3.1 Exclusions - This policy does not cover anyone under the age of 18. The Supervisory Body will be the Primary Care Trust (NHS Worcestershire) which commissions the service for the particular individual service user in question. The safeguards provide for deprivation of liberty to be made lawful through ‘standard’ or ‘urgent’ authorisation processes. These processes are designed to prevent arbitrary decisions to deprive a person of liberty and give a right to challenge deprivation of liberty authorisations. The deprivation of liberty safeguards mean that a ‘managing authority’ (i.e. the relevant hospital or care home) must seek authorisation from a ‘supervisory body’ in order to be able lawfully to deprive someone of their liberty. Before giving such an authorisation, the supervisory body must be satisfied that the person has a mental disorder and lacks capacity to decide about their residence or treatment. A decision as to whether or not a deprivation of liberty arises will depend on all the circumstances of the case (as explained more fully in chapter 2 of the Code of Practice). It is neither necessary nor appropriate to apply for a deprivation of liberty authorisation for everyone who is in hospital or a care home simply because the person concerned lacks capacity to decide whether or not they should be there. In deciding whether or not an application is necessary, a managing authority should carefully consider whether any restrictions that are, or will be, needed to provide ongoing care or treatment amount to a deprivation of liberty when looked at together. 6 4. Responsibility and Duties • Trust Board - in NHS hospitals the “Managing authority” is the Trust Board, but responsibility for DOLS is delegated to Matron/Ward Manager level. • DoLS Lead – the lead for DoLS is responsible for supporting and advising Matrons, Ward Managers and other Senior Managers on matters relating to DoLS referrals • Matron/Ward Manager – will take responsibility for making decisions re. potential referrals to the DOLS team for Urgent authorisations, and completing the documentation i.e. Form 1 and 4 for each referral. They must also take responsibility for liaising, involving and communicating their decisions to the relevant family members or carers. They must document all their actions in the patients health records and must inform the Consultant under who’s care the patient is under of the decisions made. • Senior managers - will have responsibility for understanding the DOLS processes and supporting the Matrons and Ward Managers with any urgent queries that may arise. • Deprivation of Liberty Safeguards team – will consist of best interest assessors and mental health assessors, They will be responsible for accepting the Urgent authorisation paperwork and assessing the patient within 7 days of receipt. • DoLS Administration – this team will act on the Managing Authority’s behalf and ensure that key ‘house-keeping’ processes are carried out, including communicating with the Care Quality Commission (CQC). Responsibilities carried out by DoLS Administration are set out in this text throughout this policy document. 5. Definitions Deprivation of Liberty -There is no simple definition of deprivation of liberty. The question of whether the steps taken by staff or institutions in relation to a person amount to a deprivation of that person’s liberty is ultimately a legal question, and only the courts can determine the law. This guidance seeks to assist staff and institutions in considering whether or not the steps they are taking, or proposing to take, amount to a deprivation of a person’s liberty. The deprivation of liberty safeguards give best interests assessors the authority to make recommendations about proposed deprivations of liberty, and supervisory bodies the power to give authorisations that deprive people of their liberty. 7 Managing Authority and Supervisory Body - The important roles under Deprivation of Liberty Safeguards are carried out by Managing Authorities and Supervisory Bodies. Worcestershire PCT Provider Services is a "Managing Authority", but responsibility for the application of the DOLS processes is delegated to the Matrons/ Ward Managers and their named deputies at each individual Community Hospital/Unit which is a Managing Authority in its own right. The “Supervisory Body” is NHS Worcestershire and they have responsibility as the Supervisory Body for Worcestershire residents. It is important to note however, that depending on where they normally live, i.e. outside Worcestershire, patients in the Community Hospitals could have different Supervisory Bodies. The Supervisory Body for NHS Worcestershire is co-located with the Supervisory Body for the Worcestershire Local Authority (who are responsible for receiving DOLS referrals from Care Homes). 6. Policy detail 6.1 When can someone be deprived of their liberty? Depriving someone who lacks the capacity to consent to the arrangements made for their care or treatment of their liberty is a serious matter, and the decision to do so should not be taken lightly. The deprivation of liberty safeguards make it clear that a person may only be deprived of their liberty: • in their own best interests to protect them from harm • if it is a proportionate response to the likelihood and seriousness of the harm, and • if there is no less restrictive alternative. The European Court of Human Rights (ECtHR) and UK courts have determined a number of cases about deprivation of liberty. Their judgments indicate that the following factors can be relevant to identifying whether steps taken involve more than restraint and amount to a deprivation of liberty:• • • • • • Restraint is used, including sedation, to admit a person to an institution where that person is resisting admission. Staff exercise complete and effective control over the care and movement of a person for a significant period. Staff exercise control over assessments, treatment, contacts and residence. A decision has been taken by the institution that the person will not be released into the care of others, or permitted to live elsewhere, unless the staff in the institution consider it appropriate. A request by carers for a person to be discharged to their care is refused. The person is unable to maintain social contacts because of restrictions placed on their access to other people. 8 • The person loses autonomy because they are under continuous supervision and control. It is important to remember that this list is not exclusive; other factors may arise in future in particular cases. On Community Hospital wards we would consider the following as actions that could present a Deprivation of Liberty:• • • Closed or locked doors to prevent a patient from leaving Restraint – sedation 1:1 nursing, with a degree of coercion to prevent patients from leaving 6.2 How can deprivation of liberty be identified? In determining whether deprivation of liberty has occurred, or is likely to occur, decision-makers need to consider all the facts in a particular case. There is unlikely to be any simple definition that can be applied in every case, and it is probable that no single factor will, in itself, determine whether the overall set of steps being taken in relation to the relevant person amount to a deprivation of liberty. In general, the decision-maker should always consider the following: • • • • • • • All the circumstances of each and every case What measures are being taken in relation to the individual? When are they required? For what period do they endure? What are the effects of any restraints or restrictions on the individual? Why are they necessary? What aim do they seek to meet? What are the views of the relevant person, their family or carers? Do any of them object to the measures? How are any restraints or restrictions implemented? Do any of the constraints on the individual’s personal freedom go beyond ‘restraint’ or ‘restriction’ to the extent that they constitute a deprivation of liberty? Are there any less restrictive options for delivering care or treatment that avoid deprivation of liberty altogether? Does the cumulative effect of all the restrictions imposed on the person amount to a deprivation of liberty, even if individually they would not? 6.3 What practical steps can be taken to reduce the risk of deprivation of liberty occurring There are many ways in which providers and commissioners of care can reduce the risk of taking steps that amount to a deprivation of liberty, by minimising the restrictions imposed and ensuring that decisions are taken with the involvement of the relevant person and their family, friends and carers. The processes for staff to follow are: • Make sure that all decisions are taken (and reviewed) in a structured 9 way and reasons for decisions recorded. • Follow established good practice for care planning. • Make a proper assessment of whether the person lacks capacity to decide whether or not to accept the care or treatment proposed, in line with the principles of the Act (see chapter 3 of the main Code for further guidance). • Before admitting a person to hospital or residential care in circumstances that may amount to a deprivation of liberty, consider whether the person’s needs could be met in a less restrictive way. • Any restrictions placed on the person while in hospital or in a care home must be kept to the minimum necessary, and should be in place for the shortest possible period. • Take proper steps to help the relevant person retain contact with family, friends and carers. Where local advocacy services are available, their involvement should be encouraged to support the person and their family, friends and carers. • Review the care plan on an ongoing basis. It may well be helpful to include an independent element, possibly via an advocacy service, in the review. 7. Process to follow 7.1 What does a managing authority need to do? For everybody in a hospital or care home who lacks capacity, the following questions should be asked: • Does the care or treatment being provided take away the person’s freedom to do what they want to do to such an extent that it amounts to a deprivation of their liberty? • Do you believe that the care or treatment being provided is in the person’s best interests? If the answer to these questions is ‘yes’, you need to ask yourself whether the care or treatment could be given in a way which does not deprive the person of their liberty. If the answer to this question is ‘no’, and the person cannot be cared for or treated any other way, the managing authority must apply to the supervisory body for authorisation to continue with the care programme and deprive the person of their liberty. The supervisory body will then carry out a series of assessments to decide if it is right to deprive the person of their liberty. 10 There are two kinds of authorisations: standard authorisations and urgent authorisations. • Standard authorisations follow the process outlined above. Managing authorities should apply for a standard authorisation before a deprivation of liberty occurs – for example, when a new care plan is agreed that would mean depriving a person of their liberty. • Urgent authorisations can be made by managing authorities themselves – such as where a standard authorisation has been applied for, but not yet granted, and the need to deprive a person of their liberty is now urgent. Urgent authorisations can never be made without a simultaneous application for a standard authorisation to the supervisory body. 7.2 Applying for standard authorisations Managing authorities should apply to the supervisory body for a standard authorisation using the form 4 available to download from Worcestershire County Council’s website by following the links from the PCT intranet. Information about DoLs is available by clicking Worcestershire County Council website. The supervisory body will then begin the assessment process (see below) which must be completed within 21 calendar days. A managing authority cannot apply for a standard authorisation more than 28 days before a deprivation of liberty is due to take place. 7.3 Applying for urgent authorisations Any decision to issue an urgent authorisation must be taken in the best interests of the patient in accordance with section 4 of the MCA. Where restraint is involved, the decision must comply with section 6 of the MCA. The Urgent authorisation form to be completed is Form 1 available to download via the Trust intranet site Urgent authorisations last for a maximum of seven calendar days. Day one starts the day the authorisation is signed and dated by the referring Matron/Ward Manager. The Supervisory Body may extend this by a further 7 days in exceptional circumstances. The managing authority must inform the supervisory body when an extension is needed and only one such extension can be granted. There is a standard form for this purpose. During that period, the necessary assessment process must be completed. Also, the managing authority must request a standard authorisation if it has not already done so. 7.4 How does the assessment process work? 11 The supervisory body commissions the assessments which are used to authorise a deprivation of liberty. The assessments are then carried out by a minimum of two trained assessors: the mental health assessor and the best interests assessor. There are six assessments in all, which are: • age assessment, which determines if the person is 18 years old or over • mental health assessment, which decides whether the person is suffering from a mental disorder • mental capacity assessment, which determines if a person lacks the capacity to consent to receive care or treatment in the particular hospital or care home making the application for deprivation of liberty • eligibility assessment, which determines whether the person is, or should be, subject to a requirement under the Mental Health Act 1983 (in which case they are not eligible for this process) • no refusals assessment, which determines if the person has refused treatment or made decisions in advance about the treatment they wish to receive; this assessment also determines if the authorisation conflicts with valid decisions made on the person’s behalf by a donee of a lasting power of attorney or a deputy appointed for the person by the court • best interests assessment, which determines if there is a deprivation of liberty and whether this −is:in the person’s best interests − necessary in order to keep the person from harm − a reasonable response to the likelihood of the person suffering harm and the likely seriousness of that harm. An authorisation will be granted only if all six assessments support the authorisation. 7.5 Providing support throughout the assessment process The managing authority must tell the supervisory body if the person involved has no family member or non-professional carer to support them through the assessment process. The supervisory body must then appoint an Independent Mental Capacity Advocate (IMCA), under section 39A of the Act, to support them. (This is often known as a section 39A IMCA.) The supervisory body and the managing authority must work together to make sure the person and their representative: • understand the MCA DOLS process • know their rights and entitlements • receive the right support once the authorisation process begins and after the authorisation has been granted or denied. 7.6 What happens when a MCA DOLS authorisation is granted? 12 Not every assessment process will result in an authorisation. However, once a person in a hospital or care home has an MCA DOLS authorisation, a relevant person’s representative (RPR) must be appointed to support them and look after their interests. The managing authority (together with its supervisory body) must: • make regular checks to see if the authorisation is still necessary • remove the authorisation when it is no longer necessary • provide the person’s RPR with information about the care and treatment of the person who has an MCA DOLS authorisation • be aware that an approved DoLS is specific only to the location of that managing authority – therefore a patient subject to an approved DoLS in one Community Hospital who transfers to another Community Hospital MUST have a new DoLS referral. This also applies when the patient is discharged to another facility or if the patient regains capacity – in these cases, the current DoLS is no longer valid. 7.7 What happens if a request for an authorisation is turned down? If an authorisation request is turned down, the managing authority must not deprive the person of their liberty and will need to take alternative steps. The steps will depend on the reason the authorisation was turned down. • It may be appropriate for the person to be detained under the Mental Health Act 1983. • If the person is under 18, the Children Act 1989 may be used for meeting their care requirements. • There may be ways to support the person in a less restrictive manner that avoids a deprivation of liberty. • Often, people make valid decisions about refusing care or treatment when they are still capable of doing so or there are valid refusals by attorneys or deputies appointed on their behalf. If the managing authority wishes to challenge these decisions, it can apply to the Court of Protection. • If the deprivation of liberty is not in the person’s best interests, the managing authority (together with the commissioner of care) needs to make sure that the person is supported in a way that avoids deprivation of liberty. • If the person has the capacity to make decisions about their own care, the managing authority must help them to make their own decisions. • If the relevant person is not being deprived of liberty, the managing authority should continue to support them without taking further action. 7.8 Use of Referral Forms for DoLS 13 There is a requirement to make and keep written records in relation to the DoLS process and this requirement comes from several sources, the Mental Capacity Act 2005, the Code of Practice and the Care Quality Commission. The DoLS forms are necessary because the procedures involve depriving a fellow citizen of their liberty. Completing these forms and records also enables the Managing Authority (the PCT Provider Services) to demonstrate that they have acted lawfully if their actions are later challenged. The DoLS Administration team (based in the Worcestershire Mental Health Partnership Trust) will act on the PCT Provider Services’ behalf and manage the process for the Managing Authorities to establish separate records of all DoLS related documents and for reporting to the Care Quality Commission (see Appendix 6 & 7). All the forms are accessible by following the links on the DoLS site of the PCT intranet. The link takes you directly to the Worcestershire County Council’s website where all the most current and approved DoLS forms are sited. 8 Procedures to follow 8.1 When to use an Urgent or a Standard Referral for a DoLS Urgent Referrals By far the most frequent referrals from a PCT Community Hospital will be an urgent referral. Managing authorities are able to grant themselves an urgent referral pending assessment from the Supervisory Body. This could be because it is believed that deprivation of liberty is already happening to a patient resident in the hospital without valid authorisation, or it is believed that a patient requires care under circumstances which may indicate a deprivation of their liberty is necessary immediately. This will require completion of FORM 1 for the urgent authorisation BUT please note you will also need to complete FORM 4 to apply for a Standard Authorisation as the urgent referral is only granted for a period of 7 days.. Standard Referrals If it is believed that a patient may require a standard referral but that it is not an urgent situation, then FORM 4 must be completed and the assessment from the Supervisory Body must take no longer than 21 calendar days from accepting the referral. 8.2 Procedure to be followed by Matrons and Ward Managers Firstly you will have to consider if the patient is potentially or actually experiencing deprivation of their liberty. Consider the questions and answers in Appendix 1 and the checklist in Appendix 2 to aid your assessment. 14 Firstly establish if an urgent referral is necessary - If it is believed that someone is being deprived of their liberty you must issue yourself an Urgent Authorisation (Form 1) and at the same time you should request a Standard Authorisation from the Supervisory Body (Form 4). • • • • • • • • • • • • • • Patient is identified as a potential risk from a deprivation of their liberty Matron and/or Ward Manager must be involved in the decision making process The Matron must be informed that a Deprivation of Liberty Safeguards referral is being made. If the Hospital Matron is not available, then either the PCT lead for DoLS (Vicky Preece, Lead Nurse) must be informed, or a Matron from another Community Hospital, and delegated authority will be given to the person in charge to proceed to complete and sign the forms (see Appendix 3). If neither the DoLs lead or another matron is available, then the senior manager on Call must be informed and delegated authority will be given to the person in charge to proceed to complete and sign the forms. Follow the checklist (see appendix 2) for assistance as to how to identify if the restrictions put in place in order to deliver care to the patient could result in a Deprivation of Liberty. Utilise the Deprivation of Liberty Safeguards Code of Practice (accessible through Trust intranet) to support your decisions. Wherever possible inform patients relatives, carers of decision to apply for authorisation Access Trust intranet DoLS site and complete Form 1 (Urgent authorisation) and Form 4 (Standard Authorisation) ensuring all fields are completed and the form is signed (see Appendix 4 for process) NB. The DoLS team for the Supervisory Body will not accept the referral if the form isn’t fully completed. Email the NHS mail account address with Form 1 and 4 as attachments to the DoLS team at [email protected] and please remember to cc the email to the PCT NHS mail address for DoLS which is [email protected] as this is is necessary for Trust records. It is also necessary to print off 2 copies of the forms, one to be filed in the patient’s notes and one set to give to patient/relative or IMCA if involved. This will be undertaken by DOLS Administration and copies of the forms will be sent to you for insertion in the patient’s notes. In all cases - notify the DoLS lead (Vicky Preece, Lead Nurse for Provider Services) as soon as possible after a referral has been made by emailing [email protected] This will be the trigger to look at the NHS mail system for the completed paperwork. Do not attach the DoLS forms to this email as Microsoft Outlook mail is not encrypted or secure. It is very important that if a patient subject to an approved DoLS is discharged from the managing authority, or the patient regains 15 capacity, the DoLS team of the Supervisory body must be informed asap and the message copied into [email protected] 9 Notifying the Care Quality Commission (CQC) All DoLS referrals must be notified to the CQC. Notification will be undertaken by DOLS Administration on the Managing Authority’s behalf (see appendix 6). The form will be emailed to CQC at [email protected] (http://www.cqc.org.uk/_db/_documents/RP_PoC1C_100098_20100217_v1_ 00_paper_depr_liberty_notif_FOR_PUBLICATION.doc) Furthermore, once the outcome of a DoLS referral is known, i.e. whether its been approved or not, this notification must be communicated to the CQC and this will be undertaken by DOLS Administration. Therefore, each time a DoLS referral is made, it is imperative that the process outlined in Appendix 4 is followed. This alerts the PCT DoLS lead (Vicky Preece, Lead Nurse for Provider Services) to the referral and DOLS Administration who will ensure that the DoLS referral form is emailed to the CQC and that everything in the Actions Checklist has been carried out (Appendix 6) NOTE Notifications often need to refer to confidential information. It would be against the Data Protection Act 1998 to submit a notification that included confidential personal information such as a person’s name, or any other information that could identify an individual. A unique identifier or code must be used rather than a name, when giving information about an individual in a notification. The unique identifier or code on the form will be chosen. 9.1 Actions that must be undertaken: • A record must be kept of the codes given in each notification and who they refer to in case we need to know more about the event. NB this will be undertaken by DOLS Administration. • Save and download the completed forms and place them in the patients health record - NB this will be undertaken by DOLS Administration. • Document in the Patients health records what action you have taken and what involvement relatives, family members and carers have had in the decision making process • Always document in the patients’ health records any actions, or discussions that have taken place during the request process, including those situations where it is decided that a DoLS request is not required. • Inform patient's Consultant or GP (whichever is relevant) of DOLS referral • The DoLS team will make contact with you to say the request has been received. Please follow up the referral if you do not receive a receipt. • Always refer to Deprivation of Liberty Safeguards Code of Practice for more information, accessible through Trust intranet 16 • You must provide the person themselves and any DoLS IMCA with a copy of the Form 1. • Once the outcome of the application is provided, notification of outcome must be emailed to CQC, using the original notification reference and form http://www.cqc.org.uk/publications.cfm?fde_id=14495 and emailed to [email protected] NB this will be undertaken by DOLS Administration. In the case of planned admissions where you are notified that a DoLS referral may be necessary, a Standard Authorisation request alone is needed. The procedure is identical except no Form 1 needs to be completed. 10 Training and Awareness • • • • It is important that all relevant clinical staff working in Community Hospitals have a basic awareness of DoLS and the process for authorisation. All new clinical staff as part of their workplace induction should be given basic awareness of DoLS. All Matrons and Ward Managers must have attended training sessions on DoLS and have an NHS mail account to enable them to make referrals. Training and awareness sessions should be provided to the Executive Team and senior managers who participate in the on-call rota. 11 Monitoring and compliance • • • Referrals will be audited through the DoLS team based at County Hall Specific DoLS email is set up to monitor referral forms from each individual Matron/Ward Manager and this will be monitored by the Lead Nurse for Provider Services with Lead for Safeguarding Adults. The referral process and related DoLS records will also be monitored by DOLS Administration. 17 Appendix 1 Questions and Answers on DoLS Q. WHAT IS A DEPRIVATION OF LIBERTY (DoL)? A. THE HARD ANSWER – there is NO single definition OR a standard checklist. Q. WHO IS COVERED BY DoL SAFEGUARDS? A. Anyone who is: • Aged 18 or over. • Has a mental disorder such as dementia or a learning disability • Lacks the capacity to consent to where their treatment and/or care is given. • Needs to have their liberty taken away in their own best interests to protect them from harm. Q. WHAT ABOUT THE MENTAL HEALTH ACT 1983? A. Someone who is detained under the MHA 1983 cannot be subject to a DoL at the same time. The Safeguards can be used alongside other sections such as section.7 guardianship. 18 Appendix 2 DEPRIVATION OF LIBERTY SAFEGUARDS (DoLS) – CHECKLIST THINGS TO THINK ABOUT There have been some legal cases which help us to identify DoLS issues. The following questions should be considered about each person in a hospital ward who doesn’t have the capacity to give informed consent to being there. If it is obvious that the answer to every question is no, the person is unlikely to be being deprived of their liberty. If the answer to any of these questions is yes, you should consider a referral to the Supervisory Body. A. HOW THE PERSON WAS ADMITTED TO THE HOSPITAL 1 Were force or sedatives used because the person was resisting being admitted? This does not include the use of benign force, such as gently guiding someone by the arm. 2 Was the person deceived to make sure they co-operated? For instance, were they misled into believing that they would return home the next day? 3 Did the person’s relatives, or carers who live with the person, object to them being admitted? B. THE PERSONS’ CARE AND TREATMENT WHILST IN THE HOSPITAL 4 Is the person being sedated to prevent them leaving? NB. Use of sedatives does not in itself mean that a person is deprived of liberty – it is only relevant if the purpose is to prevent the person from leaving the establishment. 5 Does the person make PERSISTENT or PURPOSEFUL attempts to leave, which are prevented by means of force or a locked door? If immobile, does the person ask to leave in a PERSISTENT and PURPOSEFUL way? NB. A locked door does not constitute deprivation on its own, even if its purpose is to prevent patients/ residents from wandering. Likewise for the use of benign force, such as gently guiding someone by the arm to return them when they are wandering. This test is met only if the person’s attempts to leave are persistent and/or purposeful 6 Is force being used to treat the person when they are resisting, other than in an emergency? 19 NB. Use of benign force to administer medication, or to feed or dress someone, does not deprive someone of liberty. Emergencies could include disturbed, threatening or self-harming behaviour. C. ACCESS TO RELATIVES AND FRIENDS 7 Have relatives or carers asked for the person to be discharged to their care, and have been refused? 8 Have the relatives or carers been refused access to the person, or had severe restrictions put on their access? NB. Reasonable restrictions on visiting hours, etc are not relevant e.g. ward closure due to Norovirus. 9 Has the person been prevented from spending time with the people who matter to them? NB. This would, for instance, include preventing the person from spending time with friends inside or outside the ward. It would NOT include guiding the person away from casual acquaintances who appear to be abusing or exploiting the person, or reasonable restrictions on the times when the person can socialise with friends, for instance because of the pattern of the establishment’s daily routine. 10 Does the way the person’s care is organised severely restrict what they can do in other ways? NB. An example of severe restriction would be placing the person for a large proportion of their waking time in a position which prevents them from moving (eg using furniture which they cannot get up from). It would NOT be a severe restriction to use furniture designed to keep the person safe, which they cannot get up from unaided, it they are usually able to get help to get out of it when they show a persistent or purposeful desire to do so. 11 Has the person’s access to the community been severely restricted BECAUSE OF CONCERNS ABOUT PUBLIC SAFETY? NB. It is not deprivation of liberty to require someone to be escorted on trips out of the care hospital, if this is in the interests of their own safety rather than that of others, even if this means that the person is sometimes temporarily not permitted to leave. 20 Appendix 3 Delegation of duties for applying for DoLS approvals within the Worcestershire PCT Provider Services Community Hospital Matrons Ward/Unit Managers On-Call Matrons Vicky Preece, Lead Nurse for Provider Services is the Trust Lead for DOLS and can be contacted for further advice on [email protected] or on 01905 760072. NB. All staff who are given delegated authority to make DOLS referrals must have an NHS Mail account to be able to use the special DOLS NHS mail address. 21 Appendix 4 DoLS REFERRAL PROCESS Please follow the links from the PCT Intranet site for access to DoLS referral forms where you will also find further DoLS information located on the DoLS website at Worcestershire County Council. Clinical team discuss possible need for DoLS for patient. If ward/unit manager is not available discuss immediately with Matron, Matron On Call or DOLS Lead. Read DoLS checklist for further guidance. If yes is answered to any question a DoLS assessment must be requested If urgent authorisation is required, complete FORM 1 detailing the granting of the urgent authorisation for deprivation prior to sending. FORM 4 MUST also be sent at the same time. If a standard authorisation is required complete FORM 4 only. Place completed forms as an attachment and email to DoLS team at [email protected] using you NHS mail account. Also copy the email to [email protected] to ensure that its received for Trust records and so that DoLS Administration can print off 2 copies - one for the patient record and one for the patient/relatives/IMCA Ensure copies of DoLs forms once received, are placed into the patient record and another given to the patient and relative/IMCA. Ensure that the patient record clearly demonstrates all actions taken, relevant communications and the reasons for the actions are clearly identifiable. Once the referral forms have been sent into the DoLS team, please inform Vicky Preece, Lead Nurse for Provider Services on 01905 760072 or email at [email protected] that a referral has been made. 22 Appendix 5 PROCESS FOR A REQUEST FOR AN EXTENSION TO AN URGENT DoLS AUTHORISATION and a REQUEST FOR A REVIEW OF DOLS PROCESS There may be instances where it is appropriate to ask for either an extension to an Urgent DoLS or ask for a a review of a current DoLS. Extension of an urgent DoLS – there may be instances where an urgent authorisation will expire before all assessments for the standard authorisation are completed. In these circumstances the managing authority should request an extension to the urgent authorisaiton. This must be done in exceptional circumstances only and only one extension may be granted. The following steps must be taken once discussion and agreement has taken place with the clinical team; • Ward manager to access FORM 2 via the PCT website • Fully complete the form in conjunction with Matron or Matron On-call • Send the form as an attachment and email to [email protected] and also copy the email to [email protected] to ensure its received for Trust records and so that DOLS Administration can arrange to print off 2 copies, one for the patient record and the other for the patient/relative/IMCA • Ensure that Vicky Preece, Lead Nurse for Provider Services is informed on 01905 760072 or by emailing on [email protected] Request for a review of a DoLS - there may be instances where it is appropriate to ask for a review of a DoLS. This may be because the period of authorised deprivation is coming to an end or there are changes in a patient’s condition or care arrangements. The following steps must be taken once a decision has been made to ask for a review; • Ward manager agrees to seek a review and accesses FORM 19 via the PCT website • Fully complete the form in conjunction with Matron or Matron on-call • Send the form as an attachment and email to [email protected] and also copy the email to [email protected] to ensure its received for Trust records and so that DOLS Administration can print off 2 copies, one for the patient record and the other for the n patient/relative/IMCA • Ensure that Vicky Preece, Lead Nurse for Provider Services is informed on 01905 760072 or by emailing on [email protected] 23 Appendix 6 ACTIONS CHECKLIST FOR DoLS REFERRALS AND NOTIFICATION TO CQC (this must be used in conjunction with the DoLS Policy) Text in black are the responsibilities of the ward managers / matrons Text in this colour are the responsibilities of DOLS Administration You must involve the Matron and Ward Manager (If Matron unavailable the on-call Matron or a Matron from another Community Hospital must be consulted before the referral is made) Wherever possible inform patients relatives, carers of decision to apply for authorisation Complete Form 1 (Urgent Authorisation) and Form 4 (Standard Authorisation) ensuring all fields are completed and the form is signed (Trust intranet DoLS site to access forms) Send email with attached Form 1 and 4 to the DoLS team at [email protected] cc. email to [email protected] . Request read receipt for email. DOLS Administration will notify the CQC at [email protected] and cc [email protected] – the form can be downloaded from (http://www.cqc.org.uk/_db/_documents/RP_PoC1C_100098_20100217_v1_00_pa per_depr_liberty_notif_FOR_PUBLICATION.doc) DOLS Administration will save and download the completed forms and send them to you to be placed in the patients health record You must document in the Patients health records what action you have taken and what involvement relatives, family members and carers have had in the decision making process include any actions, or discussions that have taken place during the request process, including those situations where it is decided that a DoLS request is not required. Inform patient's GP / Consultant of DOLS referral The DoLS team will make contact with you to say the request has been received. Please follow up the referral if you do not receive a receipt. You must provide the person themselves and any DoLS IMCA with a copy of the Form 1. Once the outcome of the application is provided, DOLS Administration will notify the outcome by emailing the CQC, using the original notification reference and form http://www.cqc.org.uk/publications.cfm?fde_id=14495 and emailed to [email protected] cc email to [email protected] Contact the DoLS Team on 01905 822624 for further advice or Vicky Preece, Lead Nurse for Provider services on 01905 760072 24 Appendix 7 MENTAL CAPACITY ACT 2005 Deprivation of Liberty Safeguards PART ONE – WARD CHECKLIST AND RECORD OF EXPLANATION OF RIGHTS Name ID No. Ward Date DoL Authorised Date of Expiry of DoL Conditions Date Conditions noted in Care Plan Explanation of Rights I confirm that the DoL has been explained to the patient both by written and verbal communication. The patient has indicated that they do/do not understand. If the patient did not understand when the DoL was first explained to them, note below further attempts made to explain. Date Rights explained by Understood Yes Comments No 25 PART TWO – RECORD OF VISITS We are required to keep a note of each time an IMCA and/or Relevant Person’s Representative visits a patient. Therefore please ask the IMCA/Representative to sign in and out on the following form: Date Print Name Signature Time in Time Out This form is to be kept with the patient’s Case Notes 26 Appendix 8 DoLS Flowchart and Procedure Check NHS Net mailbox for the Trust Form 1 - Urgent Authorisation Form 4 - Request for Standard Authorisation Has Form 4 been submitted to Supervisory Body? Download and copy forms from Frameworki for file and casenotes No Phone ward to remind them a Form 4 (request for a standard authorisation) must be completed if an urgent authorisation has been d Yes Enter details on database and Register Notification to CQC Download Form 1, check for errors and send copies to patient (inc rights leaflet), IMCA and casenotes Create (or update) record card. Create file Check Supervisory Body progress on Frameworki Create record with unique ID, enter Details on database and Register Create file and record card Note expiry date Keep track in case extension is required DoL Granted? Yes No Download and copy Decision for file Download and copy Decision for file Update record card, database & Register. Notification to CQC Update record card, database & Register. Notification to CQC Follow up until DoL ceases Archive file 27 Appendix 9 Requirements for Recording MCA DoLS According to the Department of Health Deprivation of Liberty Safeguards guide for Managing Authorities on Forms and Record Keeping, Managing Authorities must undertake basic “house-keeping” with regard to all applications: Managing authorities will need to establish a separate record of all deprivation of liberty related documents for a person whenever an urgent authorisation is given or a standard authorisation is requested. This record should remain open until the person ceases to be deprived of their liberty under the Mental Capacity Act 2005. It should contain all of the completed forms, notices, requests and other documents concerning the person and their deprivation of liberty. Decisions should be taken and reviewed in a structured way. In order to minimise the risk of mistakes, someone within the organisation should be appointed to scrutinise all deprivation of liberty related documents. To ensure that Provider Services complies with this requirement, we have set up a system for record keeping via the DOLS Administration team that includes an Access database from which we will be able to extract relevant statistics if required, a card-based follow-up system, a manual Register and a file for each individual patient. Normal procedure Issue of Urgent Authorisation 1. When the Managing Authority, ie a Community Hospital, gives itself an Urgent Authorisation for a DoLS a copy is sent to [email protected] which the DoLS administrator checks on a regular basis (at least twice a day). 2. Frameworki is checked for further information and the Authorisation (Form 1) is printed off (on blue paper). 3. The form is checked and any errors reported to ward staff for rectification. If a Request for a Standard Authorisation (Form 4) has not been completed at the same time, it is pointed out to the ward that this is a statutory requirement. 4. A file is created with a unique identifier in DOLS Administration for the patient and the documents are placed in that file. 5. Copies of the documents are made for the patient, the patient’s nearest relative, any IMCA (if already involved) and for the casenotes. 6. The details of the Urgent Authorisation are entered on the database and in the Register, using the unique identifier. 7. A follow-up card is created with the date of expiry. 28 8. Standard letters are sent to the patient and any IMCA already involved, enclosing a copy of Form 1 and, in the case of the patient, enclosing information about his or her rights. 9. Frameworki is checked on a daily basis to monitor the progress of the Request for a Standard Authorisation. 10. Two days before expiry of the Urgent Authorisation, a decision is taken with ward staff as to whether or not an extension is required and if so, Form 2 should be emailed to the Supervisory Body. Request for a Standard Authorisation 1. When a request is made a copy of Form 4 should be sent to the DoLS email address on nhs.net which the DOLS Administration checks on a regular basis (at least twice a day). 2. Frameworki is checked for further information and the Request Form 4 is printed off (on blue paper). 3. If there has been no Urgent Authorisation, a file is created with a unique identifier in DOLS Administration for the patient and the documents are placed in that file. Otherwise the documents, etc, are added to the existing file. 4. The details of the application(s) are entered on the database and in the Register, using the unique identifier. 5. A follow-up card is created (or updated) and Frameworki is checked on a daily basis to monitor the progress of the request. 6. The Statutory Notification form relating to the request is completed and sent to CQC via the DoLS nhs.net email account. 7. When the Supervisory Body’s (SB) decision is received, this is logged on the database and in the Register, and a copy of the decision is filed with the original documents. 8. The Statutory Notification form relating to the decision is completed and sent to CQC via the DoLS nhs.net email account. 9. If the DoLS is approved, the expiry date is noted on the follow-up card. 10. If the DoLS is not approved, the papers are removed from the patient’s individual file and archived. 11. Approximately 10 days before the date of expiry of a standard DoLS, a reminder is sent to the contact on the ward or unit and a note made on the follow-up card. 12. If the information about whether or not a DoLS is being extended is not received, Frameworki is checked to see whether a further application has been sent to the Supervisory Body. If no application has been sent, the ward or unit is contacted on 29 the expiry date to clarify the current position and the records are updated accordingly. 13. An end of year report is also provided for the Trust Board detailing DoLS applications for the 12 month period. 30 Equality Impact Assessment Report Template 1. Name of policy or function: Deprivation of Liberty Safeguarding (DoLS) 2. Responsible Manager: Vicky Preece, Associate Director of Nursing and Therapies and Lead Nurse, Provider Services 3. Date EIA completed: 20 September 2010 4. Description of aims of function/policy: The policy sets out the process that staff need to undertake to apply for a DoLS. It protects both patients and staff if this very difficult situation should arise. 5. Brief summary of research and relevant data The policy is based on Safeguarding and Human Rights legislation and policy. 6. Methods and outcomes of consultation: Consultation has ensured that the policy is understood and useful in practical terms. 7. Results of Initial Screening or Full Equality Impact Assessment Initial or Full Equality Impact Assessment? Initial Equality Group Race Gender Disability Age Sexual Orientation Religion or Belief Human Rights Assessment of Impact Low Low Low Low Low Low Low 8. Decisions and or recommendations (including supporting rationale) 9. Equality action plan (if required) 10. Monitoring and review arrangements (include date of next full review) Department Directorate Director Report produced by and job title Date report produced Date report published Professional Development Professional Development Vicky Preece Della Lewis, Clinical Governance Team Manager 20 September 2010 October 2010 31
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