The Deprivation of Liberty Safeguards
Interagency Policy and Procedures
Leicestershire, Leicester & Rutland
Version Control: 0.3
Date of Creation: March 2008
Last Modified: April 24th 2009
EIA Assessment: May 2009
Document Author: Stephen Vickers
Position: DoLS Team Manager/DoLS Implementation Manager
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Table of Contents
1.
Introduction………………………………………………………………………..…Page 3
2.
Rationale and Purpose………………………………………………………….....Page 3
3.
Definitions……………………………………………………………………….......Page 4
4.
Scope……………………………………………………………………………... …Page 6
5.
Policy Statement……………………………………………………………………Page 7
6.
Procedures and Guidance……………………………………………………. …Page 12
6.2
The Deprivation of Liberty Safeguards Service………………………………………………...Page
14
6.3
Applying for a Standard Authorisation…………………………………………………………..Page
15
6.4
Receiving a request for assessment for Standard Authorisation…………………………..Page
16
6.5
Instructing an IMCA………………………………………………………………………………....Page
18
6.6
Assessment process for a Standard Authorisation…………………………………………...Page
18
6.7
Process for Urgent Authorisations……………………………………………………………….Page
24
6.8
Assessment Outcomes – Granting or Declining an Authorisation…………………….. ….Page
28
7.
Conveying……………………………………………………………………………Page 34
8.
Reviews…………………………………………………………………………... ....Page 35
9.
Terminating a Standard Authorisation……………………………………… …Page 37
10.
Appeals and Complaints………………………………………………………. …Page 38
11.
Court of Protection…………………………………………………………………Page 39
12.
Information Governance………………………………………………………. …Page 39
13.
Policy Review……………………………………………………………………….Page 40
14.
Frequently Asked Questions……………………………………………………..Page 40
15.
Acknowledgements………………………………………………………………..Page 44
16.
Appendices………………………………………………………………………….Page 45
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1.
Introduction
1.1
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.
1.2
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.
1.3
The Safeguards come into force in April 2009 and from this point onwards a
Managing Authority must seek authorisation from a Supervisory Body in order to
lawfully deprive a person of their liberty. Where a request for a Standard Authorisation
for deprivation of liberty is made, the Supervisory Body is responsible for conducting a
number of assessments to determine whether the authorisation is to be granted.
Where any assessment is negative, the authorisation cannot be granted.
2.
Rational and Purpose
2.1
This document provides a local framework for the implementation of the
Deprivation of Liberty Safeguards within the Leicester City, Leicestershire County and
Rutland County areas. It 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 the Managing Authorities and the
Supervisory Bodies.
2.2
There are a total of five Supervisory Bodies within the Leicester City, Leicestershire
County and Rutland County areas. They will deliver the duties required by the
Deprivation of Liberty Safeguards through a single, jointly funded pathway. The
combined service will be hosted and managed by Leicestershire County Council.
2.3
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.
2.4
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 the Leicester City, Leicestershire County and Rutland County areas. The
document aims to highlight the processes involved with requesting, assessing,
granting and reviewing Standard Authorisations for deprivation of liberty from the
perspective of both the Managing Authorities applying for the authorisation, and the
Supervisory Body who assess and grant the authorisation.
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3.
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 (PCT), local authority, Welsh Ministers or a
local health board that is responsible for considering a deprivation of liberty request,
commissioning the assessments and, where all the assessments agree, authorising
deprivation of liberty. Within the Leicester City, Leicestershire County and Rutland
County areas, the five supervisory bodies are NHS Leicester City (NHSLC), Leicester
City Council (LeicCC), NHS Leicestershire and Rutland (NHSL&R), Leicestershire
County Council (LCC) and Rutland County Council (RCC).
The rules for deciding which PCT or local authority is the supervisory body vary
depending on whether one is dealing with a hospital or a care home.
In the case of hospital patients within the area, the PCT (NHSLC or NHSL&R)
responsible for commissioning the patient’s care or treatment is the supervisory body.
In the case of care homes, the supervisory body is the local authority (LeicCC, LCC or
RCC) for the area in which the person ordinarily resides. If the person has no ordinary
place of residence (they are of no fixed abode) then the supervisory body is the local
authority for the area in which the care home is situated.
3.3
DoLS Team - The DoLS Team is part of an integrated service hosted and managed
by LCC. The DoLS Team will undertake certain delegated functions associated with
deprivation of liberty on behalf of the Supervisory Body, including responding to
requests, conducting assessments, recommending timescales and conditions for the
authorisations and conducting reviews.
Importantly, the Supervisory Body maintain overall responsibility for granting
authorisations.
3.4
Signatory - The signatory is the relevant representative from the Supervisory Body
who has overall responsibility for granting the Standard Authorisation, attaching any
conditions recommended by the BIA during the assessment process and also setting
the period for which the authorisation will be in force.
3.5
Deprivation of Liberty - Deprivation of Liberty is a term used in the European Court
of Human Rights about circumstances when a person’s freedom is taken away. A
distinction is drawn between the deprivation of liberty of an individual (which is
unlawful unless authorised) and restrictions on the liberty of movement of an
individual. This distinction is one of degree and intensity, not nature or substance.
Determining whether deprivation of liberty is taking place should always be situation
specific for the individual concerned and should take into account factors such as the
type, duration, effects and manner of implementation of the care or treatment in
question. Chapter 2 of the Code of Practice contains guidance on where restriction
and restraint may become deprivation if liberty.
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3.6
Restraint - The use or threat of force to help do an act which the person resists, or
the restriction of the person’s liberty of movement, whether or not they resist.
Restraint can include chemical, physical, environmental, electronic and medical.
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.
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 under exceptional circumstances 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 one of the three local authorities 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
Best Interest Assessor - BIA – This refers to the assessor responsible for
conducting a range of assessments to ascertain whether an authorisation for
deprivation of liberty will be granted (see section 6.4 below for the different
assessments that can be conducted by the BIA). The best interest assessors are
appointed by the Supervisory Body and work within (or on behalf of) the DoLS Team.
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
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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.
4.
Scope
4.1
This policy applies to the following organisations, services and staff:

NHS Leicester City and NHS Leicestershire and Rutland (Supervisory
Bodies), including the interagency DoLS service and associated
directorates such as:


4.2
Commissioning directorates of Strategy and Systems; Quality
Standards and Learning; Corporate Services; IM&T; Public
Health and Medical.
PCT Provider services within localities and Continuing Health
Care.

Leicester City Council, Leicestershire County Council and Rutland
County Council (Supervisory Bodies) including the interagency DoLS
service and other relevant departments such as Safeguarding Adults;
Commissioning and Contracts; Care Management.

The Managing Authorities: All local authority, NHS, independent and
voluntary sector hospitals and registered care homes within the
Leicester City, Leicestershire County and Rutland County areas.

Managing Authorities in care homes and hospitals outside of the area
for whom the Leicester City, Leicestershire County and Rutland County
Supervisory Bodies are responsible.

The Relevant Person: Anybody being treated or cared for in a local
authority, NHS, independent or voluntary sector hospital or registered
care home within the Leicester City, Leicestershire County and Rutland
County areas, irrespective of whether they are publicly or privately
funded.

The IMCA Service within the Leicester City, Leicestershire County and
Rutland County areas

Any DoLS Paid Personal Representative services within the Leicester
City, Leicestershire County and Rutland County areas
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
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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
1983
4.3
This 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 NHS Leicester City, NHS Leicestershire and Rutland, Leicester City Council,
Leicestershire County Council, Rutland 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.
4.4
This 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.
4.5
Staff in all organisations undertaking any work related to the Deprivation of
Liberty Safeguards on a daily basis will need to refer to the following 3 documents,
each of which have a different purpose and should be used in conjunction with each
other:



The Deprivation of Liberty Safeguards Code of Practice - This
document provides information on the requirements of the law
This Deprivation of Liberty Safeguards Interagency Policy and
Procedures - This document provides information on how the
safeguards are being implemented locally in the Leicester City,
Leicestershire County and Rutland County areas 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.
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.
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Staff at all levels will work collaboratively with colleagues across organisations, to
ensure efficient and consistent working practices, to ensure timely and effective
communication and information sharing and to maximise efficiency of resources by
avoiding duplication.
Staff will adhere both to the principles of the Mental Capacity Act 2005 and the
Deprivation of Liberty Safeguards 2008 at all times and refer to both Acts and their
Codes of Practice whenever capacity, best interest and deprivation of liberty issues
arise.
Every effort will be made by those with a duty of care towards an individual to prevent
deprivation of liberty. This includes both commissioners and providers of care.
Staff will work in accordance with the principles of the Data Protection Act and in
accordance with the information governance guidance included in section 12 of this
document, sharing and recording only that data which is necessary.
Staff will seek to engage anyone involved in caring for a person, anyone named by
them as a person to consult and anyone with an interest in the person’s welfare, and
ensure they are consulted in decision-making.
Every effort should be made to resolve disputes surrounding a decision to deprive a
person of their liberty locally and informally. Both the Managing Authority and
Supervisory Body should be willing to engage in constructive discussion.
Those involved with the relevant person’s care planning and delivery will maintain
responsibility for this throughout the assessment process. The DoLS assessment
process is undertaken where necessary in addition to the individuals care planning
and delivery.
All organisations and services involved with deprivation of liberty should seek to
develop good practice by monitoring and reviewing their processes as part of the
organisation’s governance structure.
5.2
Key responsibilities of NHS Leicester City, NHS Leicestershire and Rutland,
Leicester City Council, Leicestershire County Council, Rutland County Council
in their role as Supervisory Body:
In the Leicester City, Leicestershire County and Rutland County areas, some of the
statutory functions of the Supervisory Body’s are discharged through a partnership
arrangement. The partnership arrangement will provide a service to meet some of the
requirements of the Deprivation of Liberty Safeguards.
The statutory duties of the Supervisory Body’s can not be delegated, however,
s o m e functions and duties may be “sub-contracted” where it is clear that the agent
is acting on the Supervisory Body’s behalf. Within this agreement the Deprivation of
Liberty Safeguards Team will be acting on behalf of the Supervisory Bodies in
arranging and managing the assessment and review processes required by the
MCA DoLS.
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The responsibility for granting an authorisation, setting the period of authorisation and
attaching any conditions to the authorisation cannot be delegated under this
arrangement and will therefore remain the responsibility of the relevant Supervisory
Body, not the DoLS Service.
5.3
The key responsibilities of the Supervisory Body are:
To co-ordinate a dedicated interagency Deprivation of Liberty Safeguards Service to
undertake the work related to deprivation of liberty.
To ensure there is a clear referral pathway for all Managing Authorities.
To recruit assessors that have the necessary skills, qualifications and experience as
outlined in the Code of Practice.
To ensure there are sufficient numbers of assessors to undertake the volume of
assessments required.
To ensure all staff working as assessors or in any capacity within the DoLS Service
receive adequate training to perform their role, including training in equality and
diversity issues.
To coordinate and deliver training to those services with statutory responsibilities for
the safeguards and advise on integrating the requirements across other relevant
service provision.
To ensure consistency and equality of access to, and outcomes from, Deprivation of
Liberty Safeguards services.
To have overall responsibility for granting or refusing authorisations for deprivation of
liberty and to be responsible for signing authorisations.
When giving authorisation for deprivation of liberty, to specify the duration of the
deprivation of liberty, which cannot exceed 12 months and should be for the shortest
possible practicable time.
To attach appropriate conditions to the authorisation and make recommendations
based on the best interests of the Relevant Person.
To make this document available to all local authority and independent care homes,
hospitals and relevant staff from the Supervisory Body and to ensure information
pertaining to the procedures and processes contained within this document is
communicated in a timely and effective manner.
To record management information and use it to measure the effectiveness of the
process outlined within this document and to assess the nature of the authorisations
both granted and refused in light of the local population.
To use management information and reviews to develop good practice and
communicate this information to relevant departments, such as those involved with
commissioning care and support services.
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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.
5.4
The key responsibilities of the DoLS Team are:
To make available to Managing Authorities the 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 receive applications from Managing Authorities for extensions of urgent
authorisations
To appoint assessors, IMCA’s (if required) on behalf of the supervisory body.
To recommend the relevant persons representative or paid personal representative to
the supervisory body.
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.
To provide phone support to managing authorities, supervisory bodies and the wider
public.
5.5
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.
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To adapt care planning processes to ensure consideration is given to whether a
person has the capacity to consent to the services which are to be provided and
whether their actions are likely to result in a deprivation of liberty.
To ensure clear and robust procedures are in place for staff to offer guidance and
clarity on when a request for a Standard Authorisation would be required, and the
procedures that should be followed in order to make an application to the Supervisory
Body. This requires clear policy and guidance relating to the use of restraint and
restrictive practices.
To ensure that no person is deprived of their liberty except where i) an Urgent
Authorisation is in place, ii) a Standard Authorisation is in place or iii) their liberty has
been deprived through other legal means e.g. under the Mental Health Act 1983 or an
Order from the Court of Protection.
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 (always via the DoLS
Team) in advance of the deprivation of liberty, except in urgent circumstances where
an Urgent Authorisation is already in place, in which case a standard authorisation
must be obtained from the Supervisory Body within seven calendar days of the start
of the deprivation of liberty.
To comply with any conditions attached to the authorisation as imposed by the
Supervisory Body.
To ensure that applications for authorisation are not made as standard for all
admissions to hospitals and care homes simply because the relevant person lacks the
capacity to decide whether to be admitted, or where lower levels of restriction or
restraint are used that are permissible within the meaning of section 5 & 6 of the
Mental Capacity Act 2005. The referral process should be used appropriately.
To ensure that the relevant person and their representative understands the
authorisation process and the effects of an authorisation once it is granted and that
they understand their rights and have knowledge of the complaints procedures.
To make alternative arrangements for care where an authorisation is refused and to
undertake urgent action to prevent unlawful deprivation of liberty.
To allow the BIA and any other assessors to visit the care home or hospital ward and
at anytime during the assessments and review process.
To accommodate visits from the relevant person’s representative, recording details of
visits and informing the Supervisory Body via the DoLS Team if the representative is
not maintaining appropriate contact.
To maintain records and ensure that all relevant staff are made aware of whether an
authorisation is granted or refused.
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To monitor and review circumstances around any authorisation for DoLS for
individuals within their care.
To provide on request any documents requested by the BIA or other assessors.
When Managing Authorities grant an urgent authorisation they must on the day the
urgent authorisation is granted fax form1 and form 4 to the DoLS team. Any delay in
sending these forms will be reported to the Care Quality Commissioner.
6.
Procedures and Guidance
6.1
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 Team or the Supervisory Body
and there are a number of key timescales that all staff need to be aware of and
adhere to. For clarity, the summary box below highlights these key timescales. Staff
may also find it useful to refer to the Process Flowcharts included in appendices 3 - 7
Standard Authorisations (see section 6.3) – 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 Team will acknowledge receipt of a request within 24 hours (or the next
working day if the form is received on a Friday, weekend or bank holiday)
The DoLS Team will inform the Managing Authority, in writing, that it is pursuing the
request and of it’s intended date for the BIA to commence assessments within 48
hours of the date of receipt of the original request (or within 48 hours of the next
working day if the request is received on a Friday, weekend or bank holiday).
The DoLS Team will appoint an IMCA on behalf of the Supervisory Body if needed
within 48 hours of the date of writing to the Managing Authority to confirm it is
pursuing the request.
The DoLS Team will have 21 days in total from the date of receipt of the original
request in which to complete all assessments and respond to the Managing Authority
with the supervisory bodies decision.
From the date that all stage 1 assessments are concluded by the BIA, the Mental
Health Assessor will have 96 hours in which to complete the Mental Health
Assessment at stage 2.
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Urgent Authorisations (see section 6.7) – 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.
This form must be sent to the DoLS team on the first day of the urgent
authorisation.
The Managing Authority must request a Standard Authorisation at the same time as
issuing itself an Urgent Authorisation.
The DoLS Team will inform the Managing Authority, in writing, of its intended date for
the BIA to commence assessments within 1 working day of the date of receipt of the
original request.
The DoLS Team must complete all assessments and respond to the Managing
Authority with a decision within the period of the Urgent Authorisation. The
Mental Health Assessment must be complete within 48 hours of the end of Stage 1.
The Supervisory Body can extend the Urgent Authorisation for a maximum of a
further 7 days (in exceptional circumstances) at the request of the Managing
Authority.
Third Party Requests (see section 6.7.14)
Where a Third Party requests that the Managing Authority applies for an
authorisation, the Managing Authority must respond to the Third Party as soon as
possible but within 24 hours.
The DoLS Team will have 7 days from the date that the Third 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
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If authorisation for deprivation of liberty is not granted because one or more of the
requirements are not met, but the BIA decides deprivation of liberty is occurring, the
Managing Authority will be informed immediately. The DoLS Team Manager will
inform the Supervisory Body who will need to arrange for a planning meeting to take
place within 48 hours of notifying the Managing Authority of its decision.
Within 7 days of the planning meeting taking place, an appropriate solution must
have been effected and the care plan must have been amended to ensure an
unlawful deprivation of liberty does not continue.
Any failure to meet the timeframes as outlined above will be reported by the
DoLS Team to the relevant Supervisory Body via their incident reporting
procedures. Each Supervisory Body will determine the necessary action.
6.2
The Deprivation of Liberty Safeguards Service:
NHS Leicester City, Leicester City Council, Leicestershire and Rutland NHS,
Leicestershire County Council and Rutland County Council have developed an
integrated service model for the implementation of the Deprivation of Liberty
Safeguards and have appointed a specialist DoLS Service to respond to requests for
Standard Authorisations from managing authorities.
The DoLS Team will be hosted and managed within the Older Persons Services of the
Leicestershire County Council.
The contact details for the DoLS Service are as follows:
DoLS Service
Eastern Annex,
County Hall
Leicestershire County Council
Glenfield
Leicestershire
LE3 8RL
Telephone: 0116 305 7853
Safe Haven Fax: 0116 305 5555
Email: DolsTeam@leics.gov.uk
The core team consists of the following roles:



1 x Team Manager.
3 x Best Interest Assessors
1 ½ x Administrators

A number of “floating” Best Interest Assessors will be contracted into the
team as they are needed.
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
Paid Personal Representatives, IMCAs and Mental Health Assessors will
be available to the DoLS Team as required
6.3
Applying for a Standard Authorisation (Procedure for the Managing Authority)
6.3.1
Managing Authorities will need to ensure they have workable internal procedures in
place to identify if authorisation for deprivation of liberty is required, or if it is
necessary in exceptional circumstances to issue an Urgent Authorisation (see section
6.7 below). Procedures should clearly identify who is responsible within the Managing
Authority for taking action any necessary action.
Managing Authorities should seek advice if necessary from the DoLS Team.
6.3.2
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.
6.3.3 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 Supervisory Body via the DoLS Team 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.
6.3.4 Where it is decided that an authorisation is required, the appropriate member of staff
identified in the internal procedures should complete the standard form Form 4:
Managing Authority request for a Standard Authorisation. This can be done up to 28
days in advance of the deprivation of liberty occurring.
6.3.5 Managing Authorities must send their request to the DoLS Team via the safe haven fax
number (see 6.2 for details).
6.3.6 At the same time of sending the request, the Managing Authority must contact the DoLS
Team via phone or email to inform them that a request is being sent (this procedure
should be followed even during out of hours).
6.3.7 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.
6.3.8 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
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date of expiry.
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
6.3.9 Once the request form has been sent to the DoLS Team, 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.
6.3.10 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 Third Party request, i.e.
where they have not been able to satisfy the Third Party that no deprivation of liberty
is occurring, they must submit an application to Supervisory Body via the DoLS Team
following the procedures outlined above. Where the Managing Authority has failed to
make an application, the DoLS Team will accept a referral from the Third Party on
behalf of the Supervisory Body. In such circumstances, the Care Quality Commission
and the appropriate commissioning authority (if involved) will be notified.
6.4
Receiving a request for assessment for Standard Authorisation (Procedure for
the DoLS Team)
6.4.1
Upon receipt of a request for a Standard Authorisation, the DoLS Team Administrative
Officer and duty BIA will jointly consider whether the application is appropriate,
complete or whether any additional information is required from the Managing
Authority.
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6.4.2
If the request form (Form 4) is incomplete/invalid, the DoLS Team Administrative
Officer and duty BIA 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.
6.4.3
If the DoLS Team Administrative Officer and duty BIA 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.
6.4.4
If the request form is both complete and valid, the DoLS Team Administrative Officer
will:





Generate a full DoLS file
Complete the DoLS Data Exchange form (appendix 8)
Contact the relevant Supervisory Body and arrange “sign off” date and time
Arrange with the Supervisory Body secure receipt of the DoLS Data
Exchange form (via safe haven fax)
Pass DoLS file to the DoLS team manager (or nominated deputy) for case
allocation.
6.4.5
The DoLS Team Administrative Officer will acknowledge receipt of the referral form
within 24 hours (or the next working day if the form is received on a Friday, weekend
or bank holiday) by sending a secure fax to the Managing Authority.
6.4.6
The DoLS Team Manager (or nominated deputy) will consider the case and allocate
to an appropriate BIA within 48 hrs of receiving the referral avoiding any conflict of
interest that might bring into question the objectivity of the assessment (a standard
form has been developed to record this process (appendix 9). The DoLS Team
Manager and BIA will arrange a date for the completed file to be handed over
(considering all necessary statutory deadlines).
6.4.7
Within 48 hrs of the case being allocated, the BIA will contact the Managing Authority
and inform them of the date they intend to commence the assessment process. The
BIA will be responsible for coordinating the assessment process.
6.4.8
From the date of receipt of the application, the DoLS Team will have 21 days in total
in which to complete all assessments and respond to the Managing Authority’s
request.
6.4.9
The Leicester, Leicestershire and Rutland DoLS Team have divided the assessment
process into two stages - stage 1 for “preliminary” assessments and stage 2 for “full”
assessments. The assessments at Stage 1 are conducted by a Best Interest
Assessor. Once all stage 1 assessments are complete and this is recorded on the
DoLS assessment checklist (appendix 1), the mental health assessors will have 96
hours in which to complete the mental health assessment at stage 2 of the process.
The Best Interest Assessor will complete assessment requirements within stage 2 of
the assessment process (see section 6.6 below for full details of the assessment
process).
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6.5
Instructing an IMCA
6.5.1
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 Team on behalf of the Supervisory Body will need to instruct an Independent
Mental Capacity Advocate (IMCA). In doing so, the DoLS Team will take account of
the relevant person’s cultural background, including their race, ethnicity, religious
beliefs and sexuality. The date the IMCA was instructed should be recorded on the
DoLS assessment checklist by the DoLS Administrative Officer. 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.
6.5.2
The Supervisory Bodies with responsibility for the contract with the IMCA Service will
need to ensure that the IMCA Service is pro-active in its recruitment of advocates
from a diverse range of cultural backgrounds.
6.5.3
Where a request for an authorisation is received for a care home placement that is
being funded by Continuing Health Care (CHC), the DoLS Team should inform the
head of Continuing Health Care or their deputy, prior to the assessments being
conducted, that a request for an authorisation has been made and that the BIA will be
commencing the assessment process.
6.6
Assessment process for a Standard Authorisation (Procedure for the DoLS
Team)
6.6.1
The DoLS Team Manager is responsible for appointing a BIA to commence the
assessment process. The choice of BIA will be determined by:
i) ensuring compliance with conflict regulations
ii) 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
iii) expedient use of resources
Forms are available for the DoLS Team Manager to use when appointing assessors.
These are checklists to ensure assessors meet all the regulations and that there are
no conflicts of interest. The forms include a space for any additional reason for
appointing a particular assessor to a particular case. These forms are included in
appendix 9 and 10
6.6.2
The DoLS Team will undertake the assessment process in 2 stages:

Stage 1: Preliminary stage

Stage 2: Full assessments
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6.6.3
The DoLS Team Administrative Officer is responsible for providing the BIA with
information on how to access 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 Team Administrative
Officer should also make provision to ensure information is available in other
languages and formats as and when required.
6.6.4
Upon request from the BIA, the Managing Authority must provide any relevant
assessments or care plans and enable access to and copies of any records held that
assessors or IMCAs may consider relevant.
6.6.5
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.
6.6.6
Stage 1: Preliminary Assessments
At this stage the BIA commences the initial assessments. The purpose of these
assessments is to determine whether the BIA and Mental Health Assessor will need
to undertake the full Best Interests Assessment and full Mental Health Assessment at
Stage 2. Where any requirement is not met at this stage, the assessment process
ceases immediately.
Throughout both stages of assessment, the assessors will need to use the standard
forms issued by the Department of Health. The forms for the assessments are
numbered 5 to 11 (see the list of all DoH forms and letters included in appendix 1).
Staff will need to be aware of any additional information/requirements included in the
document Deprivation of Liberty Safeguards Forms and Record Keeping.
Confirm Age Assessment
This assessment is to establish if the
relevant person is aged 18 or over.
The BIA will undertake this assessment.
Identify if liberty is being deprived
This establishes whether deprivation of
liberty is occurring or if it is going to occur.
The BIA will undertake this assessment.
Confirm No Refusals Assessment
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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
17/02/2016
Refuse Treatment (ADRT) or a refusal by
an attorney or deputy.
The BIA will undertake this assessment.
Preliminary Mental Capacity
Assessment
This is a preliminary assessment of the
relevant person’s mental capacity to
consent to the arrangements for their
care i.e. the levels of restriction or
restraint used. Unless it is evident that
the person has capacity, (in which case
all assessments end immediately), this
assessment may be concluded at stage 2
by the mental health assessor or BIA.
The BIA will undertake this assessment.
Preliminary Eligibility Assessment
This is a preliminary assessment that
establishes whether the relevant person is
subject to a requirement under the Mental
Health Act 1983 that may conflict with an
authorisation under DoLS or whether their
care should be provided under the Mental
Health Act.
This preliminary assessment will be
undertaken by the BIA. Where the BIA is
also an AMHP this assessment can be
completed at stage 1, otherwise the
Mental Health Assessor will need to
undertake the full assessment at stage 2.
If it is clear that this requirement is not
met, all assessments end. Where further
consideration is required, this
assessment will be concluded in stage 2.
If any requirement is not met at this stage, the assessment process is
immediately ceased. The DoLS Team Administrative Officer will immediately
inform the Supervisory and seek to complete the “sign off” process as soon as
is practicable. The Managing Authority will then be informed by the DoLS Team
Administrative Officer, in writing of the decision that the Standard
Authorisation is refused and the reasons for this.
The Supervisory Body will need to complete Form 13 – Supervisory Body
declines a request for a Standard Authorisation (See section 6.8 below for
procedures related to the outcomes of the assessment)
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All assessments should be recorded on the standard forms issued by the Department
of Health and the DoLS Team Assessment Checklist should be updated. Where
preliminary assessments indicate a need for stage 2, the Mental Health Assessor will
be notified and time of request noted. The mental health assessors have 96 hours in
which to complete the mental health assessment at stage 2.
At this point, the BIA can be changed if the preliminary stage 1 assessments highlight
any issues that a different BIA with specialist skills may be better suited to assessing.
For instance, different assessors may have experience of working with particular
service user groups, experience of working with people from particular cultural
backgrounds or have specific communication skills which would be of benefit to
assessment process.
Where a change of BIA occurs, it is essential that there is good communication
between the BIAs. Any reasons for changing the BIA must be recorded.
6.6.7
Stage 2: Full assessments
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
The BIA will be responsible for appointing
the Mental Health Assessor. The choice
of assessor will be governed by:




ensuring compliance with
regulations
knowledge of the relevant person
skills and specialist knowledge for
the relevant persons needs
expedience of resources
Reasons for appointing the Mental Health
Assessor will be recorded.
Mental Capacity Assessment
Stephen Vickers
This establishes whether the relevant
person lacks the capacity to consent to
the arrangements proposed for their care
or treatment. This will be conducted by
the BIA unless the relevant person is
already known to the Mental Health
Assessor, in which case, the Mental
Health Assessor will conduct this
assessment.
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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.
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 be conducted by the
BIA.
Equivalent Assessments
The Act allows equivalent assessments
to be relied upon instead of obtaining
fresh assessments. In Leicester,
Leicestershire and Rutland, the use of
equivalent assessments will be restricted
to:


Mental Health Assessment: A
mental health assessment can be
used if it has occurred within the
last 12 months, if no significant
changes have occurred in the
relevant person’s mental health
and the DoLS Manager is satisfied
that there is no reason why the
assessment may no longer be
accurate.
Age Assessment: Where age
has been recorded within a formal
assessment process having
occurred within the last 12 months
If an equivalent assessment is
use, the BIA will need to complete
Form 11.
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6.6.8
Additional duties during the assessment process
The BIA should as early as possible initiate identifying a relevant person’s
representative (although this person will not actually be appointed until an
authorisation is approved and confirmed in writing).
The role of the relevant person’s representative is to maintain contact with the
relevant person and to provide independent representation and support to the
relevant person in all matters relating to the Deprivation of Liberty Safeguards,
including triggering a review.
The code of practice provides eligibility criteria for who can be the relevant person’s
representative. At the assessment stage the BIA must identify if there is anyone they
would recommend to become the relevant person’s representative, and discuss the
representative’s role with the people interviewed during the assessment process
(even though some of these assessments may not lead to an authorisation being
granted). The standard form, Form 24: Best interests assessor action in respect of the
selection of a relevant person’s 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 Supervisory Body.
The Code of Practice provides detailed guidance on how the BIA should go about
selecting the relevant person’s representative and this should be done with due
regard to the personal attributes and cultural background of the relevant person.
The appointment of the Relevant Person’s Representative needs to be officially
signed by the Signatory for the relevant Supervisory Body.
The BIA should, throughout the assessment stage, identify and attempt to resolve any
disagreements with the IMCA or those supporting the relevant person.
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.
Where the authorisation is for a care home placement being funded by another
commissioner of care, such as Continuing Health Care, the BIA will need to ensure
that the Head of Service or their deputy is consulted regarding any conditions that
they are considering attaching to the authorisation, especially if these conditions may
require additional resources. This consultation must take place prior to the
authorisation being signed off by Signatory from the Supervisory Body.
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
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number of people within a home or ward. This will include consideration of referral to
the Care Quality Commission in line with those procedures.
The DoLS assessment checklist should be completed by the BIA throughout the
assessment process to ensure the DoLS Team Manager is able to track progress of
the assessment and to allow clear communication with the Managing Authority
regarding the progress of each assessment toward timely conclusion.
6.7
Process for Urgent Authorisations (Procedure for the Managing Authority and
DoLS Team)
6.7.1
Managing Authority Responsibilities
In exceptional circumstances, where deprivation of liberty needs to commence before
a Standard Authorisation can be obtained, the Managing Authority can issue itself an
Urgent Authorisation which makes deprivation of liberty lawful for a short period of
time.
A request for a Standard Authorisation must be made simultaneously with the
issuing of an Urgent Authorisation.
The Managing Authority will need to complete the following forms at the same time:
Form 1: For the giving of an Urgent Authorisation by a Managing Authority and Form
4: Managing Authority request for a Standard Authorisation. Both forms must be
forwarded to the DoLS Team as per the process for Standard Authorisation requests
as outlined in section 6.3 above.
The DoLS Team will need to undertake the same assessment process as for a
Standard Authorisation, but within shorter timescales.
Where the Managing Authority is considering granting an Urgent Authorisation prior to
an urgent move to alternative accommodation, they must consider the likely effect the
move may have on the person’s mental health and how this may distort the
subsequent assessment.
6.7.2
Managing Authorities should have a procedure in place giving clear guidance to staff
about the actions, responsibilities and timescales required for issuing Urgent
Authorisations.
6.7.3
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. Any care or treatment provided under an Urgent Authorisation must comply
with Section 6 of the Mental Capacity Act 2005 and the relevant people must be
consulted before granting an Urgent Authorisation (this includes anyone engaged in
caring for the person or who has an interest in their welfare).
6.7.4
The Managing Authority will need to keep records of Urgent Authorisations issued
and give written copies to the relevant person and any IMCA instructed. The relevant
person’s family, friends and carers should be notified and the relevant person should
be helped to understand their rights.
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6.7.5
The Urgent Authorisation ends upon conclusion of the Standard Authorisation or upon
expiry of the Urgent Authorisation, whichever is the earlier. The DoLS Team, on
behalf of the Supervisory Body, will inform the relevant person and any IMCA
appointed that the Urgent Authorisation has ended. This may be combined with the
outcome form for the Standard Authorisation.
6.7.6
DoLS Team responsibilities
Upon receipt of the Standard Authorisation request form, the DoLS Team will need to
undertake the same assessment process as for a Standard Authorisation, but with a
different set of timescales:




The DoLS Team will need to inform the Managing Authority of its intended date
for sending a BIA to conduct assessments within 1 working day of receipt of
the referral.
From the end of Stage 1, the mental health assessor will have 48 hours to
complete the mental health assessment.
All assessments will need to be complete and an outcome report issued with a
decision on whether the authorisation will be granted within the time period of
the original Urgent Authorisation (unless this is extended)
The DoLS Team must ensure good communication and coordination, taking
particular care where the expiry date coincides with weekends or bank
holidays.
6.7.7
Once the assessment process is complete for the Standard Authorisation, the
relevant Supervisory Body will need to make a decision to either grant the
authorisation or decline the request for a Standard Authorisation and follow the same
processes outlined in Section 6.8 below. The DoLS Team will need to inform the
Managing Authority of the need to terminate the Urgent Authorisation where
requirements for Standard Authorisation are not met.
6.7.8
Terminating an Urgent Authorisation
The Managing Authority must terminate the Urgent Authorisation at the end of the 7
day period for which it was issued (unless the Managing Authority has applied to
extend the Urgent Authorisation).
The Urgent Authorisation would also terminate if the Standard Authorisation applied
for is granted by the Supervisory Body, or if it is not granted as this would constitute
an unlawful deprivation of liberty.
6.7.9
The DoLS Team Administrative Officer will inform the relevant person and any IMCA
instructed that the Urgent Authorisation has terminated (on behalf of the Supervisory
Body). If possible, this notification should be combined with the notification of the
outcome of the assessment process for the Standard Authorisation.
6.7.10 Extending the Urgent Authorisation
In exceptional circumstances where the Standard Authorisation cannot be dealt with
within the period of the Urgent Authorisation, the Managing Authority can apply to
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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 Supervisory Body via the DoLS Team.
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 Team Manager
will consult with the Signatory from the relevant Supervisory Body before a
determination whether to grant an extension can be made. A record of any
discussions must be kept by the DoLS Service and the reasons for granting or
declining an extension will be recorded in writing.
6.7.11 Once the Supervisory Body has determined whether or not to extend the Urgent
Authorisation, the DoLS Team Administrative Officer will inform the Managing
Authority of the decision, giving reasons and keeping written records. The standard
form, Form 3: Supervisory Body’s decision regarding request for an extension of an
Urgent Authorisation should be used for this process.
6.7.12 Where the Supervisory Body agrees to extend the period of Urgent Authorisation, the
Managing Authority is responsible for informing the relevant person and any IMCA
instructed of the extension, both orally and in writing and inform them of their rights
and assist their understanding. The relevant person and IMCA must also be informed
where a request to extend an Urgent Authorisation is declined.
6.7.13 Both the Managing Authority and DoLS Team will ensure that the use of Urgent
Authorisations is recorded, monitored and audited as part of the good governance
procedures.
6.7.14 Third Party Requests – Unauthorised Deprivation of Liberty (Procedure for the
DoLS Team)
The DoLS Team may receive referrals from a third party regarding an unauthorised
deprivation of liberty. Standard letters are available for third parties to write to either
the Managing Authority (letter 1) or Supervisory Body (letter 2). The third party should
always contact the Managing Authority in the first instance.
The DoLS Team will keep a written record of the request and ascertain whether the
third 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 third
party within 24 hours). If the third party has not yet done this, the matter should be
referred back to the third party to approach the Managing Authority. The DoLS Team
Manager will consider what support the third party may require to approach the
Managing Authority and enable this process. The standard form, Form 16: Record of
Supervisory Body action on receipt of notification of a possible unauthorised
deprivation of liberty should be used by the DoLS Service at this point.
6.7.15 If the third party has previously approached the Managing Authority, the DoLS Team
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 and the
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DoLS Assessment Checklist will be started by the DoLS
Administrative Officer. The standard form, Form 17: Unauthorised
deprivation of liberty assessor’s report should be completed.

The third 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 Team 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
Team Manager will notify the third party, the relevant person, any
IMCA instructed and the Managing Authority that the DoLS Team
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.
6.7.16 If the assessment finds that no deprivation of liberty is occurring, the DoLS Team
Administrative Officer will notify the third party, the relevant person, the Managing
Authority and any IMCA of the outcome. This will be recorded by the DoLS Team
Administrative Officer Form 18: Supervisory Body’s decision following the receipt of
an unauthorised deprivation of liberty report should be used.
6.7.17 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 Team will notify the third party, the relevant
person, the Managing Authority and any IMCA of the outcome Form 18: Supervisory
Body’s decision following the receipt of an unauthorised deprivation of liberty report
should be used.
6.7.18 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
Form 18: Supervisory Body’s decision following the receipt of an unauthorised
deprivation of liberty. In such circumstances, the DoLS Team Administrator will notify
the relevant regulatory body of the Managing Authority.
The Managing Authority will need to provide the DoLS Team with the information
required for a Standard Authorisation as per section 6.3 above and must complete
Form 4: Managing Authority request for a Standard Authorisation and send it to the
DoLS Team. The DoLS Team Administrative Officer will notify the third party, the
relevant person, the Managing Authority and any IMCA that the DoLS Team will
commence assessments as per a Standard Authorisation for deprivation of liberty and
the procedures outlined in this document will be followed.
The present care and/or treatment of the relevant person that has been found to
amount to deprivation of liberty and must be discontinued while the Standard
Authorisation process is undertaken, unless the Managing Authority considers it
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necessary to continue with the care/treatment, in which case it must grant itself an
Urgent Authorisation and complete Form 1: For the giving of an Urgent Authorisation
for a Managing Authority.
If the Managing Authority grants itself an Urgent Authorisation, the DoLS Team will
need to conduct the assessments within the timescales for Urgent Authorisation as
set out in section 6.7 above.
6.8
Assessment Outcomes – Granting or Declining an Authorisation (Procedure for
the DoLS Service, Supervisory Body and Managing Authority)
6.8.1
The Assessor’s Reports
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 6.6 above.
There are particular requirements for the best interests assessment form (Form 10:
Best interest assessment form for completion by assessor). For the best interests
assessment the BIA must explain the reasons for their conclusions.
Where the best interests assessment does not support the deprivation of liberty, the
BIA will provide guidance for commissioners and care providers on future actions and
alternative care / treatment. This information should be communicated to the
Managing Authority at the earliest possible stage during the assessment process to
enable timely alternative care planning.
Where the best interests assessment supports the authorisation, the BIA will specify
the following on the Best interest assessment form:
i.
ii.
iii.
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. 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 coordinating and completing each assessment report and
for presenting the information to the DoLS Team. The completed file will then be
forwarded to the Supervisory Body.
6.8.2
Declining the authorisation
Where any assessment concludes one of the requirements is not met, all
assessments end and the authorisation will be declined. The BIA will need to
communicate this outcome to the other assessors.
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The DoLS Administrative Officer will forward the assessments via secure fax to the
relevant Supervisory Body signatory to be “signed off”.
The DoLS Administrative Officer is responsible for ensuring due process is followed
and notifying all the relevant parties on behalf of the Supervisory Body as detailed in
para 6.8.6 below.
6.8.3
Where it is deemed that deprivation of liberty is occurring, the DoLS Team Manager
or their deputy is responsible for instigating the procedure as detailed in para 6.8.4
below.
6.8.4
Granting the authorisation
Where all assessment requirements are met, the authorisation should be
granted.
The Supervisory Body will need to complete Form 12: Supervisory Body gives a
Standard Authorisation. The Supervisory Body will need 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
Once validation is complete, the DoLS Administrative Officer will then forward the
form and copies of all assessments to the relevant Supervisory Body. The relevant
Supervisory Body has responsibility for signing the authorisation and this
responsibility will rest with identified signatories from the relevant Supervisory Body.
The Signatory of the relevant Supervisory Body is responsible for ensuring due
process has been followed and all assessments have been completed correctly and
fully.
The key responsibilities of the Signatory are:


Grant the authorisation where all requirements are met as prescribed by
the Act.
Consider whether to attach conditions which may have been
recommended by the BIA.
o The signatory for the Supervisory Body will need to consider the
implications of the conditions attached to the authorisation as
recommended by the BIA, particularly with regard to potentially
sanctioning additional resources on behalf of their organisations
commissioners.
o Where the Supervisory Body does not attach the conditions as
recommended by the BIA or deviates from the BIA’s recommendations,
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they must discuss this with the BIA in case this would significantly affect
the conclusions reached by the BIA in their assessment (unless the BIA
has specified on Form10 that failure to attach the conditions would not
have affected their decision).
o The BIA must be available for the signatory to consult with prior to
signing the authorisation. Wherever possible this should be face-to-face
consultation.

Set the period of authorisation.
o The signatory for the Supervisory Body cannot extend the period of
authorisation as recommended by the BIA. However, they can discuss
with the BIA if they consider the timescale should be shortened.

Officially appointing the Relevant Person’s Representative
6.8.5
Once the signatory for the Supervisory Body has signed Form 12, the form will need
to be sent back to the DoLS Team. The DoLS Administrative Officer will then have
responsibility for ensuring due process is followed and notifying all the relevant parties
as detailed in section 6.8.6 below.
6.8.6
Recording and notifying relevant parties of the decision
Once the Supervisory Body has completed the form stating its decision to either grant
or refuse the authorisation, and the form has been signed by the appropriate person,
the DoLS Administrative Officer is responsible for ensuring the following are
undertaken:



A copy of the outcome form (Form 12 or 13) is kept and filed
The outcome is recorded on the SISS database including the date and time the
outcome report is signed and including alerts for reviews and expiry of
authorisation.
Written copies of the outcome form (with copies of all assessments attached)
are sent to the following:
o
o
o
o
o
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.

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.

Notifying the Relevant Person’s Representative
Where an authorisation is granted, a Relevant Person’s Representative is
appointed based on the BIA’s recommendations. The BIA will need to
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complete Form 25: Supervisory Body action in respect of the appointment of a
relevant person’s representative and forward this to the Signatory for the
relevant Supervisory Body. The Signatory will need to sign Form 25 to officially
appoint the Relevant Person’s Representative.
Once Form 25 has been signed by the relevant Supervisory Body, it should be
sent to the following:




The Managing Authority; the relevant person;
The Relevant Person’s Representative;
The IMCA (if required);
Any other persons consulted by the BIA.
The Representative must be given information and support to assist them in
their role and be provided with the means to contact an IMCA.
6.9

The relevant commissioning service of the Supervisory Body is informed of the
outcome.

The relevant person and their representative have information regarding how
to appeal against a decision and how to access the Court of Protection.

The Managing Authority has information regarding the relevant complaints
procedures of the Supervisory Body and how to appeal against the
assessments process.

The DoLS Service Assessment Checklist is completed and recorded.
Actions to be undertaken by the Supervisory Body and Managing Authority
where liberty is being deprived but the requirements for authorisation are not
met
In cases where the deprivation of liberty is occurring, but authorisation for deprivation
of liberty is refused because one of the requirements are not met, the Managing
Authority and Supervisory Body will need to take appropriate alternative action (action
will depend on which of the six requirements are not met (see section 6.9.2 – 6.9.7).
6.9.1
Planning Meetings
In certain circumstances it will be necessary for the Supervisory Body and Managing
Authority to have a Planning Meeting to discuss the required action in light of the
refusal of authorisation. Where a Planning Meeting is required, it should take place as
soon as is possible but no later than 48 hours after the Managing Authority has been
informed that the authorisation will not be granted (or the following working day if the
Managing Authority is informed of the refusal on a Friday). The Supervisory Body will
have responsibility for calling the planning meeting.
The required attendees at the planning meeting may include the DoLS Team
Manager, the BIA, a representative from the relevant commissioning department of
the Supervisory Body, an advocate for the relevant person (where involved), a senior
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representative from the Managing Authority and the relevant person’s lead
professional (such as a care manager, continuing health care assessor or ward key
worker).
In circumstances where the relevant person is a self-funder, care planning will need to
include those who manage the relevant person’s funds.
The purpose of the Planning Meeting will be to review the care or treatment currently
in place and agree a plan to ensure no unlawful deprivation of liberty continues,
assessing any risks as a means of reducing restriction and safeguarding issues. The
planning meeting can also consider any additional resource requirements of the
Managing Authority resulting from the recommendations of the BIA to amend the care
plan.
Within 7 days of the planning meeting taking place, an appropriate solution needs to
have been effected and the care plan will need to have been amended.
Two months after this Planning Meeting, the individual responsible for the relevant
person’s care (such as the care manager) will review the care provided to ensure that
the care regime has not reverted back into unlawful deprivation of liberty. This should
be recorded and kept in the relevant person’s records.
All outcomes from the planning meetings and dates for review should be recorded by
the Supervisory Body. Dependent upon the circumstances of the case, the
Supervisory Body may also need to consider whether referral to the relevant
regulatory body or Safeguarding Adults team is required.
6.9.2
Age Assessment
If this assessment does not meet the requirements for authorisation because the
relevant person is under the age of 18, the Managing Authority will need to refer the
case to the relevant children’s services and use of the Children Act 1989 or Mental
Health Act 1983 may be considered.
6.9.3
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.
6.9.4
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.
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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.
6.9.5
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.
6.9.6
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 AMHP
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).
6.9.7
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.
6.9.8
Responsibilities for implementing alternative care will rest with the Managing Authority
and those responsible for care, e.g. care manager, care programme coordinator, key
worker etc.
6.9.9
Responsibilities of the Managing Authority once an authorisation has been
granted or declined
If the Managing Authority receives an outcome form stating 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, 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.
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6.9.10
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.
6.9.11
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
6.9.12
Visits by the Relevant Person’s Representative must be accommodated and details of
visits are to be recorded in the relevant person’s records.
6.9.13
The Managing Authority must inform the DoLS Team if the Relevant Person’s
Representative is not maintaining appropriate contact.
6.9.14
The Managing Authority must inform the DoLS Team where the relevant person, or
their Representative, requests an IMCA.
7.0
Conveying
7.1
It is the responsibility of those involved in the delivery of the relevant person’s care or
treatment to convey the relevant person to the accommodation where the
authorisation is to take effect.
7.2
The wider provisions of the Mental Capacity Act must be met when conveying the
relevant person. Therefore:


It must be in the person’s best interests, and
Any restraint used must be proportionate and necessary to prevent harm to
that person.
7.3
Consideration must be given to the best means of conveying the relevant person and
who should be asked to support this, for instance, whether family/carers and the
ambulance service will aide the process to achieve the best outcome for the person.
7.4
In exceptional circumstances, where the Police are required to assist in the
conveying, this must be carefully considered, coordinated and planned to ensure the
person’s dignity and safety are paramount at all times.
7.5
In exceptional circumstances where a journey may involve a sustained period
requiring high levels of restraint, it may be necessary to seek an order from the Court
of Protection to ensure this is lawful. Legal advice should be sought in these
circumstances.
8.0
Reviews
8.1
A Standard Authorisation can be reviewed at any time and will be undertaken by the
DoLS Team on behalf of the Supervisory Body.
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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:



The Managing Authority should use Form 19: Request for a review of a
Standard Authorisation from the Managing Authority to the Supervisory Body.
The relevant person should use Letter 3: Letter to a Supervisory Body from a
person subject to a Standard Authorisation requesting a review of a Standard
Authorisation.
The relevant person’s representative should use Letter 4: Letter to a
Supervisory Body from a person subject to a Standard Authorisation’s
representative requesting a review of a Standard Authorisation.
Deprivation of Liberty can end before a formal review. An authorisation only permits
deprivation of liberty, it does not mean that the person must be deprived where a
change of circumstance no longer necessitates it.
Throughout the period in which the authorisation is in force, those with responsibility
for arranging and reviewing the relevant person’s care (such as the care manager,
care programme coordinator, key worker) will need to maintain active involvement.
For instance, where the relevant person is resident in a care home, the care manager
may need to maintain involvement with the person to ensure that care is provided by
the least restrictive means possible, that conditions are adhered to and that the
Managing Authority requests reviews at appropriate times.
The responsible worker will communicate any issues to the DoLS Team including
whether an IMCA may be required to support the relevant person’s representative to
exercise their rights.
8.2
Managing Authority Responsibilities
The Managing Authority must inform the Supervisory Body via the DoLS Team 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.
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
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
met and the suspension of the Standard Authorisation is lifted and forward this
to the DoLS Team.
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.
8.3
DoLS Team Responsibilities
8.3.1
The DoLS Team 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 Team will
carry out a review on behalf of the Supervisory Body.
8.3.2
The DoLS Team will maintain a list of all deprivation of liberty authorisations. One
month before authorisation is due to expire, the relevant Managing Authority will be
contacted and an assessment whether deprivation of liberty may need to continue
after expiry of the authorisation will be made jointly. Where it is determined that
authorisation may be necessary, the Managing Authority must apply to the DoLS
Team requesting re-assessment. The DoLS Team will then re-instigate the
assessment process as outlined in section 6.4 above.
8.3.3
The DoLS Team (on behalf if the Supervisory Body) must conduct a review where it
has been requested by the Managing Authority, the relevant person or the relevant
person’s representative.
8.3.4
Once a request for a review has been received, the DoLS Team should acknowledge
receipt of the request, in writing, within 24 hours at the latest of the request being
received. The DoLS Team will need to inform the relevant person, their representative
and the Managing Authority of their intention to conduct a review and should use the
standard form, Form 20: Supervisory Body notifies relevant interested parties that a
review is to be carried out.
8.3.5
DoLS Team will need to determine which of the requirements needs to be reviewed
and whether any further action is required. The DoLS Team will need to complete
Form 21: Supervisory Body records it’s decision as to whether any qualifying
requirements are reviewable. The DoLS Team will need to inform the Managing
Authority within 48 hours of receipt of the request for the review, of its intended date
for commencing the review, which requirements are to be reviewed and the name of
the BIA or Mental Health Assessor appointed to conduct this.
The review will consider any change of circumstances and conduct re-assessment of
criteria where required
8.3.6
In general, the reviews should follow the same process as the Standard Authorisation
for each of the qualifying requirements that need to be reviewed. The DoLS Team will
have 21 days in total in which to complete the review.
8.3.7
Following a review, the Supervisory Body will need to complete Form 22: Supervisory
Body’s decision following receipt of review assessments, detailing the outcome of the
reviews and the required actions. This may include:

Varying the conditions attached to the authorisation
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
Terminating the authorisation where deprivation of liberty is no longer required
or where any requirement is no longer met.
If the BIA recommends varying the conditions attached to the authorisation, this
should be discussed with the DoLS Team Manager (or their deputy). A signed copy of
the form will need to be sent to the Managing Authority, the relevant person, their
representative, any IMCA instructed and any other persons consulted during the
review by the DoLS Team Administrator.
8.3.8
The Supervisory Body is responsible for suspending the authorisation where there
has been a change in the eligibility requirement (such as admission under the Mental
Health Act 1983). The Supervisory Body is also responsible for lifting this suspension
where the relevant person becomes eligible again within 28 days following the
suspension. If no notice is given within 28 days the authorisation will be terminated.
There are standard forms available which should be used by Managing Authorities to
inform the Supervisory Body that a suspension of authorisation is required or needs to
be lifted.
8.3.9
The DoLS Team will keep records of any information received by the Managing
Authority relating to the review and record any outcomes of the review in the relevant
person’s records.
9.0
Terminating a Standard Authorisation
9.1
When a Standard Authorisation ceases to be in force, the Supervisory Body will need
to record this using Form 23: Supervisory Body gives notice that a Standard
Authorisation has ceased to be in force.
9.2
A Standard Authorisation will cease to be in force in the following circumstances:






9.3
Where the Managing Authority gave notice to the Supervisory Body via the
DoLS Team 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.
When an authorisation expires, the Managing Authority cannot lawfully continue to
deprive the person of their liberty.
Where the Managing Authority considers that the relevant person will continue to
need to be deprived of their liberty once the Standard Authorisation has expired, they
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will need to request a new Standard Authorisation to take effect immediately after the
expiry of the existing authorisation. The Managing Authority will need to complete
Form 4: Managing Authority request for a Standard Authorisation and send this to the
DoLS Service.
The DoLS Team will follow the same process for assessments as for an original
Standard Authorisation as outlined above.
There is no statutory time limit on how far in advance the Managing Authority can
request a renewal of an authorisation, however it will need to be far enough in
advance for the renewal to take effect before the existing authorisation expires, but
not so far in advance that the relevant person’s needs could not be reasonably
predicted.
9.4
The DoLS Team (on behalf of the Supervisory Body) will need to inform in writing the
following interested parties when a Standard Authorisation expires:




The relevant person
The relevant person’s representative
The Managing Authority
Every interested person named by the BIA in their report as somebody they
have consulted in carrying out their assessment.
10
Appeals and Complaints
10.1
Managing Authority
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 make a complaint 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.
11
The dispute will be investigated by either the Dols team manager and/or a Senior
Representative of the relevant Supervisory Body responsible for the authorisation and
may be resolved through the relevant Supervisory Bodies complaints procedures.
.
Court of Protection
The Mental Capacity Act 2005 enables anyone deprived of their liberty to make
speedy application to the Court of Protection to review the lawfulness of their
deprivation.
It is the responsibility of the Managing Authority to ensure that the relevant person
and their representative is aware of their rights to apply to the court both before and
after the authorisation is granted and that they have the information required in order
to make a referral to the Court. The relevant person and their representative should
be made aware of the types of questions/issues they can take to the Court as
highlighted in the Code of Practice.
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The Managing Authority and the Supervisory Body should endeavour to resolve any
concerns through mediation or their own complaints procedures before the relevant
person or their representative refer the matter to the Court.
The Managing Authority and Supervisory Body are required to comply with any
conditions imposed by the Court following a hearing.
12
Information Governance
12.1
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 personallyidentifiable. Therefore, all staff should work to strict procedures relating to
confidentiality and the safe and secure transfer and storage of information.
Specific procedures apply where the Managing Authority is a hospital setting and
where information is being transferred between these settings and the DoLS Service.
Staff from these services will need to adhere to information governance procedures
imposed by the Leicestershire County Council
All staff should adhere to the Eight Principles of the Data Protection Act and also the
Six Caldicott Principles, particularly:
12.2

Transferring the minimum amount of information necessary:
o Requesting only that information that is required during the assessment
process and keeping paper copies to a minimum

Ensuring access is on a need to know basis:
o While many people will need to be consulted during the DoLS
assessment process, personally identifiable information should only be
transferred between those with statutory duties for undertaking DoLS
work

The data obtained for Deprivation of Liberty work should be used only for that
purpose
Transferring Personally Identifiable Information:
Where information pertaining to Deprivation of Liberty is being transferred between
the DoLS Team and a Managing Authority, staff from both services must adhere to
the guidance published in this policy and they should endeavour to comply with “Safe
Haven” good practice, in particular:






Locating the fax machine in a secure environment and removing faxes from the
machine upon receipt
Taking care in dialling the correct number
Phone the intended recipient to say that a confidential fax is being sent and
ask the recipient to confirm the fax has arrived
Never leaving confidential faxes lying around
Sending the minimum amount of personally identifiable information
Always including a front-sheet with a confidentiality clause
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



12.3
Fax machines should be password protected
Personally-identifiable information sent by post should be sealed securely,
marked private and confidential and clearly labelled to a named individual.
Incoming mail should be opened away from public areas
Email may not be a secure system for transferring personally identifiable
information and should not be used unless there is provision to send encrypted
email or it has been established that the system is secure.
Storing Personally Identifiable Information:
Where information pertaining to Deprivation of Liberty is being stored by the DoLS
Team or a Managing Authority, staff from both services must adhere to the guidance
published in this policy and should endeavour to comply with good record keeping
practice, in particular:






13
Storing paper records containing personally-identifiable information in locked
cabinets that are clearly labelled
Using booking out procedures to track the whereabouts of files and records
Arranging records so they can be found urgently if required
Keeping records closed when not in use so information cannot be seen
Where information is stored electronically ensuring files are clearly labelled,
computer screens are locked when unattended and ensuring passwords are
not shared
Ensuring staff do not take manual records home
Policy Review
This policy document and the procedures contained within it will be reviewed after six
months following implementation. Thereafter, it will be reviewed on an annual basis or
as appropriate.
The review will incorporate the following:



14.
A full audit of the service
Analysis of information from any complaints or incidents that have been
reported
Analysis of equality monitoring data that has been collected and an
assessment of the authorisations granted and declined in comparison with the
local population.
Quick reference Guide to the Interagency Policy and Procedures, the Code of
Practice and the DoH Forms and Letters
This document lists frequently asked questions for the different services,
organisations and individuals that are involved with the Deprivation of Liberty
Safeguards.
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For each question, the relevant reference number from the Interagency Policy and
Procedures is given and, where appropriate, a reference to the Code of Practice and
the relevant DoH standard form are also listed.
FAQ
Interagency
Policy
Reference
Code of
Practice
Reference
DoH Form
For Managing Authorities
What are my key responsibilities with regard toe the
DoLS legislation?
5.5
3.1
How do I request a standard authorisation?
6.3
3.7 – 3.10
Where do I send the request for authorisation?
6.2
3.11 – 3.14
What information do I need to include with the
request for standard authorisation?
6.3.8
3.8
What happens if an authorisation is refused, but the
relevant person is being deprived of their liberty?
6.9
5.24
What do I need to do once the DoLS Service have
granted / refused my request for a standard
authorisation?
6.9.9
5.20 – 5.23
What do I need to do if I receive a third party request
to apply for a standard authorisation?
6.7.14
9.1 – 9.2
What do I need to do if an assessment undertaken in
response to a third party request finds that
unauthorised deprivation of liberty is occurring?
6.7.18
9.12 – 9.13
What should I do if deprivation of liberty needs to
commence before a standard authorisation is
granted?
How do I extend the period of the urgent
authorisation?
6.7.1
Form 4
Form 4
Form 1
Form 4
6.1 – 6.6
Form 1
6.7.10
6.20 – 6.28
Form 4
Form 2
When does an urgent authorisation end?
6.7.5
6.16
How do I request a review of a standard
authorisation?
8.1
8.2, 8.3, 8.5
Form 19
What do I do if the relevant person no
longer meets the eligibility requirement and
I need to suspend the authorisation?
8.2
8.19 – 8.21
Form 14
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How do I appeal against the assessment process?
10.1
What do I need to do if the relevant person will need
to be deprived of their liberty once the authorisation
has expired?
9.3
How do I appeal against any decision made by the
Supervisory Body?
10.1
8.25 – 8.29
Form 4
For the DoLS Team
What are my key responsibilities with regard to the
DoLS legislation?
5.4
What happens if the Managing Authority and the
Supervisory Body are the same organisation?
3.3
3.21
What does the DoLS Service need to do once a
request for standard authorisation has been received?
6.4
3.21
What are the timescales for a standard authorisation?
6.4.5 – 6.4.8
4.9 – 4.12
When does an IMCA need to be instructed?
6.5
3.22 – 3.28
How does the DoLS Team Manager appoint a BIA to 6.6.1
undertake the assessments?
4.13 -4.17
Can an equivalent assessment be used?
6.6.7
4.4 – 4.8
Who is eligible to undertake the assessments?
6.6.1 – 6.6.7
4.24, 4.28, 4.31,
4.32, 4,35, 4.36,
4.54 – 4.62
What happens when one or more of the requirements
are not met and the authorisation is to be declined?
6.8.2
5.18 – 5.19
Who is responsible for signing the form when an
authorisation is granted?
6.8.4
What happens when all the requirements are met and
the authorisation is to be granted?
6.8.4
5.1 – 5.8
Who needs to be notified of the decision to grant /
refuse an authorisation?
6.8.6
5.7
What needs to happen when an authorisation is
refused but the assessment determines that
deprivation if liberty is occurring?
6.9
5.24
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When should a relevant person’s representative be
appointed?
6.8.4
7.9 - 7.11
7.22 -7.24
What is the process for an urgent authorisation?
6.7.6 – 6.7.7
6.1 – 6.7
6.16 – 6.19
6.20 -6.28
What do I need to do if the MA requests an extension 6.7.10, 6.1.11,
to the urgent authorisation?
6.7.13
How will the assessments be conducted?
6.6.2 – 6.6.8
How do I respond to a request for a review?
8.3 – 8.3.9
4.1 – 4.3
4.19 – 4.61
8.6 – 8.16
Form 24
Forms
5,6,7,8,9,10
Form 20
Form 21
What happens if an assessment undertaken in
response to a third party request finds that
deprivation of liberty is occurring?
6.7.17 – 6.7.18
9.12
Form 18
What assessment needs to be undertaken if the DoLS
Service decides to pursue a third party request?
6.7.15 – 6.7.18
9.3 – 9.7
Form 16
What do I need to do when I receive a third party
request for standard authorisation?
6.7.14 – 6.7.18
9.3 – 9.7
For the Supervisory Body
What are my key responsibilities with regard to the
DoLS legislation?
5.3
3.3
When will I be asked to act as signatory for a
standard authorisation?
6.8.2 – 6.8.5
Form 12
Can I amend the conditions attached to the
authorisation as recommended by the BIA?
6.8.4
5.5
Form 13
Form 12
Can I extend / shorten the period of the authorisation
as set by the BIA?
6.8.4
5.3
Form 12
9.1
Letter 1
For a Third Party
How do I request that the managing authority should
apply for a standard authorisation because an
unauthorised deprivation of liberty is occurring?
6.7.14
How will the DoLS Service respond to my request?
6.7.14 - 6.7.15
Stephen Vickers
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Letter 2
9.4 – 9.7
17/02/2016
What will happen if the DoLS Service finds that an
6.7.16 – 6.7.18
unauthorised deprivation of liberty is/isn’t occurring?
9.10 – 9.14
When will I be informed of the outcome of my
request?
9.11
6.8.6
For the Relevant Person and/or their Representative
How do I request a review of a standard
authorisation?
8.1
8.2
Letter 3
How can I apply to the Court of Protection to review
the lawfulness of the deprivation of liberty?
11
10.1 – 10.3
10.7 -10.9
Letter 4
General
How is the work related to the Deprivation
of Liberty Safeguards being undertaken in
Leicestershire?
6.2
What other documents should staff refer to when
undertaking DoLS work?
4.5
How should the relevant person be conveyed to the
accommodation where the authorisation is to take
effect?
7.1 – 7.5
15.
2.14 – 2.15
Acknowledgements
The Leicestershire, Leicester City and Rutland DoLS Service would like to
acknowledge and thank Northamptonshire County Council and Northamptonshire NHS
Teaching Primary Care Trust for their support with the development of this document.
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16
Appendices
Appendix 1
DoLS Assessment Checklist
Section 1: Referral Process
Supervisory Body
NHS LCR
NHS LC
RCC
Surname
Reference Number
LCityC
LCountyC
Date of Birth
SISS
Other Names
Home Address
Current Address
Postcode
Address of DOL (if different from current address)
Postcode
Date of Referral
Postcode
Managing Authority
Sign off Details
Date:
Time:
Location:
Signatories:
Lead BIA
Referrers Name
Position Held by Referrer
Date BIA due to commence:
Category of Referral
Third Party
Standard
Form Completed By
Date
Standard/Urgent
Review
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Section 2: Assessment Process
Stage 1
Assessment
Date
Completed
Completed By
Requirement Met
Yes
No
Confirm age
assessment
Identify if
liberty is
being deprived
Confirm no
refusals
assessment
Preliminary
mental
capacity
assessment
Preliminary
eligibility
assessment
Assessment
process to
proceed to Stage
2?
IMCA Instructed: Yes/No
Date
Name
Stage 2 Assessment
Name of Best Interest Assessor (if different to Stage 1 BIA) ________________________
Name of Mental Health Assessor appointed _______________________________________
DateAppoited:_____________________________________________________________
Date
Completed
Completed By
Requirement Met
Yes
No
Eligibility
Assessment.
Mental
capacity
assessment
Mental Health
Assessment
Best Interest
assessment
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Section 3: Outcome process.
Yes
No
Date
Completed by
Outcome Report
presented to DoLS
Team Manager
Outcome Report given
to Supervisory Body
Authorisation Granted
Outcome report sent to
Date
Completed by
Relevant Person
Managing Authority
Relevant Persons
Representative
IMCA
Commissioning Services
Other people consulted
Other people consulted
Other people consulted
Other people consulted
Name of Relevant Person’s Representative:
___________________________________________
Date Appointed:
_________________________________________________________________
Information given to relevant person / representative about Court of Protection:
Date:
__________________________________________________________________________
Information given to Managing Authority about Appeals process:
Date:
__________________________________________________________________________
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Appendix 2
What should a managing authority (care home or hospital) consider before applying for authorisation of deprivation of liberty?
1.
Does the person lack capacity to consent to being in the care home or hospital in order to receive the
care or treatment that is necessary to prevent harm to them?
NO – The managing authority needs to
apply to the supervisory body for a standard
authorisation.
Fax completed forms to the Leicester, Leicestershire &
Rutland DOLS Service
0116 305 55 55
Complete DOLS Standard Authorisation
Form and forward a copy the DOLS Team
NO – An application CANNOT be made as the person has
the capacity to agree to or refuse the proposed care. The
person should be supported to make their own decision, and
the care plan amended accordingly.
YES – An application may be required
If the person appears to require mental health treatment to
which they do not consent and meets the criteria for
detention under the Mental Health Act, an application under
the Act many be considered.
2. Is the person who lacks capacity at
risk of deprivation of liberty now or
within the next 28 days?
9. Is the need for the person to be
deprived of their liberty so urgent that it
has to start immediately?
YES – An application may be required
NO – An application is required
YES – The managing authority should give an urgent
authorisation.
Complete DOLS Urgent Authorisation Form and forward
a copy to the detained person and to other relevant persons.
The managing authority must also apply to the supervisory
body for a standard authorisation.
NO – An application is not required. This question
should be reconsidered when changes are made to the
person’s care.
YES – An application CANNOT be made. The care plan will
need to be speedily reviewed and where necessary alternative
arrangements, made to ensure that an unauthorised
deprivation of liberty does not commence or continue. If the
person appears to meet the criteria for detention under the
Mental Health Act, an application under that Act may be
considered.
3. Can the person receive the planned care or treatment via a less restrictive but still effective alternative
than depriving them of their liberty?
NO – An application may be required
YES – An application CANNOT be made.
4. Is the person 18 years of age or older
(or going to turn 18 in the next 28 days)?
The care plan will need to be speedily reviewed and where
necessary alternative arrangements made to ensure that an
authorised deprivation of liberty does not commence or
continue and that the care or treatment is provided via a
less restrictive alternative, which may include a move or
transfer to another facility
YES (to both questions) – An application cannot be made
(unless an attorney or deputy, with the authority to do so has
consented on the person’s behalf to the things to which the
person objects)?
8. Has an attorney or deputy with the
authority to do so, indicated that they
will object to the person entering (or
staying in) the hospital or care home or
that they will refuse any or all of the
proposed treatment or care on their
behalf?
NO – An application may be required
7. Is the proposed deprivation of liberty for the purpose of mental health treatment in hospital and does the
person object to going to (or staying in) hospital or to the proposed treatment?
Does the person meet the criteria to be detained under Section 2 or 3 of the Mental Health 1983 Act instead?
NO – An application CANNOT be made but you may
need to consider the use of the Children Act or if the
person requires mental health treatment and appears to
meet the criteria for detention under the Mental Health
Act and an application under that Act may be considered.
YES – An application may be required
5. Is the person subject to any of the powers of the Mental Health Act 1983 in a way that would mean they
are ineligible for a deprivation of liberty authorisation under the Mental Capacity Act 2005?
YES – An application CANNOT be made. The
relevant Mental Health Act powers should be used
instead.
Stephen Vickers
Page 48
NO – An application may be required
NOTE: DEFINITION OF CAPACITY:
The ability to make a decision about a
particular matter at the time the decision
needs to be made.
NO – An application may be required
YES – An application CANNOT be made. The care plan
will need to be speedily reviewed and where necessary,
alternative arrangements made to ensure that an
unauthorised deprivation of liberty does not commence or
continue. If the person appears to meet the criteria for
detention under the Mental Health Act, an application
under that Act may be considered.
6. Is the proposed deprivation of liberty in order to provide treatment in a case in which the person
has made a valid and applicable advance decision to refuse that treatment?
17/02/2016
Appendix 3
DoLS Flowchart for Standard Authorisation (referral)
MA use internal procedures to determine if DoL is
required, seeking advice from the DoLS Team where
necessary
MA completes request for SA (form 4) and sends to
DoLS Team via safe haven fax.
MA inform all relevant people
Is the Request for SA
complete/appropriate/valid?
Yes – DoLS Team AO begins
DoLS Team Assessment
Checklist
No - Refer back to MA for
further information/action
DoLS Team AO contacts relevant SB to
arrange “sign off” and arrange receipt of
referral details via safe haven fax (page 1 of
DoLS Team Assessment Checklist)
Is the matter resolved?
DoLS Team AO acknowledges receipt
of application within 24 hours
No – Report to DoLS Team
Manager
DoLS Team Manager Appoints BIA
within 48 hours of receiving
application (recorded on Checklist for
Appointment of BIA)
Within 48 hours of case allocation the BIA
contacts the MA to advise of Intended date
to commence assessments (Stage 1)
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Appendix 4
DoLS Flowchart for Standard Authorisation (Assessment)
Within 48 hours of case allocation the BIA contacts the MA to advise of
intended date to commence assessments (Stage 1)
Is an IMCA required?
No Ensure relevant person
representative is aware of
application.
Yes – DoLS AO to instruct IMCA within
48 hours (24 hours if UA). AO to record
date IMCA instructed on checklist.
BIA to request relevant person’s care plans/
Assessment/records. BIA to consider if any
additional resources required to undertake
assessments i.e. interpreters.
DoLS team AO faxes all forms to
the relevant SB signatory to be
“signed off”.
DOL’s AO will notify all relevant
people of outcome & provide MA
with information of complaints
procedures for the SB.
Liberty is being deprived however
other requirements not met consider planning meeting between
SB and MA to discuss required
action (within 48 hours).
Appointed BIA commences Stage 1 for preliminary assessments
(forms 5,6,7,8,9,10 (and 11 if valid)).
Are all assessments positive at stage 1?
File forwarded to team manager
for validation. completed)
YES proceed to stage 2 (forms 6, 7, 8, 9,
10 (and 11 if valid)).
No - assessment process
ceases immediately
Relevant person and their
representative provide with
information about the
Court of Protection.
DoLS team AO faxes all forms
to the relevant SB signatory to
be “signed off”.
DOL’s AO will notify all
relevant people of outcome &
provide MA with information
of complaints procedures for
the SB.
File forwarded to team
manager for validation. PRPR
identified if required (form ??
completed)
Yes - BIA completes form 24 if
recommending RPR - Provide RPR
with DOL guide for RPR’s
BIA can be changed at this stage if highlighted that
another BIA would be more appropriate.
Are all of the assessments positive at stage 2?
Mental health Assessor is appointed and will have 96 hours (48
hours if UA) in which to undertake assessment
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Appendix 5
DoLS Flowchart for Urgent/Standard Referrals
MA use internal procedures to determine if
DoL is required, seeking advice from the
DoLS Team where necessary
Where DoL needs to commence before a standard authorisation
can be obtained, the MA must issue itself an urgent
authorisation for up to 7 days. The MA must complete Form 1
Is the Request for SA
complete/appropriate/valid?
At the same time it has granted the UA, the MA must request a
SA by completing Form 4 - Send to DoLS Team via safe haven
fax.
Yes – DoLS Team AO
begins DoLS Team
Assessment Checklist
No - Refer back to MA for
further information/action
DoLS Team AO contacts
relevant SB to arrange “sign
off” and arrange receipt of
referral details via safe haven
fax (page 1 of DoLS Team
Assessment Checklist)
Is the matter resolved?
No – Report to DoLS Team
Manager
The DoLS Team AO confirms receipt of Form 4 within 1 working
day. BIA to be appointed within 24 hours and MA informed of date
to commence assessments.
The DoLS Team will have to complete all assessments and reach a
decision within the period of the urgent authorisation (see
Standard Authorisation Flowchart for assessment process)
Complete stage 1 of assessments, if proceeding to stage 2 MH
assessor to be appointed and must complete assessment within
48 hours.
Can the assessments be carried out within the period of the
urgent authorisation?
Yes – Follow assessment and notification process for
standard authorisation - UA terminated once decision
on SA is made by the SB
No - The MA can apply to extend the period of urgent
authorisation by a maximum of a further 7 days. The MA
must complete Form 2:
The SB will need to determine whether or not to extend the
urgent authorisation and issue Form 3
Extension is granted - All assessments must be
carried out within the period of the extension of the
urgent authorisation.
Notification process for standard authorisation
should now be followed
Stephen Vickers
Extension is refused – Urgent review of care by MA and the
deprivation of liberty must cease. DoLS Team completes the
process for a standard authorisation
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Appendix 6
DoLS Flowchart for Third Party Referrals
Request received by DoLS Team from Third party who
believes that there may be a risk of DoL (DoLS AO logs
call)
Advise the Third Party to raise concerns directly with the MA (letter 1 may
be used)
DoLS Team will consider what support if any the third party requires.
Did the MA respond to Third Party concern within 24 hours?
Yes
No - Third Party can refer case
directly to the DoLS Team
(letter 2 may be used) – SB
notified of referral by DoLS
Team
Is the matter resolved?
No – MA should
submit request for SA
to DoLS Team
(following DoLS
referral process for SA)
Yes – No further action
required
Is the request frivolous or vexatious, or has the
question whether or not there has been an
unauthorised deprivation of liberty already been
decided with no subsequent change of
circumstances?
Does the RP have somebody to support them?
No - DoLS will complete form 17
and inform all relevant people
that matter will be pursued
Yes, inform RPR of
request from Third
Party
BIA appointed (Assessment must
be completed within 7 days)
Form 17 completed.
Yes - complete Form
16 inform all relevant
people that matter will
not be pursued
No - DoLS Team to
appoint IMCA.
IS DOL
OCCURRING?
Yes – Has the DoL already been authorised?
Yes - The DoLS Team will
notify all relevant parties that
the DoL has already been
authorised. Form 18
completed
Stephen Vickers
No - The MA is deemed to have
requested a standard
authorisation.
Form 18 completed
No - The DoLS Team will notify all
relevant parties that the BIA has determined
that no DoL is occurring. Form 18 to be
completed.
MA to complete Form 4 and request SA.
Care/treatment that’s amounts to DOL must be discontinued
while SA process is undertaken unless MA grants itself a UA
and complete Form 1.
DoLS will follow process for SA or UA as appropriate.
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Appendix 7
DoLS Flowchart for Standard Authorisation Review Process
SB may carry out review at any time
Valid SA authorisation is in force
RP (letter 3), PRPR, RPR (letter 4), MA (Form 19) may at anytime request the SB for a
review (via the DoLS Team).
SB must arrange a review if requested by eligible person
DoLS Team (on behalf of SB) will notify the RP, the RPR and the MA that a review is to take place – BIA
appointed by DoLS Team Manager (Form 20) – SB notified of review by DoLS Team
No qualifying requirement
reviewable – SB needs
take no action in
respect of the SA
BIA to decide whether any qualifying requirement is reviewable (consider non-qualification,
change of reason or variation of conditions on existing authorisation) (Form 21)
If any requirement is
no longer met, SB
must terminate SA
immediately (Form
23)
One or more qualifying requirements appear to be reviewable
BIA to conduct a separate review assessment in relation to each
qualifying requirement that appears to be reviewable
If the review relates to any of the other requirements a
new assessment is required
No
Yes
Is the requirement of
the assessment still
met?
SB must terminate SA
immediately
SB needs take
no action in
respect of the
SA
Has the reason that it is met
changed from the reason
originally stated on the SA?
No
Yes
BI reviews only - for variation solely
of conditions
If change is not
significant
SB may vary the
conditions of the SA
If change is
significant new BIA
assessment required
SB must make
any appropriate
amendments to
the authorisation
BI reviews only - for change of
reasons
New BI Assessment is
required
SB must consider whether any
conditions should be changed following
the new assessment.
Review completed (Form 22)
DoLS Team to notify (on behalf of SB): RP, RPR, MA, IMCA of the outcome of
the review and what, if any, variation has been made to the SA (any variation must
be made in writing)
The DoLS team (on behalf of the SB) will keep a written record of:
Each request for a review that is made
The outcome of each request
Each review that is carries out
The outcome of each review that is carried out
Any variation of a SA made as a consequence of the review
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Appendix 8
Data Exchange Form
Section 1: Referral Process
Supervisory Body
NHS LCR
NHS LC
RCC
Surname
Reference Number
LCityC
LCountyC
Date of Birth
SISS
Other Names
Home Address
Current Address
Postcode
Address of DOL (if different from current address)
Postcode
Date of Referral
Postcode
Managing Authority
Sign off Details
Date:
Time:
Location:
Signatories:
Lead BIA
Referrers Name
Position Held by Referrer
Date BIA due to commence:
Category of Referral
Third Party
Standard
Form Completed By
Date
Standard/Urgent
Review
This form should be completed and forwarded to the appropriate Supervisory Body
once “sign off” details and Lead BIA are established. A full case record can be accessed
by contacting the DOLS Team.
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Appendix 9
DoLS Service Checklist for DoLS Team Manager for the Appointment of Best
Interest Assessors
Name of Best Interest Assessor
Name of Managing Authority
Name of Supervisory Body
Name of Relevant Person
SISS Number
You must be able to tick all of the following to appoint this person as a Mental
Health Assessor (MHA).
Requirement
Tick all that
apply
The BIA is not involved in the care or treatment of the person they are
assessing nor in decisions about their care
The BIA is not in a line management relationship with the professional
proposing the deprivation of liberty or the mental health assessor
The BIA does not have a financial interest in the case of the person they are
assessing (a person is considered to have a financial interest in a case where that person is
a partner, director, other office-holder or major shareholder of the managing authority that
has made the application for a standard authorisation)
The BIA is not the same person as the mental health assessor
The BIA is not a relative of the person being assessed or a relative of a
person with a financial interest in the person’s care (see Code of Practice
paragraph 4.13 for the definition of ‘relative’)
Where undertaking the eligibility assessment, the BIA is authorised as an
AMHP
Where the managing authority and supervisory body are the same body, the
BIA is not employed by the body or providing services to it
There are no other conflict of interest situations that might bring into
question the objectivity of an assessment
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Additional Information
Please use the space below to record any other relevant information or reasons
for appointing this person as a BIA for this particular case:
You may want to consider the following:





The reason for the proposed deprivation of liberty
Whether the potential assessor has experience of working with a particular service group
Whether the potential assessor has experience of working with people from the cultural
background of the person being assessed
For the mental capacity assessment would an assessor who already knows the relevant person
be of benefit?
Any other specific needs of the person being assessed, e.g. communication needs)
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Appendix 10
DoLS Service Checklist for DoLS Team Manager for the Appointment of Mental
Health Assessors
Name of Mental Health Assessor
Name of Managing Authority
Name of Supervisory Body
Name of Relevant Person
SISS Number
You must be able to tick all of the following to appoint this person as a mental
health assessor (MHA).
Requirement
Tick all that
apply
The MHA is not the same person as the BIA
The MHA is a doctor
The MHA is approved under section 12 of the Mental Health Act 1983 or is
a registered medical practitioner with at least 3 years’ post-registration
experience in the diagnosis or treatment of mental disorder. (To undertake
the eligibility assessment MHA’s must be section 12 approved)
The MHA has completed the standard training for deprivation of liberty
mental health assessors (If the MHA completed the standard training more than 12
months ago – they must have also undertaken further training relevant to their role as mental
health assessor in the 12 month period prior to selection)
The MHA does not have a financial interest in the case of the person they are
assessing (a person is considered to have a financial interest in a case where that person is
a partner, director, other office-holder or major shareholder of the managing authority that
has made the application for a standard authorisation)
The MHA is not a relative of the person being assessed or a relative of a
person with a financial interest in the person’s care (see Code of Practice
paragraph 4.13 for the definition of ‘relative’)
There are no other conflict of interest situations that might bring into
question the objectivity of an assessment
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Additional Information
Please use the space below to record any other relevant information or reasons
for appointing this person as a MHA for this particular case:
You may want to consider the following:





The reason for the proposed deprivation of liberty
Whether the potential assessor has experience of working with a particular service group
Whether the potential assessor has experience of working with people from the cultural
background of the person being assessed
For the mental capacity assessment would an assessor who already knows the relevant person
be of benefit?
Any other specific needs of the person being assessed, e.g. communication needs)
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