DEPRIVATION OF LIBERTY SAFEGUARDS (DoLS) If you would like

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.
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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
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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.
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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.
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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.
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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.
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•
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.
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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?
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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?
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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
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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 wor-pct.Dols-WorcestershireGo[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