Fillable UK Gov Department of Health & Social Care - Deprivation of Liberty Form 11

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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 11

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1
Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 11
RECORD THAT AN EQUIVALENT ASSESSMENT IS BEING USED
STANDARD AUTHORISATION PROCEDURE
In certain circumstances, it may not be necessary to carry out one or more of the six assessments
usually required for a standard authorisation. This form should be used to record that a previous
equivalent assessment has been used instead.
Where a previous assessment is relied on, it is treated as having been carried out in connection
with the current request for a standard authorisation. Because it stands in place of the one usually
now required, it must be copied to the people entitled to receive copies of the assessments used in
connection with the current request for a standard authorisation.
Any equivalent assessments being used should be securely attached to this form.
PART A — BASIC INFORMATION
Full name of the person being assessed
Name of the hospital or care home where it is
proposed to deprive the person of their liberty
Name and address of the supervisory body
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 where it is
proposed to deprive the person of their liberty
(Place a cross in the relevant box and, where
applicable, state the address)
Name
Name
Name
Address
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
CASE
NUMBER
GFSB-Liberty Form 11.indd 1 16/2/09 12:11:12
2
PART B — FORMAL STATEMENT
The assessments indicated in Part C of this form are not required.
In each case where an equivalent assessment is being used:
(a) the supervisory body already has a written existing assessment of the person
(b) the existing assessment complies with all of the requirements that an assessment of that kind must
comply with in relation to a standard authorisation
(c) the existing assessment was carried out within the previous 12 months or is an age assessment
(d) the supervisory body is satisfi ed that there is no reason why the existing assessment may no longer
be accurate.
If an equivalent best interests assessment is being used, before deciding that it was satisfi ed that there is
no reason why the existing best interests assessment may no longer be accurate, the supervisory body took
into account any information given, or submissions made, by:
(a) any relevant person’s representative appointed for the person
(b) any IMCA instructed for the person in relation to their deprivation of liberty.
PART C — THE EQUIVALENT ASSESSMENTS BEING USED
Where an equivalent assessment is being used, place a cross in the middle column next to the relevant
assessment. Then give a brief description of the equivalent assessment in the right-hand column. For
example, write ‘The attached mental capacity review assessment dated … which was carried out in
connection with a review under Part 8 of Schedule A1 to the Mental Capacity Act 2005’.
Assessment
Age assessment
Mental health assessment
Mental capacity assessment
Equivalent Description of the equivalent assessment
being used?
GFSB-Liberty Form 11.indd 2 16/2/09 12:11:13
Please Use Continuation Sheet
Please Use Continuation Sheet
Please Use Continuation Sheet
3
No refusals assessment
Eligibility assessment
Best interests assessment
Please sign and date this form. Please make sure that any equivalent assessments being used are
securely attached to this form.
Signed
(on behalf of the supervisory body)
Dated
NOTES
You should give a copy of this form to the person who is co-ordinating all of the assessments required
following the recent request for a standard authorisation.
This is because the supervisory body may not give a standard authorisation unless and until it has written
copies of all the assessments. This includes having copies of any equivalent assessments that are being
used in place of those usually required.
Signature
Print name
Position
Date
GFSB-Liberty Form 11.indd 3 16/2/09 12:11:13
Please Use Continuation Sheet
Please Use Continuation Sheet
Please Use Continuation Sheet
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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 11

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Completed 28 May 2020

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