Deprivation of Liberty Safeguards Practice and Procedures Policy
Deprivation of Liberty Safeguards:
Practice and Procedures Policy
Version 1
Name of responsible (ratifying) committee Safeguarding Committee
Date ratified
Document Manager (job title)
Date issued
07/11/2013
Patient Safety Clinical Coordinator (Adult
Safeguarding)
20 th January 2014
Review date
Electronic location
Related Procedural Documents
Key Words (to aid with searching)
Version Tracking
January 2017
Clinical Policies
Mental Capacity Act Policy, Consent Policy,
Safeguarding Adults Policy, RCN Restraint Guidance,
Restraint Policy
Mental capacity act; capacity assessment; best interests; deprivation of liberty safeguards
Version Date Ratified Brief Summary of Changes Author
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CONTENTS
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
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QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.
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1. INTRODUCTION
The Mental Capacity Act Deprivation of Liberty Safeguards (DoLS) were introduced in April 2009.
These safeguards protect vulnerable adults who lack capacity to make certain decisions regarding their care, treatment or residence and are, or may, become deprived of their liberty within a hospital or care home. DoLS authorisation provides a legal framework and protection when a deprivation of liberty is considered to be unavoidable and in the persons best interests.
DoLS were introduced in response to the 2004 ‘Bournewood judgment’ in the European Court of
Human Rights (HL v UK (Application No: 45508/99)). This case was brought by carers of an autistic man who was kept at Bournewood Hospital against their wishes. The Court found that the circumstances by which HL was admitted to and kept in hospital breached the human right to liberty (Article 5(1) European Convention of Human Rights Deprivation of liberty) and also of Article
5(4), the right to have the lawfulness of detention reviewed by a court.
Use of the DoLS Authorisation can avoid similar breaches of human rights and provides protection for people:
Who lack the mental capacity specifically to consent to treatment and care in either a hospital or care home:
And
The care can only be provided in circumstances that amount to a deprivation of liberty and;
The care is in their best interests to protect them from harm; and
Detention under the Mental Health Act 1983 in not appropriate for the person at that time.
DoLS are underpinned by the five key principles of the Mental Capacity Act:
A presumption of capacity - every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless it is proved otherwise;
The right for individuals to be supported to make their own decisions - people must be given all appropriate help before anyone concludes that they cannot make their own decisions;
That individuals must retain the right to make what might be seen as eccentric or unwise decisions;
Best interests – anything done for or on behalf of people without capacity must be in their best interests; and
Least restrictive intervention – anything done for or on behalf of people without capacity should be the least restrictive of their basic rights and freedoms
2. PURPOSE
This policy outlines the legal framework around DoLS and gives guidance on the local policies, practice and procedures that should be followed by Portsmouth Hospitals NHS Trust staff when working with individuals who may lack mental capacity or are or may become deprived of their liberty.
All persons working in a professional or paid role with people who may lack mental capacity have a legal duty to have regard to the Mental Capacity Act Code of Practice. Staff should view this guidance as supplementary to the statutory Mental Capacity Act Code of Practice and the DoLS
Code of Practice.
Both Codes of Practice are available on the Safeguarding Adults departmental intranet site and also on the Department of Health website: www.dh.gov.uk
It is a requirement of our registration with the Care Quality Commission that they be notified of all applications for a DoLS authorisation and its outcome. It is vital that a copy of the DoLS application forms are sent to Trust Safeguarding Safeguarding.Adults@porthosp.nhs.uk as this provides the trigger for the CQC notification.
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3. SCOPE
All staff working within the Trust are likely to come into contact with vulnerable people who may lack the mental capacity to consent to care or treatment where it may be necessary to deprive that person of their liberty in their best interests, in order to protect them from harm.
DOLS authorisations can only be granted for persons aged 18 years and over. For all queries regarding mental capacity and consent to or refusal of treatment and care for those aged 16-18 years, please contact the consultant pediatrician on call or the Legal Department for advice (ext
6527 or via Hospital Duty Manager out of Hours).
Assessing mental capacity and making decisions for those unable to do so for themselves is an interdisciplinary and/or multidisciplinary issue. Therefore, this policy applies to all permanent, locum, agency and bank staff of Portsmouth Hospitals NHS Trust and the MDHU (Portsmouth), including doctors, nurses, allied health professionals, support staff, social care professionals and managers.
Whilst the policy outlines how the Trust will manage DoLS it does not replace the personal responsibilities of staff with regard to issues of professional accountability for governance.
In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety.
4. DEFINITIONS
Deprivation of Liberty Safeguard – a legal authorisation that allows a managing authority to deprive someone who lacks mental capacity of their liberty.
Mental capacity - Mental capacity is the ability of an individual to make decisions about specific aspects of their life.
Mental Incapacity - an inability to make a particular decision at a particular time due to “an impairment or disturbance in the functioning of their mind or brain”.
A person may be assessed as lacking capacity if they have any impairment of the brain or mind, and are unable to do one or more of the following four things:
Understand information given to them
Retain that information long enough to be able to make the decision
Weigh up the information available to make the decision
Communicate their decision
Managing Authority - the organisation responsible for the care home or hospital applying for the
DoLS authorisation i.e. Portsmouth Hospitals NHS Trust
Supervisory Body / Authority – the Local Authority which covers the persons normal place of residence. Local Authorities are responsible for considering a DoLS request, arranging the required assessments and agreeing or denying a DoLS authorisation.
5. DUTIES AND RESPONSIBILITIES
Chief Executive – To ensure that the Trust complies with relevant legal and statutory requirements related to the Deprivation of Liberty Safeguards.
All Consultants should have a working knowledge of the MCA Code of Practice and will act as decision makers and are responsible for ensuring their teams complete the relevant assessments and documentation. They will also provide guidance within their teams.
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All Managers - To be aware of Trust Policy and Guidelines and to ensure their Staff comply with the requirements of these documents.
The Learning and Development Department will facilitate the provision of e-learning opportunities for all staff groups at induction and in line with Essential Skills Policy.
Clinical Service Centre Management Teams will identify key clinicians to undertake additional training and ensure effective cascade of key information to staff groups.
Medical staff (ST3 and above) are responsible for completing both the urgent and standard authorisation forms and are designated signatories for the DoLS forms.
Duty Matrons and Hospital@Night can act as designated signatories if required out of hours.
Individual members of staff must ensure they follow this policy.
The Governance Department, once informed by Adult Safeguarding is responsible for all CQC
DoLS notifications.
Safeguarding Adult Lead Nurse is responsible for collation of DoLS data and reporting of any known instances of an unauthorised DoLS.
CSC Safeguarding Operational Leads will act as an information resource within their area and across the Trust, providing support and education as required.
6. PROCESS
6.1. Applying for a DoLS Authorisation
Decide if the current situation may equate to a deprivation of liberty.
A DoLS authorisation cannot be used in order to force treatment or care on a person who has the mental capacity to a make a decision about the proposed treatment, care and the manner and location in which it is to be provided.
DoLS only apply to people who lack the mental capacity to decide whether to remain in a hospital or care home for treatment and care. Whether a particular situation amounts to a deprivation of liberty and therefore needs to be authorised under the DoLS provisions is a legal question and is decided on the facts of the individual case. There is no one particular restriction of circumstance that is the defining factor and case law is constantly reviewing this.
The law draws a distinction between a ‘restriction of movement’ and a ‘deprivation of liberty’.
Restriction of movement does not need to be authorised under the DoLS provisions.
However the principles of the Mental Capacity Act 20005 apply to any restriction of movement. In particular, if it should be deemed necessary to do so in the persons best interest, it must be a proportionate response to the assessed risks and for as short a period as necessary. If the limitations or restrictions placed upon person may be considered mild or moderate in nature then continuing to accommodate the person in hospital, in their best interests can be lawful under the MCA.
When considering if a situation amounts to a deprivation of liberty the type, duration, proportionality, effects and manner of implementation of the measure in question needs to be considered. Professionals need to consider the guidance in this policy and the Codes of
Practice.
Factors to consider include:
Restraint is used, including sedation, to admit a person to an institution where that person is resisting admission.
The patient would be prevented from leaving hospital or care home if they attempted to do so.
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Professionals exercise complete control over the care and movements of a person for a significant period
A request by carers to discharge a patient to their care is refused by a hospital or care home.
Professionals exercising control over assessments, treatment, contacts and residence
The person is unable to maintain social contacts because of restrictions placed on visitors or movements by the hospital or care home.
The person loses autonomy because they are under continuous supervision and control.
Professionals should particularly take into account the wider context of these factors, the effect on the person in question and their views; the views of family and carers and the benefit that any restrictions are aimed to give. DoLS Decision Making Guidance has been developed and offers further information on the circumstances that could equate to a deprivation of liberty within the acute hospital setting (Available on Safeguarding Adult intranet site).
In the situation where the person to be admitted is already subject to a DoLS authorisation in a care home, then it is very likely that the Trust will need to apply for DoLS authorisation in order to effect admission. For elective cases this should be applied for in advance of the planned admission date and it is the admittin g clinicians’ responsibility to ensure this is completed.
6.2. Does the Mental Health Act 1983 apply?
When a person lacking mental capacity is in a hospital or care home, receiving treatment for a mental disorder and is or is likely to have their liberty deprived consideration should be given as to whether to use the provisions of the Mental Health Act rather than DoLS. If the person fits the criteria for a mental health section to be applied then that should be the chosen route.
A mental health section does not normally allow treatment of a physical problem or illness that is unrelated to their mental health condition. In these circumstance a DoLS may be required, but the law is complex so senior clinical and legal advice should be sought.
Factors that may indicate use of the Mental Health Act rather than DoLS include:
The patients lack of capacity to consent to treatment and care is fluctuating or temporary and the patient is not expected to consent when they regain capacity. This may be particularly relevant to patients having acute psychotic, manic or depressive episodes;
A degree of restraint needs to be used which is justified by the risk to other people but which is not permissible under the MCA because, exceptionally, it cannot be said to be proportionate to the risk to the patient personally; and
There is some other specific identifiable risk that the person or others might potentially suffer harm as a result. For example, if there is a risk that the person may need to be returned to the hospital or care home at some point in a manner that would not be authorised under DoLS.
6.3. When else can’t a DoLS be used?
The person is under 18 years of age;
The person has made a valid and applicable Advance Decision refusing a necessary element of treatment for which they were admitted to hospital (see MCA Policy)
The use of the safeguards would conflict with a decision of the persons attorney or
Deputy of the Court of Protection;
The patient lacks capacity to make decisions on some elements of the care and treatment they need, but has capacity to decide about a vital element and has already refused it or is likely to do so.
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6.4. Completing the DoLS application forms.
The application process is summarised in the Deprivation of Liberty Safeguards – applying for a DoLS authorisation (Safeguarding Adults intranet site)
There are two application forms, DoLS form 1- Urgent Authorisation and DoLS form 4 –
Request for a Standard Authorisation (Appendix 1 and 2)
Within the acute hospital, it is most common that a deprivation of liberty occurs as suddenly and unexpectedly e.g. an emergency admission situation or as a result of deterioration. In these circumstances, when the deprivation is already occurring and cannot be avoided, the
Trust as the managing authority must apply for an Urgent Authorisation by completing DoLS form 1. For all Urgent Authorisations a Standard Authorisation (DOLS form 4) must also be completed. Once DoLS forms are completed and signed it is legal to prevent the person leaving hospital.
An Urgent Authorisation lasts for only 7 days, with day 1 being the day of application.
For elective admissions where it is believed a deprivation of liberty will or is likely to occur on admission to hospital then a Standard Authorisation (DoLS form 4) can be applied for in advance. Standard Authorisations can be granted for differing lengths of time, dependant on the individual circumstances.
The forms can be completed electronically or by hand. Unless the signatory has an
‘electronic signature’ then forms will need to be printed and signed by hand.
6.5. Who completes the DoLS forms?
It is the responsibility of the clinical team caring for the patient to apply for a DoLS authorisation. The care team should not be referring to other services for this. Trust signatories for DoLS forms are:
Medical staff (ST3 grade and above)
Duty Matron and Hospital@Night can also act as designated signatories if required out of hours
6.6. What happens to the forms once completed?
Both DoLS form 1 and 4 need to be sent to the relevant DoLS office. The office should be telephoned and details will be given how to affect this.
Portsmouth DoLS Office: 023 9268 8666 – for residents in postcodes PO1-PO6
Southampton DoLS Office: 023 8083 4776 – for residents of Southampton City
Hampshire DoLS Office: 01962 845213 – all other Hampshire postcodes
Visitors to the area: seek assistance from Portsmouth Office
Faxes must be sent using Safehaven procedures.
DoLS forms must not be sent out of the Trust from a port.hosp.nhs email address as these are not secure for patient identifiable data. An nhs.net email account can be used to send forms to a gcxs.gov.uk secure email address (DoLS office will supply email address if required). N.B. an email address ending in .gov.uk is not a secure email for patient identifiable data.
Do not put the forms in the post.
The CSC management team should also be informed that a DoLS application has been made.
6.7. Who else needs a copy of the forms?
The original forms should be filed in the patient’s medical record.
The patient must be given a copy of the DoLS forms, and they must have it explained to them. It may not be appropriate to do this at the time of the application, however they
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must be given prior to discharge and staff should document in the medical notes that they have done so.
Trust Safeguarding Office. Email electronic copy of the forms (or scan and email hand written forms) and send to Safeguarding. Adults –group mailbox (on the global email address list). It is a requirement of our registration with the Care Quality Commission
(CQC) that we inform them of all DoLS applications and outcomes. This is managed centrally and is triggered by receipt of the forms in the Trust Adult Safeguarding Office who informs the Governance Department.
6.8. What happens next?
The Supervisory Body makes arrangements for the required assessments to be undertaken.
Clinical staff should support this assessment process but do not undertake the assessments themselves. Access to the medical records will be required by the assessors.
The assessments will be undertaken by a Best Interest Assessor and will normally be within the 7-day period of the Urgent Authorisation. If for any reason the assessment process will take longer, then the Supervisory Body will advise the Trust and an Urgent Extension will be required. The clinical team caring for the patient will be given the required form and responsible for applying for any extension.
On completion of the assessment process, the Supervisory Body will either grant or deny the
DoLS authorisation. The DoLS Office will send the outcome forms to the ward and these forms must be filed in the medical record. A copy forms will also be sent to the Trust
Safeguarding Office.
6.8.1. A Standard DOLS Authorisation is granted
The care plan should include ongoing review of the treatment plan and the need for a continuing DoLS order.
A patient held under DoLS may be kept in Portsmouth Hospital for the proposed treatment and care until:
The course of treatment is completed and the patient now longer needs to remain in hospital and can return to their normal place of residence
Arrangements have been made for on-going care to continue in another location e.g. care home or specialist hospital
The DoLS is judged to no longer be required. The clinical team must inform the
DoLS Office and Trust Adult Safeguarding office.
The DoLS expires. If continuing treatment and care is required and this would mean that the person continues to be deprived of their liberty then an extension to the Standard Authorisation will be required. DoLS form 4 should be completed again and sent off to the DoLS Office as above.
Or
The persons mental capacity returns and they are able to make their own decision about continuing with treatment and care . In this circumstance the
DoLS is no longer valid, even if the person decides to leave hospital or refuses to comply with treatment and care against medical advice.
A DoLS Authorisation is specific to the Managing Authority that applied for the authorisation. Therefore it is permissible to transfer a patient who is held under a
DoLS to another ward within the same location and belonging to the same provider, however any movement should be undertaken in the persons best interest. It would be acceptable to move someone out of intensive care who no longer needs this level of care, from MAU to the relevant specialty ward or even to another ward for provision of a side room if this was deemed essential, however they should not be outlied.
In the event of the death a person who is subject to a DoLS Authorisation the Coroner must be informed, as this may be considered a death in custody.
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6.8.2. A Standard DoLS Authorisation is refused
If the authorisation is refused or cannot be granted because the qualifying criteria have not been met, then the treatment and care plan should be reviewed again to see if less restrictive alternatives can be put in place. In this way the patient may consent to remain in hospital and undergo treatment.
Alternatively consideration could be given to whether a different treatment option or care location can be arranged which would be acceptable to the patient e.g. change of antibiotics to allow administration to take place in the community, a less invasive or aggressive therapy, transfer to a facility closer to family.
If the patient refuses all options presented then clinical staff should take steps to reduce the risks of discharge e.g. TTO’s, liaison with GP, social care and other community services, informing next of kin etc.
However if there are major concerns about the patients safety should they leave hospital and fail to comply with what is deemed essential treatment and care, senior clinical and legal advice should be sought. In some cases application to the Court of
Protection may be required. Requests for legal advice should be made through the
Trust Legal Services office ext. 6527 or via Hospital Duty Managers out of hours.
6.9. Unauthorised Deprivations of Liberty
If staff are concerned that an unauthorised deprivation of liberty has occurred or is likely to occur within the Trust then a senior clinician should review the situation as a matter of urgency and steps taken to avoid any further, or prevent a potential future deprivation of liberty. In order to achieve this it may be necessary to apply an Urgent Authorisation or review the steps outlined in 6.82.
Any unauthorised deprivation of liberty must be reported as an adverse incident and graded as Red. It must also be reported immediately to the CSC Management team or the Hospital
Duty Manager if out of hours. The Trust Adult Safeguarding office must also be notified.
All unlawful DoLS will be reported to the Trust Board, the CQC and external Safeguarding partners. The Trust Adult Safeguarding office will coordinate these notifications with the
Governance Department and the relevant CSC Management Team.
If there is a concern that a deprivation of liberty may be occurring in non-Trust accommodation then staff should discuss the concerns with their line manager as soon as possible and the also the Managing Authority of the care home of hospital. The Supervisory
Authority should also be notified.
7. TRAINING REQUIREMENTS
All clinical staff working directly with patients should have a basic understanding of DoLS. An introduction will be included in Adult Safeguarding training on induction.
All designated Trust signatories for DoLS authorisations must undertake additional training. A variety of training is available via classroom, e-learning and MOT and is delivered by both Adult
Safeguarding Leads and our external partners in Hampshire and Portsmouth Social Care.
Each line manager has the responsibility to ensure that their staffs are afforded the opportunity to undertake all essential skill training. In the event of failure to undertake the training the Essential
Skills Framework policy will be invoked with regard failure to comply with Trust policy
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8. REFERENCES AND ASSOCIATED DOCUMENTATION
Mental Capacity Act 2005
– found at: http://www.opsi.gov.uk/acts/acts2005/ukpga_20050009_en_1
Deprivation of Liberty Safeguards: A guide for hospitals and care homes. DH. 2009
What are the Mental Capacity Act 2005 Deprivation of Liberty Safeguards. DH. 2008
Mental Health Act 2007 – found at: http://www.legislation.gov.uk/ukpga/2007/12/contents
The Mental Capacity Act 2005 Deprivation of Liberty Safeguards and you. Easy Read. DH. 2009
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly.
All policies must include this standard equality impact statement. However, when sending for ratification and publication, this must be accompanied by the full equality screening assessment tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy Documentation
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
10. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS
Monitoring of compliance with this guidance will be undertaken at two levels: one at a corporate level related to corporate function and response and at a divisional level related to compliance at practice level. Results will be reported to the Safeguarding Committee.
Key Performance Indicators
Indicator
75% of all clinical staff based on inpatient areas will have completed training in DoLS
75% of clinical staff respond correctly to
DoLS questions within Safeguarding
Audit
Measure
Report from Learning
& Development
Department
Audit ( sample of 30 staff per CSC)
Frequency
Annually
Responsible
Officer
Lead Nurse
Annually Safeguarding
Operational
Leads
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Appendix 1: Urgent Authorisation
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Appendix 2: Request for a standard authorisation
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