Fill - Free fillable UK Gov Department of Health & Social Care - Deprivation of Liberty Form 12 Supervisory Body's Decision Standard Authorisation PDF form

Mental Capacity Act 2005

DEPRIVATION OF LIBERTY FORM No. 12

SUPERVISORY BODY’S DECISION

STANDARD AUTHORISATION

The following standard authorisation has been given

PART A — BASIC INFORMATION

Full name of the person being deprived

of their liberty

Their date of birth (or estimated age if

unknown)

Name and address of the hospital or care home

at which their deprivation of liberty is authorised

Name and address of the managing authority

responsible for this hospital or care home (this is

the person registered under Part 2 of the Care

Standards Act 2000, or the NHS body that

manages the hospital)

Name and address of the supervisory body

granting this standard authorisation

Person to contact at the supervisory body

Name

DOB d d m m y y y y

Est. age Years

Name

Address

Name

Address

Name

Address

Name

Telephone

CASE

NUMBER

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The present address of the person being

deprived of their liberty

(If, for example, the person is currently living at

home and has not yet been admitted to the

hospital or care home, this will be their home

address. If they are currently living at a different

hospital or care home to the one to which the

request for a standard authorisation relates, this

will be the hospital or care home where they are

at present.)

PART B — THE SUPERVISORY BODY’S DECISION

The supervisory body has received written copies of all the required assessments.

All of the assessments are positive, i.e. each assessment has come to the conclusion that the person meets

the qualifying requirement to which the assessment relates.

This standard authorisation has been given.

PART C — DETAILS OF THE STANDARD AUTHORISATION

C1 DATE ON WHICH THE STANDARD AUTHORISATION COMES INTO FORCE

This standard authorisation is to come into force:

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

A Immediately

B On the following date:

C2 THE PERIOD DURING WHICH THE AUTHORISATION IS TO BE IN FORCE

This standard authorisation is to expire:

Enter the date below Ø

At the end of the day on:

(The period speciﬁ ed must not exceed the maximum period speciﬁ ed in the best interests

assessment)

As above (already living at the above

hospital or care home)

At a different address which is that given

immediately below:

Address

ddm

yyyy

ddm

yyyy

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C3 THE PURPOSE FOR WHICH THIS STANDARD AUTHORISATION IS GIVEN

The purpose for which this standard authorisation is given should be described here.

Note: there is a legal requirement that the giving of a Mental Capacity Act 2005 deprivation of liberty

safeguards authorisation must be for the purpose of giving care or treatment to the person to whom the

authorisation relates. The entry below should therefore identify the care and/or treatment that constitutes

the purpose for which the authorisation is given. It should be borne in mind, however, that the deprivation of

liberty authorisation does not itself authorise the care or treatment concerned, the giving of which is subject

to the wider provisions of the Mental Capacity Act 2005.

The purpose of authorising the deprivation of the person’s liberty in the above hospital or care home is so

that they may receive the following care and/or treatment:

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Please Use Continuation Sheet

C4 ANY CONDITIONS TO WHICH THIS STANDARD AUTHORISATION IS SUBJECT

Before deciding whether to give the authorisation subject to conditions, the supervisory body had regard

to any recommendations in the best interests assessment concerning such conditions. The supervisory

body should consult the best interests assessor if the best interests assessor’s recommendations are not

being followed and the best interests assessor has indicated in their assessment report that they would

like to be consulted again in that event, since some of the other conclusions that they have reached in their

assessment may be affected.

Place a cross in box A or B Ø

A This standard authorisation IS NOT subject to any conditions

B This standard authorisation IS subject to the following conditions set out

immediately below

If you placed a cross in box B above, list below the conditions to which this standard authorisation is

subject. Be precise about the form of words entered here. Hospital and care home staff must comply with

any conditions that are speciﬁ ed. They have no authority to do anything that does not comply with such

conditions.

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PART D — THE SUPERVISORY BODY’S REASONS

The reason(s) why each qualifying requirement is met are as follows:

D1 AGE REQUIREMENT

Place a cross in box A OR B Ø

A The person’s date of birth has been established and s/he is aged 18 or over.

B Although it has not been possible to establish the person’s date of birth, the

supervisory body is satisﬁ ed that they are aged 18 or over.

D2 MENTAL HEALTH REQUIREMENT

The person is suffering from mental disorder:

By reference to the mental health assessment, describe the mental disorder(s) from which the

person is suffering.

D3 MENTAL CAPACITY REQUIREMENT

The person lacks capacity to make their own decision about whether they should be accommodated in the

hospital or care home for the purpose of being given the proposed care and/or treatment because of an

impairment of, or a disturbance in the functioning of, the mind or brain. As a consequence:

Place a cross in ONE OR MORE of the boxes below (A–D) Ø

A The person is unable to understand the information relevant to the decision.

B The person is unable to retain the information relevant to the decision.

C The person is unable to use or weigh that information as part of the process

of making the decision.

D The person is unable to communicate their decision (whether by talking, using

sign language or any other means).

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Please Use Continuation Sheet

D4 NO REFUSALS REQUIREMENT

The person satisﬁ es the no refusals requirement. This is because:

Place a cross in ONE of the boxes below (A or B) Ø

A They have not made an advance decision or a lasting power of attorney under

the Mental Capacity Act 2005 and no deputy has been appointed by the Court of Protection.

B Any advance decision they have made does not prevent them from being given the

treatment proposed, and any decisions made by a donee of a lasting power of attorney

or deputy do not conﬂ ict with these proposals for their accommodation, treatment and care.

D5 ELIGIBILITY REQUIREMENT (CARE HOME CASES ONLY)

The person satisﬁ es the eligibility requirement because:

Place a cross in the box below to conﬁ rm that the statement made there is correct Ø

A Accommodating them in this care home will not conﬂ ict with any requirement

imposed on them under any of the following provisions of the Mental Health

Act 1983

(a) a community treatment order

(b) a guardianship application or order

D6 ELIGIBILITY REQUIREMENT (HOSPITAL CASES ONLY)

The person satisﬁ es the eligibility requirement for the following reason:

Place a cross in EITHER Box A OR B Ø

A They are not subject to any relevant provision of the Mental Health Act 1983 and do not

meet the criteria for being detained under section 2 or 3 of the Mental Health Act

1983.

B To the extent that they are relevant, the following statements are all true:

(a) The person is not detained in a hospital under one of the following sections

of the Mental Health Act 1983: sections 2, 3, 4, 35–38, 44, 45A, 47, 48 or 51.

(b) If the person is LIABLE to be detained under one of these sections, the purpose for

which the standard authorisation is requested does not consist wholly or partly of

medical treatment for mental disorder in a hospital.

them in this hospital will not conﬂ ict with a requirement imposed on them in

connection with their liability to detention under the Mental Health Act 1983, for

example as a condition of a leave of absence or conditional discharge from hospital.

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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(d) If the person is on a community treatment order, the purpose for which the

standard authorisation is requested does not consist wholly or partly of medical

treatment for mental disorder in a hospital.

(e) If the person is on a community treatment order, accommodating them

in this hospital will not conﬂ ict with a requirement imposed on them under the

community treatment order.

(f) If the person is subject to guardianship, accommodating them in this hospital will

not conﬂ ict with a requirement imposed on them by their guardian.

(g) Although the person is subject to guardianship, they either do not object to being

accommodated in this hospital for the purpose of being given some or all of the

medical treatment proposed for their mental disorder, or a donee of a lasting

power of attorney or deputy appointed by the Court of Protection has made a

valid decision to consent to each matter to which they do object.

(h) Although the person meets the statutory criteria for being detained under

section 2 or 3 of the Mental Health Act 1983, they either do not object to being

accommodated in this hospital for the purpose of being given medical treatment for

their mental disorder or to any or all of that proposed treatment, or a donee or deputy

has made a valid decision to consent to each matter to which the person does object.

(i) Although the person meets the statutory criteria for being detained under

section 2 or 3 of the Mental Health Act 1983, or is subject to guardianship, the purpose

for which the standard authorisation is requested does not include treatment for

mental disorder.

D7 BEST INTERESTS REQUIREMENT

The person satisﬁ es the best interests requirement for the following reasons:

When completing this section, either copy the reasons given in the best interests assessment or

give a sufﬁ cient summary of the reasons to demonstrate to a reader that each of the requirements is

fulﬁ lled.

A For the following reasons, the proposed arrangements for the person’s care and/or treatment

amount to depriving them of their liberty in this hospital or care home.

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Please Use Continuation Sheet

B For the following reasons, although the proposed arrangements amount to depriving the person of

their liberty they are in the person’s best interests:

C For the following reasons, although the proposed arrangements amount to depriving the person of

their liberty they are necessary in order to prevent harm to the person:

D Although the proposed arrangements amount to depriving the person of their liberty, for the

following reasons they are a proportionate response to the likelihood of the person otherwise

suffering harm and the seriousness of that harm:

PART E — PROVIDING COPIES OF THIS STANDARD AUTHORISATION

As soon as practicable, the supervisory body must give a copy of this standard authorisation to the

following:

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Please Use Continuation Sheet

(a) the managing authority of the hospital or care home

(b) the person being deprived of their liberty

(d) any IMCA instructed for the person under section 39A of the Mental Capacity Act 2005 in relation to their

deprivation of liberty

(e) every person named by the best interests assessor in their report as an interested person whom they

have consulted in carrying out their assessment.

This form is also your notice that any urgent authorisation that has been in force comes to an end when this

standard authorisation comes into force.

PART F — PROVIDING COPIES OF THE ASSESSMENTS

Copies of all the assessments in relation to the above person (including any equivalent assessments) have

been attached to this standard authorisation. They will be sent as soon as practicable to all of the persons

listed in paragraphs (a) to (d) of Part E above.

Unless they also fall within paragraphs (a) to (d) of Part E above, interested persons consulted by the

best interests assessor are entitled to receive a copy of this standard authorisation but not copies of the

assessments.

Signed

(on behalf of the supervisory body)

Dated

NOTE TO THE MANAGING AUTHORITY OF THE HOSPITAL OR CARE HOME

Providing rights information

The managing authority must take such steps as are practicable to ensure that the person understands the

following matters:

(a) the effect of this authorisation

(b) the right to apply to the Court of Protection, asking it to terminate or vary this authorisation

2005

(d) the right to have a section 39D IMCA instructed

(e) how to have a section 39D IMCA instructed.

These steps must be taken as soon as is practicable after this authorisation is given, and must include

giving the required information both orally and in writing. The written information given to the person must

also be given to their representative as soon as is practicable after it is given to the person themselves.

If you are informed that a section 39D IMCA has been instructed for the person, this written information must

also be given to that IMCA.

NOTICE TO THE SUPERVISORY BODY

The supervisory body must appoint a person to be the ‘relevant person’s representative’ as soon as

practicable after this standard authorisation is given.

Signature

Print name

Position

Date

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