health and adult social services the deprivation of ......department: jane bowen;...

Health and Adult Social Services

THE DEPRIVATION OF LIBERTY SAFEGUARDS

INTER-AGENCY POLICY AND PROCEDURES

The Deprivation of Liberty Safeguards Inter- Agency Policy and Procedures 1.2 March 2013

Category: Mental Capacity Act

Version Control: 1.3

Date of Creation: September 2008

Implementation Date: April 2009

Last Modified: July 2014

Review Date July 2015

EIA Assessment: January 2009

Approving Body NCC-DMT

Date of Approval March 2009

Document author (s)/Key

Contributors including Department Rosa Hannaford, Policy Team, Strategic Planning and

Commissioning, Health and Adult Social Services, NCC

Contact Person (Responsible person) and department: Jane Bowen; [email protected]

Deprivation of Liberty Safeguards Lead NCC

For public access online

(internet) (tick as

appropriate) For staff access only (intranet)? (tick as appropriate)

Yes

No

Yes

No

PLEASE NOTE: The shaded boxes throughout this document tell you which standard Department of Health (DH) forms / letters to use and where to find guidance in the Code of Practice..

Hardcopies of this document are considered uncontrolled please refer to intranet for latest 2 version


CONTENTS Page No

1 INTRODUCTION 6

2 RATIONALE AND PURPOSE 7

3 DEFINITIONS 7

3.1 Managing Authority 7

3.2 Supervisory Body 7

3.3 Dols Service 8

3.4 Signatory 8

3.5 Deprivation Of Liberty 8

3.6 Restraint 8

3.7 Relevant Person 8

3.8 Standard Authorisation 8

3.9 Urgent Authorisation 8

3.10 Capacity 9

3.11 Registered Care Home 9

3.12 Code Of Practice 9

3.13 Independent Mental Capacity Advocate (IMCA) 9

3.14 BIA 9

3.15 Mental Health Assessor 9

4 SCOPE 10

4.1 Organisations, Services And Staff 10

4.2 Persons Who Meet Following Criteria 10

4.3 What The Policy Does Not Cover? 10

5 POLICY STATEMENT 11

5.1 Governing Principles 11

5.2 Key Responsibilities Of Northamptonshire County Council as 11 Supervisory Body

5.2.1 Key Responsibilities Of Dols Service 12

5.2.2 Key Responsibilities Of Managing Authorities: Care Homes & 13 Hospitals



6 PROCEDURES AND GUIDANCE 14

6.1 Applying for an authorisation 14

6.2 Applying For A Standard Authorisation (Procedure For The 15 Managing Authority)

6.2.1 Information To Be Provided To DoLS Service By Managing 16 Authority

6.2.1.1 Additional Information 16

6.3 Receiving A Request For Assessment For Standard Authorisation 17 (Procedure For The DoLS Service)

6.3.1 Instructing An IMCA 18

6.4 Assessment Process For A Standard Authorisation (Procedure 19 For The DoLS Service)

6.4.1 Stages In The Assessment Process 20

6.4.2 Deprivation of Liberty Assessments 20

6.4.2.1 Confirm Age Assessment 20

6.4.2.2 Confirm No Refusal Assessment 21

6.4.2.3 Mental Capacity Assessments 21

6.4.2.4 Mental Health Assessment 21

6.4.2.5 Eligibility Assessment 21

6.4.2.6 Best Interest Assessment 22

6.4.2.7 Equivalent Assessments 22

6.4.2.8 Additional Duties during the Assessment Process 23

6.5 Process For Urgent Authorisations (Procedure For The Managing 24 Authority And DoLS Service)

6.5.1 Managing Authority Responsibilities 24

6.5.2 Dols Service Responsibilities 25

6.5.3 Extending The Urgent Authorisation 25

6.6 Third Party Requests – Unauthorised Deprivation Of Liberty 26 (Procedure For The DoLS Service)

6.7 Assessment Outcomes – Granting Or Declining An Authorisation 28 (Procedure For The DoLS Service, Supervisory Body And Managing

Authority)

6.7.1 The Assessor’s Reports 28

6.8 Declining The Authorisation 29

6.9 Granting The Authorisation 29

6.10 Recording And Notifying Relevant Parties Of The Decision 30

6.10.1 Actions To Be Undertaken By The Supervisory Body And 31 Managing Authority Where Liberty Is Being Deprived But The

Requirements For Authorisation Are Not Met

6.10.2 Age Assessment 31

6.10.3 Mental Health Assessment 31



6.10.1.4 Mental Capactiy Assessment 31

6.10.1.5 Best Interest Assessment 32

6.10.1.6 Eligibility Assessment 32

6.10.1.7 No Refusals Assessment 32

6.10.2 Responsibilities Of The Managing Authority Once An 32 Authorisation Has Been Granted Or Declined

6.11 Reviews 33

6.11.1 Managing Authority Responsibilities 33

6.11.2 DoLS Service Responsibilities 34

6.12 Terminating A Standard Authorisation 34

6.13 Appeals And Court Of Protection 35

6.13.1 Managing Authority Appeals 35

6.13.2 Court Of Protection 36

7 INFORMATION GOVERNANCE 36

7.1 Transferring Personally Identifiable Information 37

8 RELATED POLICIES, PROCEDURES AND FORMS 37

Appendix 1 38

Appendix 2 39



1 INTRODUCTION

The Deprivation of Liberty Safeguards 2008 are an amendment to the Mental Capacity Act 2005. They provide a legal framework to protect those who may lack the capacity to consent to the arrangements for their treatment or care and where levels of restriction or restraint used in delivering that care are so extensive as to potentially be depriving the person of their liberty. The safeguards apply where that person’s care is being delivered in a registered care home or hospital and has not been authorised under the Mental Health Act 1983. These safeguards will prevent arbitrary decisions to deprive a person of their liberty and provide a robust and transparent framework in which to challenge deprivation of liberty authorisations. The safeguards therefore protect the rights of vulnerable individuals. The safeguards come into force in April 2009 and from this point onwards a Managing Authority (see definitions below) must seek authorisation from a Supervisory Body in order to lawfully deprive a person of their liberty. Where a request for a Standard Authorisation for deprivation of liberty is made, the Supervisory Body is responsible for conducting a number of assessments to determine whether the authorisation is to be granted. Where any assessment is negative, the authorisation cannot be granted.

The DoLS Service is managed by Northamptonshire County Council:

Deprivation of Liberty Safeguards Team

Mental Health Services

Floor 3, Tithe Barn Offices

Wellingborough

NN8 1BN

Telephone: 01604 368280

Safe Haven Fax: 01604 362005

[email protected]


mailto:[email protected]

The Deprivation of Liberty Safeguards Inter- Agency Policy and Procedures 1.2 March 2013 2 RATIONALE AND PURPOSE TIONALE AND PURPOSE This document provides a local framework for the implementation of the Deprivation of Liberty Safeguards within Northamptonshire and aims to set out the processes and procedures that must be followed by those that have a duty of care towards a person who is, or may become deprived of their liberty. This includes both Managing Authorities and the Supervisory Bodies.

The Supervisory Bodies will deliver the duties required by the Deprivation of Liberty Safeguards through a service managed by Northamptonshire County Council in order to deliver a single pathway.

The Deprivation of Liberty Safeguards (DoLS) Code of Practice, published under sections 42 and 43 of the Mental Capacity Act 2005, provides extensive guidance and information about the Act and how it works in practice and should remain the main point of reference for staff working with deprivation of liberty issues.

This document does not replace the DOLS Code of Practice or seek to repeat the content or guidance contained within it. This document is intended to clearly outline the key responsibilities and procedures related to the implementation of the legislation within Northamptonshire. The document aims to highlight the processes involved with requesting, assessing, granting and reviewing Standard Authorisations for deprivation of liberty from the perspective of both the Managing Authorities applying for the authorisation, and the Supervisory Body who assess and grant the authorisation.

3 DEFINITIONS DEFINITIONS

3.1 Managing Authority The person or body with management responsibility for the hospital or care home in which a person is, or may become deprived of their liberty.

3.2 Supervisory Body A primary care trust, local authority, Welsh Ministers or a local health board that is responsible for considering a deprivation of liberty request, commissioning the assessments and, where all the assessments agree, authorising deprivation of liberty. As a result of changes introducted by the Health and Social Care Bill

2012 and the abolition of primary care trusts from April 1st

2013, supervisory body responsibilites for DoLs request from hospital will fall to local authorities. Throughout the policy the term Supervisory Body is used to mean NCC.



3.3 DoLS Service The DoLS Service is a service managed by NCC. The DoLS Service undertake the work associated with deprivation of liberty on behalf of the Supervisory Body, including responding to requests, conducting assessments, specifying timescales and conditions for the authorisations and conducting reviews. The Supervisory Body maintains overall responsibility for granting authorisations.

3.4 Signatory The signatory is the relevant Senior Manager from the Supervisory Body who has overall responsibility for granting the Standard Authorisation, attaching any conditions recommended by the BIA during the assessment process and also setting the period for which the authorisation will be in force.

3.5 Deprivation of Liberty Deprivation of Liberty is a term used in the European Court of Human Rights about circumstances when a person’s freedom is taken away. A distinction is drawn between the deprivation of liberty of an individual (which is unlawful unless authorised) and restrictions on the liberty of movement of an individual. This distinction is one of degree and intensity, not nature or substance. Determining whether deprivation of liberty is taking place should always be situation specific for the individual concerned and should take into account factors such as the type, duration, effects and manner of implementation of the care or treatment in question. Following the Supreme Court judgement in the case of P v Cheshire West and Chester Council and another P and Q v Surrey County Council, the threshold for deprivation of liberty has been redefined creating a new ‘acid test’ to determine deprivation in line with Article 5 of the European Convention on Human Rights in the following circumstances:

The person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements.

Chapter 2 of the Code of Practice contains guidance on where restriction and restraint may become deprivation if liberty.

3.6 Restraint The use or threat of force to help do an act which the person resists, or the restriction of the person’s liberty of movement, whether or not they resist. Restraint may only be used where it is necessary to protect the person from harm and is proportionate to the risk of harm.

3.7 Relevant Person A person who is, or may become, deprived of their liberty in a hospital or care home. Hardcopies of this document are considered uncontrolled please refer to intranet for latest 8 version


3.8 Standard Authorisation An authorisation given by the Supervisory Body after completion of the statutory assessment process, giving lawful authority to deprive a relevant person of their liberty in the relevant hospital or care home.

3.9 Urgent Authorisation An authorisation given by a Managing Authority for a maximum of seven days, which may be extended by a maximum of a further seven days by a Supervisory Body. The Urgent Authorisation gives the Managing Authority lawful authority to deprive a person of their liberty while the Standard Authorisation process is undertaken.

3.10 Capacity Mental capacity is always referred to as time and situation specific. Where the term ‘lack of capacity’ is used throughout this document it refers specifically to the capacity to decide whether or not to consent to care or treatment that involves circumstances that amount to deprivation of liberty at the time at which that decision needs to be made.

3.11 Registered Care Home This includes both residential and nursing homes that can be managed by the county council or privately owned.

3.12 Code of Practice This refers to the Deprivation of Liberty Safeguards Code of Practice which supplements the main Mental Capacity Act 2005 Code of Practice.

3.13 Independent Mental Capacity Advocate (IMCA) This is someone who provides support and representation for a person who lacks capacity to make specific decisions, where the person has no-one else to support them. An IMCA is not the same as an ordinary advocate. The IMCA service was established by the Mental Capacity Act 2005.

3.14 BIA Best Interest Assessor – This refers to the assessor responsible for conducting a range of assessments to ascertain whether an authorisation for deprivation of liberty will be granted. The best interest assessors are appointed by the Supervisory Body and work within the DoLS Service.

3.15 Mental Health Assessor This is a separate assessor to the BIA, who is responsible for undertaking some of the assessments at stage 2 of the assessment process that relate to the mental health of the relevant person. The mental health assessor must conduct the mental health assessment, but may also be responsible for the eligibility assessment and mental capacity assessment where appropriate. The mental health assessor must be a doctor who is either approved under section 12 of the



Mental Health Act 1983 or is a registered medical practitioner with at least 3 years post-registration experience in the diagnosis or treatment of mental disorder.

The Mental Health Assessor is appointed by the Supervisory Body.

4 SCOPE

The policy applies to the following:

4.1 Organisations, Services and Staff

I. Northamptonshire County Council (Supervisory Body), including the interagency DoLS service and other relevant departments such as Safeguarding Adults; Commissioning and Contracts; Care Management.

II. The Managing Authorities: All local authority, NHS, independent and voluntary sector hospitals and registered care homes in the county.

III. Managing Authorities in care homes and hospitals out of county for whom the Northamptonshire Supervisory Bodies are responsible.

IV. The Relevant Person: Anybody being treated or cared for in a local authority, NHS, independent or voluntary sector hospital or registered care home in the county, irrespective of whether they are publicly or privately funded.

4.2 Persons Who Meet Following Criteria

The Deprivation of Liberty Safeguards and the processes contained within this policy document apply to all persons that meet the following criteria:

Where they are over the age of 18 and Where they are lacking the capacity to consent to the arrangements for

their care or treatment and Where they are receiving care or treatment within a hospital or care home

and Where they are receiving care where levels of restriction and restraint

are so high that they constitute a deprivation of liberty and

Where detention is not already authorised under the Mental Health Act

4.3 What The Policy Does Not Cover?

I. The policy does not replace the Deprivation of Liberty Safeguards

Code of Practice 2008, the Mental Capacity Act 2005 or any policies



on the use of restraint that are in use by Northamptonshire County Council, independent care homes or hospital units. All organisations should refer to their own restraint policies and use them in conjunction with this document.

II. The policy does not cover procedures for Managing Authorities to identify deprivation of liberty or any procedures prior to the submission of a request for a Standard Authorisation. These procedures will need to be produced internally for each care home or hospital unit.

5 POLICY STATEMENT

5.1 Governing Principles The following principles will be adhered to by all those with a duty of care towards an individual who is, or may be deprived of their liberty. This includes the Managing Authority and Supervisory Body:

Staff will carry out their duty to ensure optimum care for customers and patients that meets the needs of the individual and protects their Human Rights.

The dignity and well-being of the relevant person will be paramount at all times.

Staff will adhere both to the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards 2008 at all times and refer to both Acts and their Codes of Practice whenever capacity, best interest and deprivation of liberty issues arise.

Every effort will be made by those with a duty of care towards an individual to prevent deprivation of liberty. This includes both commissioners and providers of care.

5.2. Key Responsibilities of Northamptonshire County Council as Supervisory Body are:

To co-ordinate a dedicated Deprivation of Liberty Safeguards Service.

To ensure there is a clear referral pathway for all Managing Authorities.

To ensure there are sufficient numbers of assessors to undertake the volume of assessments required.

NCC to provide training to Best Interest Assessors, Mental Health Assessors and Supervisory Signatories with statutory responsibilities for the safeguards. Also coordinate annual refresher training required by the regulations.



To have overall responsibility for granting or refusing authorisations for deprivation of liberty and to be responsible for signing authorisations.

To make this document available to all local authority and independent care homes, hospitals and relevant staff from the Supervisory Body and to ensure information pertaining to the procedures and processes contained within this document is communicated in a timely and effective manner.

To ensure appropriate records are maintained for service development.

To use management information and reviews to develop good practice and communicate this information to relevant departments care homes and settings, such as those involved with commissioning care and support services, for external reporting to the Department of Health.

To collect equalities monitoring information for deprivation of liberty cases and use this information to monitor any differential impact on particular groups and enhance anti-discriminatory practices.

To enhance contract monitoring of care homes and hospitals through combined intelligent information and intelligence (not personal data) arising from assessments of care plans and levels of restrictive practices.

5.2.1 Key Responsibilities Of DoLS Service

The key responsibilities of the DoLS Service are:

To provide Managing Authorities with standard forms for use when requesting a Standard Authorisation of deprivation of liberty and to ensure referral processes are effective, secure and safe.

To receive applications from Managing Authorities for Standard Authorisations of deprivation of liberty and to respond to applications within the timescales specified within the procedures section of this document.

To appoint assessors, IMCA’s and relevant person’s representatives. To facilitate and conduct the six necessary assessments of the relevant

person to ascertain whether or not they meet the qualifying requirements for a Standard Authorisation to be given.

To give notice of the decision in writing to the requisite people and to other persons entitled to notice by the most appropriate means.

To access relevant resources that will enhance the quality of the assessment process e.g. specialist opinion; interpreters etc.

To respond to requests to review an authorisation for deprivation of liberty. To record assessment information and outcomes in accordance with



statutory requirements and to complete necessary information for management monitoring purposes.

5.2.2 Key Responsibilities Of Managing Authorities: Care Homes & Hospitals The following are the key responsibilities of care homes and hospitals in their role as Managing Authorities:

To deliver care in as least restrictive means as viable that is proportionate and necessary to prevent harm to that individual.

To adapt care planning processes to ensure consideration is given to

whether a person has the capacity to consent to the services which are to be provided andwhether their actions are likely to result in a deprivation of liberty.

To ensure clear and robust procedures are in place for staff to offer

guidance and clarity on when a request for a Standard Authorisation would be required, and the procedures that should be followed in order to make an application to the Supervisory Body. This requires clear policy and guidance relating to the use of restraint and restrictive practices.

To ensure that no person is deprived of their liberty except where i) an

Urgent Authorisation is in place, ii) a Standard Authorisation is in place or iii) their liberty has been deprived through other legal means e.g. under the Mental Health Act 1983.

To grant themselves Urgent Authorisation where deprivation of liberty

needs to commence before a Standard Authorisation can be obtained.

To obtain Standard Authorisation from the Supervisory Body in advance of the deprivation of liberty, except in urgent circumstances where an Urgent Authorisation is already in place, in which case authorisation must be obtained from the Supervisory Body within seven calendar days of the start of the deprivation of liberty. A combined form 4 and 1 is available and can be found on the NCC website; http://www3.northamptonshire.gov.uk/councilservices/adult-social-care/safeguarding/Pages/deprivation-of-liberty-safeguards.aspx To comply with any conditions attached to the authorisation as imposed by theSupervisory Body.

To accommodate visits from the relevant person’s representative,

recording details of visits and informing the Supervisory Body if the representative is not maintaining appropriate contact.

To maintain records and ensure that all relevant staff are made aware

of whether an authorisation is granted or refused.

To contact the relevant coroner's office should a person in their care who is deprived of their liberty die whilst subject to that authorisation.


http://www3.northamptonshire.gov.uk/councilservices/adult-social-care/safeguarding/Pages/deprivation-of-liberty-safeguards.aspx

http://www3.northamptonshire.gov.uk/councilservices/adult-social-care/safeguarding/Pages/deprivation-of-liberty-safeguards.aspx

The Deprivation of Liberty Safeguards Inter- Agency Policy and Procedures 1.2 March 2013 6 PROCEDURES AND GUIDANCE

This section of the document outlines the key processes involved in the Deprivation of Liberty Safeguards. Different aspects of the procedures are the responsibility of the Managing Authority, the DoLS Service or the Supervisory Body and there are a number of key timescales that all staff need to be aware of and adhere to.

6.1 Applying for an authorisation

Standard Authorisations (sections 6.2, 6.3 and 6.4) – for use where it is anticipated that deprivation of liberty will occur

Managing Authorities can apply for a Standard Authorisation up to 28 days in advance of the anticipated deprivation of liberty.

The DoLS Service will acknowledge receipt of a request within 24 hours (or the next working day if the form is received on a Friday or bank holiday)

The DoLS Service will appoint an IMCA if needed as soon as practicable. Urgent Authorisations– for use where the person is already being deprived of their liberty or will be in the immediate future

The Managing Authority can issue itself an Urgent Authorisation for up to 7 days.

The Managing Authority must request a Standard Authorisation at the same time as issuing itself an Urgent Authorisation.

The DoLS Service will inform the Managing Authority, in writing, of its intended date for the BIA to commence assessments as soon as practicable

The DoLS Service must complete all assessments and respond to the Managing Authority with a decision within the period of the Urgent Authorisation.

The DoLS Service can extend the Urgent Authorisation for a maximum of a further 7 days (only in exceptional circumstances).

A combined form 4 and 1 is available on NCC website: http://www3.northamptonshire.gov.uk/councilservices/adult-social-care/safeguarding/Pages/deprivation-of-liberty-safeguards.aspx

Third Party Requests

Where a 3rd Party requests that the Managing Authority applies for an authorisation, the Managing Authority must respond to the 3rd Party within 24 hours.



The DoLS Service will have 7 days from the date that the 3rd Party request was received in order to ascertain whether an unauthorised deprivation of liberty is occurring.

If the DoLS Service find that an unauthorised deprivation of liberty is occurring, it will have 21 days in which to complete all assessments as per a Standard Authorisation.

After the assessment process If all the assessments in the standard authorisation assessment process indicate that the relevant person meets all the qualifying requirements, then the supervisory body will give a deprivation of liberty authorisation. If any of the qualifying requirements are not met, DoLs cannot be authorised. Feedback will be provided to the managing authority and where further action is required this will be communicated to appropriate agencies.

Chapter five of the Code of Practice identifies potential outcomes of the assessment process and offers guidance on what should happen next.

Any failure to meet the timeframes as outlined above must be reported to the relevant Supervisory Body via their incident reporting procedures

Code of Practice – Chapter 5

6.2 Applying For A Standard Authorisation (Procedure For The Managing

Authority)

I. Managing Authorities will need to ensure they have workable internal

procedures in place to identify if authorisation for deprivation of liberty is required, or if it is necessary in exceptional circumstances to issue an Urgent Authorisation. Procedures should clearly identify who is responsible for taking action at this stage. Managing Authorities should seek advice if necessary from the DoLS Service at this stage.

II. Managing Authorities will need to ensure every effort has been made to avoid deprivation of liberty and care is being provided within the provisions of the Mental Capacity Act.

III. If the relevant person is already subject to a DoLS authorisation and a move is planned to another care home or hospital and their liberty may be deprived, the Managing Authority must apply to the DoLS Service for a new authorisation following the procedures outlined in this section. An authorisation applies to the person in a particular environment and an authorisation only applies to that hospital or care home.

IV. Where it is decided that an authorisation is required, the appropriate member of staff identified in the internal procedures should complete the standard form- Form 4: Managing Authority request for a Standard Authorisation or NCC combined form. This can be done up to 28 days in



advance of the anticipated deprivation of liberty occurringThe request form should be sent by fax to the DoLS Service using the following Safe Haven Fax number: 01604 362005

V. Managing Authorities must make every effort to send their request to the correct Supervisory Body

VI. Where the Managing Authority needs to send requests for Standard Authorisations for more than one relevant person, these should be sent individually on a case-by-case basis.

6.2.1 Information to Be Provided To DoLS Service by Managing Authority The Managing Authority is required to provide the following information to the DoLS Service at this stage:

Relevant person’s information (including name, gender, age, address) The name, address and telephone number of the Managing Authority

(and a named contact)

The purpose for which the authorisation is requested

The date from which the authorisation is sought Whether the Managing Authority has given an Urgent Authorisation

and the date of expiry.

6.2.1.1 Additional Information The request for a Standard Authorisation must also include, if available, the following information:

Medical information relating to the relevant person The diagnosis of the mental disorder from which the relevant person

is suffering

Any relevant care plans / assessments

The racial, ethnic or national origins of the relevant person

Details of the proposed restrictions on liberty Whether there is an existing Standard Authorisation in force in relation

to the relevant person, and date of expiry. Whether or not an IMCA is required (an IMCA would be required if the

relevant person does not have somebody not engaged in providing their care or treatment in a professional capacity or for remuneration to support them)

Contact details of anyone engaged in caring for the person or who have been named by the relevant person as someone to consult.

Information about any legislative considerations, such as:

Lasting Power of Attorney

Advance Decision to Refuse Treatment

Mental Health Act requirements Hardcopies of this document are considered uncontrolled please refer to intranet for latest 16 version


VII. Once the request form has been sent to the DoLS Service, the Managing Authority should, if judged appropriate/practicable, inform the family and carers of the relevant person that an application for a Standard Authorisation has been made. The Managing Authority should also keep a copy of the request form and clear written records of the reasons for the request.

VIII. If a Managing Authority receives a request from a third party to apply for an authorisation, or to change the care regime, the Managing Authority must respond to this request within 24 hours. Where the Managing Authority has been unable to resolve the 3rd party request, i.e. where they have not been able to satisfy the 3rd party that no deprivation of liberty is occurring, they must submit an application to the DoLS Service following the procedures outlined above. Where the Managing Authority has failed to make an application, the Supervisory Body will accept a referral from the 3rd party. In such circumstances, the Care Quality Commission will be notified.

IX. Where the Supervisory Body and the Managing Authority are the same organization it can act in both capacities. However, in such a situation, the BIA cannot be an employee of the Supervisory Body/Managing Authority, or provide services to it.

6.3 Receiving a Request for Assessment For Standard Authorisation (Procedure For The DoLS Service)

I. Northamptonshire DoLS Service has duties as a Supervisory

Body towards Managing Authorities where:

For registered care homes

The relevant person is ordinarily resident within Northamptonshire or

The relevant person is not ordinarily resident in England or Wales or

The relevant person has no fixed abode or

The relevant person is funding their own care

For hospitals

Nene Clinical Commissioning Group and Corby Clinical Commissioning Group has commissioned the relevant person’s care or

The hospital is within Northamptonshire and the relevant person has self-funded their care.

Managing Authorities must make every effort to send their application to the correct Supervisory Body. In the event that the Northamptonshire DoLS Service receives a referral that is the responsibility of a Supervisory Body in another area, the DoLS Service will inform the Managing Authority of this and redirect the form to the Supervisory Body of the correct authority. In the event that that



Supervisory Body requests assistance from the Northamptonshire DoLS Service in undertaking the assessments, the ADASS Protocol for the Inter-Authority Management of Deprivation of Liberty Safeguards Applications will be applied.

I. Upon receipt of a request for a Standard Authorisation, the DoLS Service Senior Administrator will initially acknowledge receipt of the referral form within 24 hours (or the next working day if the form is received on a Friday or bank holiday) by sending a secure fax to the Managing Authority.

II. The DoLS Service will consider whether the application is appropriate, complete or whether any additional information is required from the Managing Authority.

If the request form (Form 4) is incomplete/invalid, the DoLS Service will refer back to the Managing Authority for further information/necessary action. The application process will be restarted on receipt of the revised request form/information.

If the DoLS Service considers that the request has been made too far in advance of expiry of an existing authorisation, this should be resolved with the Managing Authority and the application process stopped until another request form is received at a more appropriate time.

If the request form is both complete and valid, within 48

hours of receipt of the original application (or within 48 hours of the next working day if the form is received on a Friday or bank holiday) the DoLS Service will inform the Managing Authority, in writing, of its intended date for sending a BIA to commence the assessment process.

II. From the date of receipt of the original application, the DoLS Service will have 21 days in total in which to complete all assessments and respond to the Managing Authority’s request.

6.3.1 Instructing An IMCA

I. The relevant person must have someone who can provide support to them throughout the assessment process, such as a family member, friend or carer. This person cannot be someone who provides care or treatment in a professional capacity or for remuneration. If the relevant person does not have somebody available to support them, then the DoLS Service will need to instruct an Independent Mental Capacity Advocate (IMCA). In doing so, the DoLS Service will take account of the relevant person’s cultural background, including their race, ethnicity, religious beliefs and sexuality.



II. There is a standard referral form available for the DoLS Service to use when instructing an IMCA (Form 30: Supervisory Body instructs an IMCA to represent a person who is, or may become, subject to a deprivation of liberty authorisation). This form requires the DoLS Service to identify the purpose of the IMCA and under which section of the Mental Capacity Act they are being instructed. The DoLS Service should provide as much detail as possible when instructing an IMCA.

III. The date the IMCA was instructed should be recorded on the DoLS checklist by the senior administrator. In the case of applications for Standard Authorisations, this will be done within 48 hours of confirming that the application should be pursued, or within 24 hours or next working day for Urgent Authorisations. There is a standard form available for the IMCA to use to provide their report to the Supervisory Body (Form 31: IMCA Report to the Supervisory Body) The Supervisory Body with responsibility for the contract with the IMCA Service will need to ensure that the IMCA Service is pro-active in it’s recruitment of advocates from a diverse range of cultural backgrounds.

Form 30

Form 31

6.4 Assessment Process for A Standard Authorisation (Procedure For The DoLS Service)

I. Once a request form has been received and the DoLS Service have confirmed receipt and informed the Managing Authority of its intended date for commencing the assessment, the BIA Lead is then responsible for appointing the duty BIA to commence the assessment process. The choice of BIA will be determined by:

ensuring compliance with conflict regulations the skills and experience required for that specific assessment. This

may include experience of working with a particular disability or service group and also knowledge of the persons cultural background

expedient use of resources



6.4.1 Stages in the Assessment Process

Northamptonshire DoLS Service will undertake the assessment process

I. The DoLs administrator is responsible for ensuring the BIA has access to any resources required to undertake the assessments, such as interpreters or speech therapists, which may support the relevant person or anyone with an interest in their care or treatment. The DoLs administrator should also make provision to ensure information is available in other languages and formats as and when required.

II. The Managing Authority must provide the BIA conducting assessments with any relevant assessments or care plans and enable access to and copies of any records held that assessors or IMCA may consider relevant.

III. Staff should refer to section 4 of the Code of Practice for full guidance on each of the assessments, their purpose and how they should be conducted.

Assessors are personally accountable for their decisions and Managing Authorities and Supervisory Bodies must not dictate or seek to influence their decisions. However the Supervisory Body retains liability for the assessment process.

Code of Practice Section – Chapter Four 6.4.2 Deprivation of Liberty Assessments

6.4.2.1 Confirm Age Assessment This assessment is to establish if the relevant person is aged 18 or over.

The BIA will undertake this assessment.

Form 5



6.4.2.2 Confirm No Refusals Assessment This establishes whether an authorisation for deprivation of liberty would conflict with other existing authority for decision making for that person, such as a valid and applicable Advance Decision to Refuse Treatment (ADRT) or a refusal by an attorney or deputy.


Form 8 6.4.2.3 Mental Capacity Assessment

This establishes whether the relevant person lacks the capacity to consent to the arrangements proposed for their care or treatment.


Form 7

6.4.2.4 Mental Health Assessment This assessment must be conducted by a Mental Health Assessor. The purpose is to establish whether the relevant person is suffering from a mental disorder within the meaning of the Mental Health Act 1983.

Form 6 This assessment will be conducted by the Mental Health Assessor who must be approved under Section 12 of the Mental Health Act 1983 to undertake this assessment.

6.4.2.5 Eligibility Assessment This establishes whether the relevant person is subject to a requirement under the Mental Health Act 1983 that may conflict with an authorisation under DoLS or whether their care should be provided under the Mental Health Act.

This will be conducted by the BIA, unless the BIA is not an AMHP, in which case the assessment will be conducted by the Mental Health Assessor who must be approved under Section 12 of the Mental Health Act 1983 to undertake this assessment.

Form 9



6.4.2.6 Best Interests Assessment This assessment establishes whether the proposed deprivation of liberty is in the relevant person’s best interests, is necessary to prevent harm to themselves and that the deprivation of liberty is proportionate to the likelihood and seriousness of the harm. This assessment must consider all circumstances of the case including how issues of equality and human rights are addressed. This assessment must be conducted by the BIA.

Form 10


If any requirement is not met at this stage, the assessment process is immediately ceased and the Managing Authority is informed, in writing of the decision that the Standard Authorisation is refused and the reasons for this. The BIA will need to complete Form 13 – Supervisory Body declines a request for a Standard Authorisation (See section 6.7, 6.8 an 6.9 below for procedures related to the outcomes of the assessment).

Form 13

6.4.2.7 Equivalent Assessments The Act allows equivalent assessments to be relied upon instead of obtaining fresh assessments.

Form 11 Guidance regarding the use of equivalent assessments can be found in Chapter four of the Code of Practice

Code of Practice – Chapter Four



6.4.2.8 Additional Duties during the Assessment Process – The

Appointment of the Relevant Person’s Representative

I. The BIA should at this stage initiate identifying a Relevant Person’s Representative, although this person will not actually be appointed until an authorisation is approved and confirmed in writing.

The role of the Relevant Person’s Representative is to maintain contact with the relevant person and to provide independent representation and support to the relevant person in all matters relating to the Deprivation of Liberty Safeguards, including triggering a review.

The code of practice provides eligibility criteria for who can be the Relevant Person’s Representative. At the assessment stage the BIA must identify if there is anyone they would recommend to become the relevant person’s representative, and discuss the representative’s role with the people interviewed during the assessment process (even though some of these assessments may not lead to an authorisation being granted).The standard form, Form 24: Best interests assessor action in respect of theselection of a relevant persons representative should be completed at this point.

If the relevant person does not have anyone who could act as his or her representative, the BIA should consider appointing a paid representative. The responsibility for ensuring a Relevant Person’s Representative is appointed at the point of an authorisation being granted rests with the DoLS Lead.

The Code of Practice provides detailed guidance on how the BIA should go about selecting the Relevant Person’s Representative and this should be done with due regard to the personal attributes and cultural background of the relevant person.

Form 24 The appointment of the Relevant Person’s Representative needs to be officially signed by the Signatory for the relevant Supervisory Body (see para 6.9 (VI) below)

II. The BIA should, throughout the assessment stage, identify and attempt to resolve any disagreements with the IMCA or those supporting the relevant person. III. The BIA should attempt, wherever possible, to discuss with the Managing Authority any possible recommendations they intend to make in their report to ensure early remedial action in the event of an authorisation not being granted The BIA will need to refer to the Safeguarding Adults Team and Interagency Safeguarding Adults Procedure when the BIA considers practices to be abusive within the meaning of those procedures including where deprivation of liberty is



affecting a number of people within a home or ward. This will include consideration of referral to the Care Quality Commission in line with those procedures.

6.5 Process for Urgent Authorisations (Procedure for The Managing Authority And DoLS Service).

6.5.1 Managing Authority Responsibilities

In circumstances, where deprivation of liberty needs to commence before a Standard Authorisation can be obtained, the Managing Authority can issue itself an Urgent Authorisation which makes deprivation of liberty lawful for a short period of time. A request for a Standard Authorisation must be made simultaneously with the issuing of an Urgent Authorisation. The Managing Authority will need to complete the following forms at the same time: Form 1: For the giving of an Urgent Authorisation by a Managing Authority and Form 4: Managing Authority request for a Standard Authorisation. Form 4 must be forwarded to the DoLS Service as per the process for Standard Authorisation requests.

DOHForm 1 & Form 4 or NCC combined form The DoLS Service will need to undertake the same assessment process as for a Standard Authorisation, but within shorter timescales.

A flowchart illustrating the sequence of events for this procedure can be found in the Code of Practice

Code of Practice – annex 3 page 110 I. Managing Authorities should have a procedure in place giving clear guidance to staff about the actions, responsibilities and timescales required for issuing Urgent Authorisations.

II. Managing Authorities should refer to the Code of Practice for clear guidance governing the circumstances in which an Urgent Authorisation can and cannot be issued.



6.5.2 DoLS Service Responsibilities

I. Upon receipt of the Urgent Authorisation request form, the DoLS Service will need to undertake the same assessment process as for a Standard Authorisation, as set out in the Code of Practice Chapter 4.2, but with a different set of timescales

II. Once the assessment process is complete for the Standard Authorisation, the DoLS Service will need to make a decision to either grant the authorisation or decline the request for a Standard Authorisation.

Code of Practice – Chapter Four 6.5.4 Extending the Urgent Authorisation I. In exceptional circumstances where the Standard Authorisation cannot be dealt with within the period of the Urgent Authorisation, the Managing Authority can apply to extend the period of the Urgent Authorisation for a maximum of a further 7 days. The standard form, Form 2: Managing Authority request for an extension in the duration of an Urgent Authorisation must be sent to the DoLS Service.

Form 2 II. The Managing Authority must keep a written record of the reason for the request and notify the relevant person in writing. In such circumstances, the DoLS Service Lead will consult with the Signatory from the Supervisory Body before determining whether to grant an extension and keep a record of any discussions that take place. The reasons for granting or declining an extension will be recorded in writing.

III. Unless the duration of the urgent authorisation is extended by the supervisory body, or a standard authorisation is given before the urgent authorisation expires, the authority to deprive the person of liberty will cease once the urgent authorisation period has expired. It is therefore essential that any request for an extension of an urgent authorisation is made promptly. This will necessitate good communication between the managing authority and the supervisory body regarding the progress of the standard authorisation assessment process. Particular care may need to be taken where an urgent authorisation is due to expire over the weekend or on a bank holiday, when appropriate people at the managing authority and supervisory body may not be immediately available.

IV. Both the Managing Authority and DoLS Service must ensure that the use of Urgent Authorisations is recorded, monitored and audited as part of the organisation’s governance procedures. Hardcopies of this document are considered uncontrolled please refer to intranet for latest 25 version


Code of Practice Chapter 6.21 6.6 Third Party Requests – Unauthorised Deprivation of Liberty (Procedure For The DoLS Service)

I. The DoLS Service may receive referrals from a third party regarding an unauthorised deprivation of liberty. Standard letters are available for 3rd parties to write to either the Managing Authority (letter 1) or Supervisory Body (letter 2). The 3rd party should always contact the Managing Authority in the first instance.

The DoLS Service should keep a written record of the request and ascertain whether the 3rd party has requested that the Managing Authority apply for an authorisation. (Where this is the case the Managing Authority is required to respond to the 3rd party within 24 hours). If the 3rd party has not yet done this, the matter should be referred back to the 3rd party to approach the Managing Authority. The DoLS Service will consider what support the 3rd party may require to approach the Managing Authority and enable this process.

II. If the 3rd party has previously approached the Managing Authority, the DoLS service will either:

Appoint a BIA to ascertain whether or not there is an unauthorised deprivation of liberty. This assessment must be completed within 7 days. At this stage an IMCA will be instructed if required

The 3rd party, the relevant person, the Managing Authority and any IMCA will be notified of the decision to investigate the matter and the BIA that has been appointed to undertake the assessment.

The DoLS Service will consider any additional services required in order to support the assessment process, such as an interpreter or other communication support needs.

Or, if the request is considered either vexatious or frivolous, or if it has already been decided that no deprivation is occurring, the DoLS Service

will notify the 3rd

party, the relevant person, any IMCA instructed and the Managing Authority that the DoLS service has been asked to decide whether or not there is an unauthorised deprivation of liberty occurring, but that the matter is not to be pursued.

III. If the assessment finds that no deprivation of liberty is occurring, the DoLS Service will notify the 3rd party, the relevant person, the Managing Authority and



any IMCA of the outcome. This will be recorded by the DoLS Service. The DoLS Service will need to complete standard form, Form 18: Supervisory Body’s decision following the receipt of an unauthorised deprivation of liberty report.

Form 18

IV. If the assessment finds that deprivation of liberty is occurring, the BIA will need to ascertain whether this has already been authorised. If the deprivation of liberty has already been authorised, the DoLS Service will notify the 3rd party, the relevant person, the Managing Authority and any IMCA of the outcome. The DoLS Service will need to complete standard form, Form 18: Supervisory Body’s decision following the receipt of an unauthorised deprivation of liberty report.

Form 18

V. If the deprivation of liberty is not already authorised, the Managing Authority is deemed to have requested a Standard Authorisation in relation to the relevant person. The DoLS Service will need to complete standard form, Form 18: Supervisory Body’s decision following the receipt of an unauthorised deprivation of liberty. In such circumstances, the DoLS Service will notify the relevant regulatory body of the Managing Authority.

Form 18 The Managing Authority will need to provide the DoLS Service with the information required for a Standard Authorisation and must complete Form 4: Managing Authority request for a Standard Authorisation and send it to the DoLS Service. The DoLS Service will notify the 3rd party, the relevant person, the Managing Authority and any IMCA that the DoLS Service will commence assessments as per a Standard Authorisation for deprivation of liberty and the procedures outlined in this document will be followed.

If the concerned person does not accept the outcome of the assessment, they can apply to the Court of Protection to hear their case.

Form 4 or NCC combined form

If the Managing Authority grants itself an Urgent Authorisation, the DoLS Service will need to conduct the assessments within the timescales for Urgent Authorisation.


The Deprivation of Liberty Safeguards Inter- Agency Policy and Procedures 1.2 March 2013 6.7 Assessment Outcomes – Granting or Declining an Authorisation (Procedure for the DoLS Service, Supervisory Body And Managing Authority)

6.7.1 The Assessor’s Reports I. The assessors are responsible for recording the outcomes and completing the standard forms relevant to the assessments they are responsible for as outlined in section 6.4 above. II. There are particular requirements for the best interests assessment form (form 10: best interest assessment form for completion by assessor). For the best interests assessment the BIA must explain the reasons for their conclusions. Where the best interests assessment does not support the deprivation of liberty, the BIA will provide guidance for commissioners and care providers on future actions and alternative care / treatment. This information should be communicated to the managing authority at the earliest possible stage during the assessment process to enable timely alternative care planning.

Form 10

Where the best interests assessment supports the authorisation, the BIA will specify the following on the best interest assessment form:

The reasons concerning whether or not the care/treatment amounts to deprivation of liberty, whether this is in the person’s best interests, whether it is necessary to prevent harm to that person and whether it is a proportionate response to the likelihood of the person suffering harm.

Any conditions related to the deprivation of liberty authorisation and how to avoid deprivation of liberty in the future. The BIA should not specify any conditions that do not relate directly to the deprivation of liberty.

Recommend the length of authorisation

The BIA is responsible for pulling together each assessment report and completing the relevant outcome form that details the BIA’s decision as to whether the authorisation should be granted or declined.


The Deprivation of Liberty Safeguards Inter- Agency Policy and Procedures 1.2 March 2013 6.8 DECLINING THE AUTHORISATION

I. Where any assessment concludes the requirement is not met, all assessments end and the authorisation will be declined. The BIA will need to communicate this to the other assessors and complete Form 13: Supervisory Body Declines A Request For A Standard Authorisation. The BIA will complete Form 10 up to section D5

Form 10 & Form 13 The BIA is required to give details on this form as to why the relevant person failed to meet one or more of the requirements.

6.9 GRANTING THE AUTHORISATION

I. Where all assessment requirements are met, the authorisation will be

granted.

The BIA will need to complete form 12: supervisory body gives a standard authorisation. The BIA needs to include the following information on the form:

The date on which the authorisation comes into force and the period for which it is set. The purpose for which the authorisation is given

Any conditions to be attached to the authorisation

The reasons why each qualifying requirement is met

II. The signatory of the supervisory body is responsible for ensuring due process has been followed and all assessments have been completed correctly and fully. The signatory cannot overturn the decision of the BIA to grant the authorisation, but can highlight where re-assessment may be necessary. Where the supervisory body and managing authority are the same organisation, such as where the care home involved is managed by NCC, the senior manager acting as signatory should not be directly involved in the management of that service. An alternative senior manager from a different service area of the relevant supervisory body should act as signatory in these circumstances.

The key responsibilities of the signatory are:

Grant the authorisation where all requirements are met as prescribed by the Act.

Consider whether to attach conditions as recommended by the BIA.

Set the period of authorisation.



Officially appointing the Relevant Person’s

Form 12 6.10 Recording and Notifying Relevant Parties of The Decision

Once the DoLS service has completed the form stating it’s decision to either grant or refuse the authorisation, and the form has been signed by the appropriate person, the DoLS lead is responsible for ensuring the following are undertaken:

I. A copy of the outcome form (form 12 or 13) is kept and filed

II. The outcome is recorded on the careFirst database including the

date and time the outcome report is signed and including alerts for reviews and expiry of authorisation.

III. Written copies of the outcome form (with copies of all assessments

attached) are sent to the following: The managing authority;

The relevant person;

The relevant person’s representative;

The IMCA (if instructed); Any other persons consulted by the BIA and named in the best

interests assessment report as an interested person e.g. continuing healthcare team, caseworker or care manager.

IV. Any information or documentation for the relevant person, anyone

consulted throughout the assessment process or with an interest in

their care or treatment should be made available in other languages

and formats as and when required.

Form 12 or 13

VI. Appointing the Relevant Person’s Representative Where an authorisation is granted, a Relevant Person’s Representative is appointed based on the BIA’s recommendations. The Relevant Person’s Representative Form 24 will be required to sign and return Form 24 within a two week period to ensure compliance with the appointment process.

Form 24



The DoLS Service will need to complete Form 25: Supervisory Body action in respect of the appointment of a relevant person’s representative. Once Form 25 has been signed by the relevant Supervisory Body, it should be sent to the following:

The Managing Authority.

The Representative will be given information and support to assist them in their role and be provided with the means to contact an IMCA.

Form 25

6.10.1 Actions to Be Undertaken By The Supervisory Body And Managing Authority Where Liberty Is Being Deprived But The Requirements For Authorisation Are Not Met

Where the DoLS Service refuses authorisation for deprivation of liberty because one of the requirements are not met, but agrees that deprivation of liberty is occurring, depending on which of the 6 requirements are not met the Managing Authority, along with the Supervisory Body will need to take appropriate alternative action and convene an urgent planning meeting.

6.10.1.2 Age Assessment If this assessment does not meet the requirements for authorisation because the relevant person is under the age of 18, the managing authority will need to refer the case to the relevant children’s services and use of the Childrens Act 1989 or Mental Health Act 1983 may be considered.

6.10.1.3 Mental Health Assessment If this assessment does not meet the requirement for authorisation because the relevant person does not have a mental disorder as defined by the Mental Health Act 1983, the managing authority cannot legally detain the relevant person without their permission. A planning meeting will need to be scheduled within at the latest 48 hours of the managing authority being notified of the refusal in order to consider how to modify the care plan to avoid a deprivation of liberty.

6.10.1.4 Mental Capacity Assessment If this assessment does not meet the requirement for authorisation and it is found that the person does have the mental capacity to make decisions about their care, it is unlawful to deprive them of their liberty against their will. A planning meeting will need to be scheduled within 48 hours of the managing authority being notified of the refusal in order to consider how to best support the person to meet their needs.



6.10.1.5 Best Interests Assessment Where this assessment does not meet the requirement for authorisation because deprivation of liberty is deemed not to be in the relevant person’s best interests, the care plan will need to be amended to avoid unlawful deprivation of liberty. A planning meeting will need to be scheduled within 48 hours of the managing authority being notified of the refusal in order to consider alternative arrangements for care or treatment.

6.10.1.6 Eligibility Assessment If this assessment does not meet the requirement for authorisation because the relevant person was identified as needing to be subject to the Mental Health Act 1983 instead of the deprivation of liberty safeguards, an assessment will need to be made under the Mental Health Act 1983. a referral should be made to the AMPH service. (refer to sections 4.55 to 4.57 of the DoLS code of practice for further information on what to do if a person is assessed as ineligible).

6.10.1.7 No Refusals Assessment Where this assessment does not meet the requirement for authorisation because there is a valid refusal from a donee or deputy or where an applicable and valid Advance Decision to Refuse Treatment is in place, alternative arrangements for care or treatment will need to be made. This may include application to the court of protection if there is a question about the refusal. A planning meeting will need to be scheduled within 48 hours of the managing authority being notified of the refusal in

order to consider alternative arrangements.

Responsibilities for implementing alternative care will rest with the managing authority and those responsible for care, e.g. care manager, care

programme coordinator, key worker, continuning healthcare team, etc.

6.10.2 Responsibilities of the Managing Authority Once an Authorisation Has Been Granted Or Declined

I. If the managing authority receives notification from the DoLS service that the authorisation has been granted, it must take all practical and possible steps to ensure that the relevant person understands the effects of the authorisation, their rights, and the complaints procedures and consider any specific communication needs. Information should be provided to the relevant person, and to their representative, both orally and in writing.

II. Whether the authorisation is granted or not, the outcome form must be included in the relevant person’s records and be made known to all relevant staff.

III. The managing authority must make alternative arrangements for care where authorisation is not granted, based on the recommendations made in the outcome form and ensuring urgent action to prevent unlawful deprivation of liberty. The managing authority must comply with the supervisory body where a planning meeting is required to discuss where



deprivation of liberty is occurring but not authorised (see section 6.10.1 above)

IV. Visits by the relevant person’s representative must be accommodated and details of visits are to be recorded in the relevant person’s records.

V. Inform the DoLS service if the relevant person’s representative is not maintaining appropriate contact.

VI. Inform the DoLS service where the relevant person, or their representative, requests an IMCA and if any conditions have not been able to be met within the set timescale.

6.11 REVIEWS

A standard authorisation can be reviewed at any time and will be undertaken by the DoLS service on behalf of the supervisory body.

Reviews will be conducted where any of the statutory grounds for review as stated in the Code of Practice are met, or where the Managing Authority, the relevant person or their representative requests a review. Standard forms and letters are available for the following to use to request a review:

https://www.gov.uk/government/publications/mental-capacity-act-2005- deprivation-of-liberty-safeguards-forms-for-managing-authorities

Deprivation of Liberty can end before a formal review. An authorisation only permits deprivation of liberty; it does not mean that the person must be deprived where a change of circumstance no longer necessitates it.

6.11.1 Managing Authority Responsibilities

The Managing Authority must inform the DoLS Service of any of the following events:

Where the deprivation of liberty is no longer necessary and the authorisation will be ended

Where any circumstances have changed that may require a review Where any circumstances have changed that may require review of the

eligibility assessment and short term suspension of the authorisation (such as admission under the Mental Health Act 1983). Under these circumstances the Supervisory Body can suspend the authorisation. The Managing Authority must complete Form 14: Managing Authority notifies the Supervisory Body that a Standard Authorisation should be suspended because the eligibility criteria is no longer being met and forward this to the DoLS Service.

Form 14 Hardcopies of this document are considered uncontrolled please refer to intranet for latest 33 version

https://www.gov.uk/government/publications/mental-capacity-act-2005-deprivation-of-liberty-safeguards-forms-for-managing-authorities




Where the relevant person becomes eligible again within 28 days following a suspension. Under these circumstances the Supervisory Body will remove the suspension, unless no notice is given in 28 days and the authorisation will be terminated. The Managing Authority should complete Form 15: Managing Authority notifies the Supervisory Body that the eligibility requirement is again met and the suspension of the Standard Authorisation is lifted and forward this to the DoLS Service.

Where the Managing Authority identifies that the relevant person has

regained capacity on a long-term basis and the authorisation will need to be terminated.

Where the deprivation of liberty may need to continue after expiry of the authorisation by submitting a new form four including current presentation

When a person in their care who is deprived of their liberty had died whilst subject to that authorisation.

Form 4 (or NCC combined form) Form 15

6.11.2 DoLS Service Responsibilities

I. The DoLS service must be aware of the statutory grounds for conducting

reviews as stated in the code of practice. if the statutory grounds are met, the DoLS service must carry out a review.

II. The DoLS service must also conduct a review where it has been requested by the managing authority, the relevant person or the relevant person’s representative.

III. Where a managing authority applies to the DoLS service again for re-assessment due to the imminent expiry of the current standard authorisation, the DoLS service will need to re-instigate the assessment process.



6.12 TERMINATING A STANDARD AUTHORISATION

I. When a standard authorisation ceases to be in force, the DoLS service

will need to record this using form 23: supervisory body gives notice that a standard authorisation has ceased to be in force.

II. A standard authorisation will cease to be in force in the following circumstances:

Where the managing authority gave notice to the DoLS service that this person has ceased to meet the eligibility requirement and 28 days have elapsed since that notice was given without the suspension being lifted. This will include circumstances where capacity has been regained.

The standard authorisation has expired. A review of the standard authorisation has been completed and the

review concluded that the person no longer meets the requirements for being deprived of their liberty.

Following a change in the place where the person is deprived of their liberty, the standard authorisation has been replaced with a new authorisation for the new place and therefore ceases to have effect.

The Court of Protection or another court has made an order that the standard authorisation is invalid or that it shall no longer have effect.

The person has died, once notified the Supervisory Body will complete a form 23.

III. When an authorisation expires, the managing authority cannot lawfully continue to deprive the person of their liberty.

There is no statutory time limit on how far in advance the managing authority can request a renewal of an authorisation, however it will need to be far enough in advance for the renewal to take effect before the existing authorisation expires, but not so far in advance that the relevant person’s needs could not be reasonably predicted. The DoLS service will endeavour to contact the managing authority 30 days prior to an authorisation expiring to avoid unlawful deprivation of liberty occurring.

Form 23



6.13 APPEALS AND COURT OF PROTECTION

6.13.1 Managing Authority Appeals

To comply with Article 5(4) of the European Convention on Human Rights, anybody deprived of their liberty in accordance with the safeguards described in this Code of Practice is entitled to the right of speedy access to a court that can review the lawfulness of their deprivation of liberty. The Court of Protection, established by the Mental Capacity Act 2005, is the court for this purpose. Chapter 8 of the main Code provides more details on its role, powers and responsibilities.

Once an authorisation has been granted or refused by the supervisory body, the managing authority itself cannot appeal against the decision. However, the managing authority can appeal against the assessment process if it believes there was a fault in the assessment process or negligence on the part of the assessor, or whether a change in the condition of the person requires a re-assessment/ independent/ review assessment.

The dispute will be investigated by the senior manager of the supervisory body and will be resolved through the NCC complaints procedures.

Where the investigation finds that there was a fault in the assessment process, failure to use the Court of Proctection or negligence on the part of the assessor, the particular assessment in question will be conducted again and the process for either granting or declining the authorisation will be followed depending on the outcome.

Where the appeal is not upheld, the Managing Authority will be informed that the original decision to grant or decline the authorisation remains in force.

6.13.2 Court Of Protection

The Mental Capacity Act 2005 enables anyone deprived of their liberty to make speedy application to the Court of Protection to review the lawfulness of their deprivation.

It is the responsibility of the managing authority to ensure that the relevant person and their representative is aware of their rights to apply to the court both before and after the authorisation is granted and that they have the information required in order to make a referral to the court. The relevant person and their representative should be made aware of the types of questions/issues they can take to the court as highlighted in the code of practice. Hardcopies of this document are considered uncontrolled please refer to intranet for latest 36 version


The managing authority and the supervisory body should endeavour to resolve any concerns through mediation or their own complaints procedures before the relevant person or their representative refer the matter to the court.

The managing authority and supervisory body are required to comply with any conditions imposed by the court following a hearing.

7 INFORMATION GOVERNANCE

Due to the nature of the Deprivation of Liberty Safeguards, the information that will need to be transferred and stored will be highly confidential and personally-identifiable. Therefore, all staff should work to strict procedures relating to confidentiality and the safe and secure transfer and storage of information and comply with the Data Protection Act 1998.

o during the DoLS assessment process, personally identifiable information should only be transferred between those with statutory duties for undertaking DoLS work The data obtained for Deprivation of Liberty work should be used only for that purpose

7.1 Transfering Personally Identifiable Information

Where information pertaining to deprivation of liberty is being transferred between the DoLS service and a managing authority that is a hospital setting, staff from both services must adhere to the guidance published in the following documents:

Safe Haven Policy for the Exchange of Patient Identifiable Information (NHS Northamptonshire)

Sharing Personally Identifiable Information: Northamptonshire Interagency Protocol (NHS Northamptonshire). NCC policy is currently being developed.



8 REALATED POLICES, PROCEDURES AND FORMS

Staff in all organisations undertaking any work related to the Deprivation of Liberty Safeguards on a daily basis will need to refer to the following documents, each of which have a different purpose and should be used in conjunction with each other:

The Deprivation of Liberty Safeguards Code of Practice – This document provides information on the requirements of the law

This Deprivation of Liberty Safeguards Interagency Policy and Procedures - This document provides information on how the safeguards are being implemented locally in Northamptonshire and the procedures that will need to be followed

The Deprivation of Liberty Safeguards Forms and Record Keeping – This document contains all the standard forms and letters issued by the Department of Health for the processes involved in the Safeguards. Staff will need to be aware of any additional requirements included in this document that relate to the completion/submission of these forms.

Interagency Safeguarding Adults Procedures

Mental Capacity Act 2005 ADASS Protocol for the Inter-Authority Management of Deprivation

of Liberty Safeguards Applications

Data Protection Act

Mental Health Act 1983 Hardcopies of this document are considered uncontrolled please refer to intranet for latest 38 version


Appendix 1

Deprivation of Liberty Letter 1

Letter to managing authority concerning unauthorised deprivation of liberty

Sender’s address Contact

telephone number Date Name and address of managing authority

Dear Sir/Madam

Re [name of person/resident]

I am writing to you about the above-named person, who is accommodated in your hospital/care home [delete as applicable].

I am the person’s [state relationship or interest in the matter, e.g. ‘child’, ‘friend’, ‘representative’, etc].

It appears to me that this person lacks capacity to consent to the arrangements made for their care or treatment and is subject to an unauthorised deprivation of liberty. I am therefore writing, in accordance with the provisions of the Mental Capacity Act 2005, to ask you to give an urgent deprivation of liberty authorisation and to request a standard authorisation from the supervisory body.

My reasons for believing that this person is subject to an unauthorised deprivation of liberty are that …. [briefly state reasons]

As I am sure you know, if you do not request a standard authorisation within a reasonable period, I may ask the supervisory body to decide whether or not there is an unauthorised deprivation of liberty.

Thank you for your consideration of this matter.

Yours faithfully

Signature

Name of sender in block capitals

Notes The use of this letter is not mandatory. However, any oral or written request should include the information in bold in the above letter. Hardcopies of this document are considered uncontrolled please refer to intranet for latest 39 version


Appendix 2

Deprivation of Liberty Letter 2

Letter to supervisory body concerning unauthorised deprivation of liberty

Sender’s address Contact

telephone number Date Name and address of supervisory body

Dear Sir/Madam

Re [name of person/resident]

I am writing to you about the above-named person who is accommodated in [Name and address of hospital or care home].

I am the person’s [state relationship or interest in the matter, e.g. ‘child’, ‘friend’, ‘representative’, etc]

On [enter date], I wrote to/spoke with the managing authority of the [name of hospital or care home]. I informed them that it appeared to me that this person lacked capacity to consent to the arrangements made for their care or treatment and was subject to an unauthorised deprivation of liberty. I asked them to give an urgent deprivation of liberty authorisation and to request a standard authorisation, in accordance with the provisions of the Mental Capacity Act 2005.

My reasons for believing that this person is subject to an unauthorised deprivation of liberty are that …. [briefly state reasons]

I understand that the managing authority has not requested a standard authorisation.

I am therefore writing to make a formal request that you now decide whether or not this person is subject to an unauthorised deprivation of liberty.

Thank you for your consideration of this matter. Yours

faithfully

Signature

Name of sender in block capitals

Notes The use of this letter is not mandatory. However, any oral or written request should include the information in bold in the above letter.


health and adult social services the deprivation of ......department: jane bowen;...

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