Number / North East Regional MCA/DoLS LIN
Mental Capacity Act 2005
Deprivation of Liberty Safeguards Combined Forms No. 1 and 4
Request for Standard Authorisation and Details of any Urgent Authorisation Given
(To be completed by the Managing Authority electronically)
Part A:- Relevant Person’s details
Name of Relevant Person
Address of Relevant Person
(where they are ordinarily resident)
Relevant Person’s Current location
(where they physically are now) / Their ordinary residence as given above
A different address
(please specify here)
The Hospital or Care Home named below
Gender (as defined by the person) / Female / Male
Their date of birth (or estimated age) / D.O.B / Age
Date of Admission
Hospital or Registered Adult Care Home where the person is or is likely to be deprived of their liberty within the next 28 days. / Name
Address
(please include hospital ward if applicable)
Postcode
Name of the Managing Authority
Name of Supervisory Body
Person completing form / Name
Job Title
Telephone
Current G.P and address of Relevant Person / Name
Address
Name all of the organisations funding the Relevant Person’s care/treatment / LA / Health / Self Funder
Part B: Demographic Information
B1 Racial, ethnic or national origin
Tick one of the boxes below
White / Mixed or Mixed British
A / British / E / White and Black African
B / Irish / F / White and Asian
C / Any other White background / G / Any other Mixed background
D / White and Black Caribbean
Asian or Asian British / Black or Black British
H / Indian / M / Caribbean
J / Pakistani / N / African
K / Bangladeshi / P / Any other Black background
L / Any other Asian background
Other ethnic groups
R / Chinese / Z / Not stated (to include cases in which their person refused to divulge their ethnic origin or when their ethnic origin is not known)
S / Other
B2 – The person’s religion or belief
Tick one of the boxes below
1 / None / 6 / Muslim
2 / Christian / 7 / Sikh
3 / Buddhist / 8 / Any other religion
4 / Hindu / 9 / Not stated
B3 – The person’s sexual orientation
Tick one of the boxes below
1 / Heterosexual / 4 / Other
2 / Lesbian or gay / 5 / Prefer not to say
3 / Bisexual / 6 / Not known
B4 – The disability that is causing the person’s current incapacity
Tick only one of A or B or C
A / Physical disability, frailty and/or temporary illness
Hearing impairment
Visual impairment
Dual sensory loss
OR
B / Mental Health
Please also place a cross in this box if the Mental Health condition is Dementia
OR
C / Learning Disability
B5 – The person’s preferred communication method or preferred first language
State how the person communicates e.g. spoken English, interpreter required (specify language), BSL signer required, etc.
Part C:– Qualifying information
Tick the relevant boxes below
C1 / The person is aged 18 or over.
C2 / The person is suffering from a mental disorder – any disorder or disability of the mind.
C3 / The purpose of accommodating the person here is to give them care or treatment.
C4 / The person lacks capacity to make their own decision about whether to be accommodated here for the purpose of being given the proposed care or treatment.
C5 / The person has not, as far as the Managing Authority is aware, made a valid advance decision that prevents them from being given any of the proposed treatment.
C6 / Accommodating the person here, and giving them the proposed care or treatment, does not, as far as the Managing Authority is aware, conflict with a valid decision made by a Donee of a Lasting Power of Attorney or Deputy appointed by the Court of Protection under the Mental Capacity Act 2005.
C7 / Even though the circumstances amount to depriving the person of their liberty, it is in their best interests to be accommodated here so that they may be given the proposed care or treatment.
C8 / This is necessary in order to prevent harm to them, and is a proportionate response to the harm they are likely to suffer if they are not so deprived of liberty, and the seriousness of that harm.
C9 / The person concerned is not, as far as the Managing Authority is aware, subject to an application or order under the Mental Health Act 1983 or, if they are, that order or application does not prevent an Urgent Authorisation being given.
PART D – Why authorisation is needed
The purpose of depriving the person of their liberty in the above hospital or care home must be so that they can receive care and/or treatment
All areas of this section must be completed
(a) Give specific details of the types of care and treatment you are providing or intending to provide Include any sedative or similar medication being proposed as part of care management regime.
(b) State what restrictions on the person’s liberty are in place and why you think they cumulatively amount to a DOL
E.g. refusal to discharge, enhanced supervision, locked door, restricted movement/access, sedation, restrict family/carer contact etc.
(c) Why can’t the care and/or treatment described above be provided in a way that is less restrictive of the person’s rights and freedom of action?
E.g. it would be less safe or less effective, specialised equipment. required
(d) What alternatives to deprivation of liberty have been tried or considered?
E.g. Could the care be provided at their home with increased support? Has living with relatives been unsuccessful?
(e) What harm is the person likely to come to if they are not deprived of their liberty here?
E.g. What are the risks? Self neglect, abuse, mistreatment, further deterioration in welfare or health.
PART E:– Details of this Urgent Authorisation (If one is required tick box below)
N.B:- You may only grant an Urgent Authorisation if you are able to tick all 9 boxes in Section C above and box E1 below.
E1 / I consider it likely that the person will meet all the qualifying requirements for a Standard Authorisation and the need for the person to be deprived of their liberty here is so urgent that I am immediately granting the Managing Authority an Urgent Authorisation.
(a) Why is the need to deprive the person of their liberty so urgent that it needs to begin immediately? E.g. Risks are already occurring.
N.B :- This Urgent Authorisation permits the Managing Authority to immediately deprive the person of their liberty here, but only for the purpose of enabling them to be given the care or treatment specified above in section D of this form, which is provided under the MCA 2005.
E2 The duration of this Urgent Authorisation
Important note: The day on which the Urgent Authorisation is given counts as the first of the days. For example, if an Urgent Authorisation is given for seven days at 11.30pm on Monday 3rd, it will expire at midnight on the following Sunday 9th.
This Urgent Authorisation comes into force immediately once you sign and date this form and can last for up to seven days.
It is to be in force for a period of: / (Insert number of) DAYS
This Urgent Authorisation will expire at midnight on:
The Standard Authorisation is required from the following day
E3 – Please indicate which situation applies:-
In all cases it must be likely that the person will meet all of the qualifying requirements for a Standard Authorisation.
Tick one of the boxes below (A- G)
Boxes A-D relate to people who are not currently subject to a standard authorisation
A / As the person is already accommodated here and being deprived of their liberty I have given an Urgent Authorisation, pending the outcome of the Standard Authorisation assessment process.
B / The person is already accommodated here but is not yet being deprived of their liberty, however, during the next 28 calendar days; it is likely that we will need to do so.
C / The person is not yet accommodated here but when admitted during the next 28 days will be deprived of their liberty.
D / A Court of Protection order is about to expire. The person is already accommodated here and being deprived of their liberty, which the Court of Protection has authorised. However, given the date on which the Court’s order is expected to expire, it would be unreasonable to delay any longer requesting a Standard Authorisation.
E / None of the above applies. However it is likely that the person will need to be deprived of their liberty and will meet all of the requirements for a Standard Authorisation.
Boxes E-G relate to people who are currently subject to a Standard Authorisation
E / The existing authorisation is due to expire and it is reasonable to request that a new Standard Authorisation comes into force immediately.
F / There is a change in the place where the person is deprived of their liberty, we therefore require a new Standard Authorisation that authorises their deprivation of liberty here.
G / A part 8 review has been requested or is in progress. Any new Standard Authorisation that is now given will be in force after the existing authorisation comes to an end.
Part F: Information about interested persons
F1 Information about key family members and friends
Anyone named by the person as someone to
be consulted about their welfare / Name
Address
Postcode
Telephone
Anyone engaged in caring for the person or
interested in their welfare / Name
Address
Postcode
Telephone
Any Donee of a Lasting Power of Attorney
granted by the person / Name
Address
Postcode
Telephone
As anybody undergoing the DoLS process must have a representative, if you have not identified anyone above, the Supervisory Body will instruct an IMCA.
F2 Information about key professionals
Social Care Staff
(e.g. Social Worker, Care Manager, Assessing Officer) / Name
Address
Postcode
Telephone
Health Staff
(e.g. named nurse, CPN, Consultant) / Name
Address
Postcode
Telephone
Any Deputy appointed for the person by
the Court of Protection / Name
Address
Postcode
Telephone
F3 Whether there is a valid and applicable advance decision
Tick box A, B or C below
A / The person has made an advance decision that may be valid and applicable to some or all of the treatment.
B / As far as I am aware the person has not made an advance decision that may be valid and applicable to some or all of the treatment.
C / The proposed deprivation of liberty is not for the purpose of giving treatment.
Part G: Mental Health Act 1983 regimes
The person is subject to the following Mental Health Act 1983 regimes
(The Hospital Treatment, Community Treatment and Guardianship regimes are defined in paragraphs 8 to 10 of Part 2 of Schedule 1A to the Mental Capacity Act 2005.)
Only tick box A, B or C below if any of those options apply, otherwise leave the boxes blank
A / Hospital Treatment regime (under Mental Health Act 1983)
B / Community Treatment regime (under Mental Health Act 1983)
C / Guardianship regime (under Mental Health Act 1983)
PART G: Other information that should be provided if it is available to, or could reasonably be obtained by, the Managing Authority.
G1 / Relevant medical information
Any information relating to the person’s health that you consider relevant to the deprivation of their liberty
G2 / Diagnosis of the mental disorder
The disorder or disability of the mind that the person is suffering from. E.g. learning disability, dementia, brain injury etc.
G3 / Relevant care plans or needs assessments
The following relevant care plans and/or needs assessments are attached:
G4 / Other information which you believe to be relevant:
Eg. dates of admission to care, where the person was admitted from, social care history, was the person subject to the DoLS elsewhere?
Signed
(on behalf of Managing Authority) / Signature
Print Name
Position / Job Title
Date and Time / Date / Time
PART H — RECORD THAT THE DURATION OF THIS URGENT AUTHORISATION HAS BEEN EXTENDED
This part of the form must be completed if the duration of the urgent authorisation is extended by the Supervisory body. Do not complete this part of the form in any other circumstances, simply leave it blank.
H1 DETAILS OF ANY EXTENSION
The duration of this urgent authorisation has been extended by the supervisory body.
Enter number of days in the box below
The period specified must not exceed seven days
It is now in force for a FURTHER / DAYS
This urgent authorisation will now expire at the end of the day on:
H2 PROVIDING COPIES OF ANY EXTENSION
As soon as practicable after signing this form below, the managing authority will give copies of this amended form to:
(a) the person to whom the urgent authorisation relates
(b) any section 39A IMCA acting for them.
Signed
(on behalf of Managing Authority) / Signature
Print Name
Position / Job Title
Date and Time / Date / Time
Deprivation of Liberty Safeguards Combined Form No. 1 and 4 – 10/05/2013 1