Fill - Free fillable Dh 123271 GFSB-Liberty Form 10.indd PDF form

Mental Capacity Act 2005

DEPRIVATION OF LIBERTY FORM No. 10

BEST INTERESTS ASSESSMENT

PART A — WHY THIS FORM IS BEING COMPLETED

Place a cross in ONE of the boxes below Ø

A1 This form is being completed in relation to a request for a standard authorisation.

(If you place a cross in this box you must also take the person being assessed

through the steps necessary to appoint a representative and complete Form 24.)

A2 This form is being completed in relation to a review of an existing standard

authorisation under Part 8 of Schedule A1 to the Mental Capacity Act 2005.

Note: Where the supervisory body decides that the best interests requirement should

be reviewed solely because details of the conditions attached to the authorisation need

to be changed, and the review request does not include evidence that there is a

signiﬁ cant change in the person’s overall circumstances, there is not need for a full

reassessment of best interests. This form does not need to be completed in such a case,

and the supervisory body can simply vary the conditions attached to the authorisation in

such ways, if any, as it considers appropriate. In making any decision whether a change

is signiﬁ cant, regard must be had to the nature of the change and the period that the

change is likely to last for.

PART B — BASIC INFORMATION

Name, address and profession of the assessor

Full name of the person being assessed

Their date of birth (or estimated age if unknown)

Name of the hospital or care home in which the

person is, or may become, deprived of their liberty

Name of the PCT or local authority that is the

supervisory body

Name

Address

Profession

Name

DOB

Est. age Years

Name

ddm

yyyy

CASE

NUMBER

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The present address of the person being

assessed

(Place a cross in the relevant box and, where

applicable, state the address)

Address of the hospital or care home in which the

person is, or may become, deprived of their liberty

(Place a cross in the relevant box and, where

applicable, state the address)

PART C — PERSONS CONSULTED AND MATTERS TAKEN INTO ACCOUNT

I have assessed whether the person meets the best interests requirement.

C1 PERSONS WHO HAVE BEEN CONSULTED

Note: before embarking on the full best interests assessment consultation process, the best interests

assessor may ﬁ rst wish to check that there is prima facie evidence that a deprivation of liberty may be

occuring, or is likely to occur, since, if it is apparent that there is no deprivation of liberty, the full best

interests consultation process will be unnecessary.

Place a cross in the boxes below to conﬁ rm the statements in A, B or C Ø

A I have spoken to the person to whom this assessment relates, in accordance

with section 4(6) of the Mental Capacity Act 2005.

B I have consulted the managing authority of the hospital or care home and

taken their views into account.

C In carrying out this assessment, I have also consulted the following interested persons:

Note: before completing the rest of Part C, please read the notes at the end of the form, and in particular

the deﬁ nition of ‘interested persons’.

As stated on the request for a standard

authorisation

As stated immediately below

Address

As stated on the request for a standard

authorisation

As stated immediately below

Address

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D I have consulted the following additional individuals who were named by the person being assessed

as people to be consulted in relation to the matters now under consideration, and have taken their

views into account:

Name Address

more than ﬁ ve interested persons were consulted, please give the names and addresses of any

other individuals in Part G of this form.

Name Address

If more than two people in this category were consulted, please give the names and addresses of

any other individuals in Part G of this form.

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E I have consulted the following additional individuals, who are engaged in caring for the person being

assessed or are interested in their welfare, and have taken their views into account:

C2 MATTERS THAT I HAVE CONSIDERED AND TAKEN INTO ACCOUNT

I have considered what I believe to be all of the relevant circumstances and, in particular, the

matters referred to in section 4 of the Mental Capacity Act 2005.

I have taken into account the conclusions of the mental health assessor as to how the person’s

mental health is likely to be affected by their being deprived of liberty.

I have taken into account any assessment of the person’s needs in connection with accommodating

the person in the hospital or care home.

I have taken into account any care plan that sets out how the person’s needs are to be met while

the person is accommodated in the hospital or care home.

In carrying out this assessment, I have taken into account any information given to me, or

submissions made, by any of the following:

(a) any relevant person’s representative appointed for the person

(b) any IMCA instructed for the person in relation to their deprivation of liberty.

Note: if this form is being used to record a Part 8 review assessment, and the best interests requirement

is being reviewed solely because details of the conditions attached to the standard authorisation need to

be changed in a situation in which there is a signiﬁ cant change in the person’s overall circumstances, now

proceed directly to Part F4 of this form.

Name Address

If more than two people in this category were consulted, please give the names and addresses of

any other individuals in Part G of this form.

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PART D — WHETHER PERSON MEETS THE BEST INTERESTS REQUIREMENT

Note: if the answer to ANY of the questions D1 to D4 is No then the person is NOT eligible to be deprived of

their liberty under the Mental Capacity Act 2005. Only if the answer to ALL of the questions below is Yes is

the best interests requirement met.

In my opinion:

Place ONE cross in each row (no need to complete questions D2 to D4 if the answer to

question D1 is No) Ø

D1 The person is, or is to be, kept in the hospital or care home for the purpose Yes No

of being given care or treatment in circumstances that amount to depriving

them of their liberty.

D2 This is in the person’s best interests. Yes No

D3 This is necessary in order to prevent harm to the person. Yes No

D4 This is a proportionate response given the likelihood that the person will Yes No

otherwise suffer harm and the seriousness of that harm.

Reasons for opinion

D5 The reasons for my opinion concerning whether or not the proposed arrangements for the person’s

care and/or treatment amount to depriving them of their liberty in the hospital or care home are:

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Please Use Continuation Sheet

D6 If the proposed arrangements amount to depriving the person of their liberty, the reasons for my

opinion that they are, or are not, in the person’s best interests are:

Note: you should consider the provisions of section 4 of the Mental Capacity Act 2005, the additional factors

referred to in paragraph 4.61 of the deprivation of liberty safeguards Code of Practice and all other relevant

circumstances. Remember that the purpose of the person’s deprivation of liberty must be to give them care

or treatment. You must consider whether any care or treatment the person needs can be provided effectively

in a way that is less restrictive of their rights and freedom of action.

D7 If the proposed arrangements amount to depriving the person of their liberty, the reasons for my

opinion that they are, or are not, necessary in order to prevent harm to the person are:

Note: include particulars of the harm that will be avoided by depriving the person of their liberty.

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Please Use Continuation Sheet

D8 If the proposed arrangements amount to depriving the person of their liberty, the reasons for my

opinion that they are, or are not, a proportionate response to the likelihood of the person otherwise

suffering harm and the seriousness of that harm are:

Note: include why the risk of harm, and the seriousness of the harm, justiﬁ es deprivation of liberty.

Please go on to:

• Part E of the form if the best interests requirement is not met; OR

• Part F of the form if the best interests requirement is met.

PART E — BEST INTERESTS REQUIREMENT IS NOT MET

Part E must be completed if you decided that the best interests requirement is not met.

Place a cross in EITHER box E1 or E2 below Ø

E1 For the reasons given above, it appears to me that the person IS, OR IS LIKELY TO BE,

deprived of their liberty. In my view, the deprivation of their liberty under the Mental

Capacity Act 2005 is not appropriate. Consequently, unless the deprivation of liberty

is authorised under other statute, the person is, or is likely to be, subject to an

unauthorised deprivation of liberty.

E2 For the reasons given above, it appears to me that the person IS NOT, OR IS NOT LIKELY

TO BE, deprived of their liberty. Consequently, the person is not, or is not likely to be,

subject to an unauthorised deprivation of liberty.

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Please Use Continuation Sheet

If you have put a cross in box E1, please offer any suggestions that you have that may be beneﬁ cial to

the commissioners and/or providers of services in deciding on their future action. This might, for example,

include a recommendation about an alternative approach to care or treatment that would avoid deprivation

of liberty:

PART F — BEST INTERESTS REQUIREMENT IS MET

If you are recording a Part 8 review assessment simply record the maximum

authorisation period already granted and ignore Box F2

F1 MAXIMUM AUTHORISATION PERIOD

State period in the box below. This must not exceed one year Ø

In my opinion, the maximum period it is appropriate for the

person to be deprived of liberty under this standard authorisation is:

F2 DATE WHEN THE STANDARD AUTHORISATION SHOULD COME INTO FORCE

I recommend that the standard authorisation should come into force:

Place a cross in box A or enter the date in row B Ø

A As soon as possible

B On (date):

ddm

yyyy

Please Use Continuation Sheet

F3 RECOMMENDATIONS AS TO CONDITIONS

Complete F3 if you are completing this form in connection with a request for a standard

authorisation.

Complete F4 INSTEAD if you are completing this form to record a Part 8 review assessment.

Do NOT complete both F3 and F4.

See the notes at the end of this form for guidance on imposing conditions.

Place a cross in box A or box B Ø

A I have no recommendations to make as to the conditions to which any standard

authorisation should or should not be subject (proceed to Part G of this form).

B I recommend that the conditions speciﬁ ed immediately below should be attached

to any standard authorisation that is given.

Any standard authorisation given should be subject to the following conditions:

(If more than six conditions are recommended, please add any additional conditions in Part G.)

GFSB-Liberty Form 10.indd 9 16/2/09 12:09:48

Should any recommended conditions not be imposed:

If you have made recommendations about conditions, place a cross in one of the boxes below Ø

A I would like to be consulted again, since this may affect some of the other

conclusions that I have reached in my assessment.

B I do not need to be consulted again, since I do not think that the other conclusions

reached in this assessment will be affected.

F4 RECOMMENDATIONS AS TO VARYING ANY CONDITIONS

Only complete F4 if you are using this form to record a Part 8 review assessment. In all other cases,

do not complete F4.

Place a cross in EITHER box A OR box B Ø

A I am of the opinion that the existing conditions to which the standard authorisation is

subject are appropriate and should not be varied.

B I recommend that any existing conditions to which the standard authorisation is subject

should be varied in the way shown immediately below.

The conditions to which the standard authorisation is subject should be varied so that the person is now

subject to the following conditions and to no others:

(If there are more than six conditions, please add any additional conditions in Part G of this form.)

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PART G — ANY OTHER RELEVANT INFORMATION

Please use the space below to record any other relevant information, including any additional conditions

that should or should not be imposed and any other interested persons consulted by you.

PART H — THE AGE ASSESSMENT

Place a cross in ONE of the four boxes below Ø

H1 The person’s date of birth is given on the ﬁ rst page of this form and this form

also constitutes the age assessment that is required.

H2 I have not been able to ascertain the person’s exact date of birth. However, I am

satisﬁ ed that they are aged 18 or over, and this form also constitutes the age

assessment that is required.

H3 It is not clear whether or not the person is aged 18 or over. In my opinion, a more

detailed age assessment is required and Form 5 should be completed.

H4 In my opinion, an age assessment is not required. The current request is for a

replacement standard authorisation and there is no reason to believe

that the age assessment previously done is not accurate.

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Please Use Continuation Sheet

Signed

Dated

WHAT TO DO NOW

It is essential that you give a copy of this assessment to the supervisory body as soon as you have

completed it. This is because the supervisory body may not give a standard authorisation unless and until it

has written copies of all the assessments.

If the person does not meet the best interests qualifying requirement, a standard authorisation may not be

given and all other on-going assessments should stop. You should immediately notify the supervisory body,

and then provide them with a copy of this assessment as soon as practicable. You must keep a written

record of the assessment.

Unauthorised deprivation of liberty

See below concerning the steps that must now be taken.

NOTES

Providing the eligibility assessor with relevant information

The eligibility assessor, if they are not also the best interests assessor, must ask the best interests assessor

to provide them with any relevant eligibility information that the best interests assessor may have, and the

best interests assessor must comply with the request. Relevant information might, for example, include:

(a) whether the person is subject to guardianship under the Mental Health Act 1983

or meets the

statutory criteria for being detained under section 2 or 3 of that Act; and, if so

(b) whether they object to being accommodated in hospital in order to be given the treatment that it is

proposed to give them there for their mental disorder; and, if they do

has consented to each matter to which they themselves object.

Deﬁ nition of ‘interested persons’

Any of the following is an interested person:

(a) the relevant person’s spouse or civil partner

(b) where the relevant person and another person of the opposite sex are not married to each other but

are living together as husband and wife: the other person

but are living together as if they were civil partners: the other person

(d) the relevant person’s children and step-children

(e) the relevant person’s parents and step-parents

(f) the relevant person’s brothers and sisters, half-brothers and half-sisters, and stepbrothers and

stepsisters

(g) the relevant person’s grandparents

1 References in this form to provisions of the Mental Health Act 1983 include provisions of other enactments that have the same effect

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(h) a deputy appointed for the relevant person by the court

(i) a donee of a lasting power of attorney granted by the relevant person.

One person is another’s partner if the two of them (whether of different sexes or the same sex) live as

partners in an enduring family relationship.

Recommending that conditions are or are not imposed

According to the law, the best interests assessor may recommend that conditions should be attached to a

standard authorisation, but should not specify conditions that do not directly relate to the issue of deprivation

of liberty. Conditions could, for example, deal with contact issues, issues relevant to the person’s culture or

other major issues related to the deprivation of liberty, without which deprivation of liberty would cease to be

in the person’s best interests. Conditions may also be recommended to work towards avoiding deprivation

of liberty in future.

Unauthorised deprivation of liberty

The supervisory body and managing authority must address the situation urgently where there is an

unauthorised deprivation of liberty. The possibility of legal proceedings may arise.

Paragraph 5.24 of the deprivation of liberty safeguards Code of Practice states as follows:

‘Where the best interests assessor comes to the conclusion that the best interests requirement is

not met, but it appears to the assessor that the person being assessed is already being deprived of

their liberty, the assessor must inform the supervisory body and explain in their report why they have

reached that conclusion. The supervisory body must then inform the managing authority to review the

relevant person’s care plan immediately so that unauthorised deprivation of liberty does not continue.

Any necessary changes must be made urgently to stop what would be an unlawful deprivation of

liberty. The steps taken to stop the deprivation of liberty should be recorded in the care plan. Where

possible, family, friends and carers should be involved in deciding how to prevent the unauthorised

deprivation of liberty from continuing. If the supervisory body has any doubts about whether the matter

is being satisfactorily resolved within an appropriately urgent timescale it should alert the inspection

body.’

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