1
Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 22
SUPERVISORY BODY’S DECISION
FOLLOWING REVIEW ASSESSMENT(S) UNDER PART 8 OF
SCHEDULE A1 TO THE MENTAL CAPACITY ACT 2005
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 relevant hospital or
care home
Name and address of the supervisory body
Person to contact at the supervisory body
PART B — OUTCOME OF THE REVIEW ASSESSMENTS
Complete EITHER B1 or B2. Do NOT complete both.
Complete B1 if one or more review assessments concluded that the person does not meet a
qualifying requirement. The effect of such a nding is that the standard authorisation is
terminated.
Complete B2 if all of the review assessments concluded that the person does meet the qualifying
requirements. The effect is that the standard authorisation continues in force.
Name
DOB d d m m y y y y
Est. age Years
Name
Address
Name
Address
Name
Telephone
Email
CASE
NUMBER
GFSB-Liberty Form 22.indd 1 19/2/09 13:26:38
2
Place a cross in Box B1 or Box B2 Ø
B1 One or more of the review assessments concluded that the person does not
meet the qualifying requirement to which it relates.
The following qualifying requirement(s) were not met:
Place a cross in the relevant box[es] below Ø
A Age
B Mental health
C Mental capacity
D No refusals
E Eligibility
F Best interests
The supervisory body has therefore terminated this standard authorisation.
If you placed a cross in box B1, please now sign and date the form. You DO NOT need to complete
any other part of this form. You DO need to complete Form 23.
B2 All of the review assessments carried out concluded that the person does meet
the qualifying requirement to which they relate.
The standard authorisation therefore continues in force, subject to any variations
and modi cations stated below.
If you placed a cross in box B2, please complete the rest of the form.
PART C — CHANGE OF REASONS
So far as stated below in this part of the form (Part C), the reasons given in the standard authorisation as to
why the person meets the qualifying requirements are hereby varied.
C1 MENTAL HEALTH REQUIREMENT
Place a cross in box A, B or C. Where C applies, give the new reason immediately below Ø
A A mental health review assessment was not carried out.
B The reason(s) why the person meets the mental health requirement IS/ARE the
reason(s) stated in the standard authorisation.
C The reason(s) why the person meets the mental health requirement IS NOT/ARE
NOT the reason(s) stated in the standard authorisation.
GFSB-Liberty Form 22.indd 2 19/2/09 13:26:38
3
New Reason
The standard authorisation is hereby varied so that the reason(s) given in it as to why the person meets the
mental health requirement is/are now that the person suffers from the form(s) of mental disorder speci ed
below.
By reference to the mental health review assessment, list the relevant diagnosis/diagnoses or
descriptive terms (e.g. depression, dementia), using boxes D–G below:
D
E
F
G
C2 MENTAL CAPACITY REQUIREMENT
Place a cross in box A, B or C. Where C applies, give the new reason immediately below Ø
A A mental capacity review assessment was not carried out.
B The reason(s) why the person meets the mental capacity requirement IS/ARE
the reason(s) stated in the standard authorisation.
C The reason(s) why the person meets the mental capacity requirement IS NOT/ARE
NOT the reason(s) stated in the standard authorisation.
New Reason
The standard authorisation is hereby varied so that the reason(s) given in it as to why the person meets the
mental capacity requirement is/are now as stated below.
By reference to the mental capacity review assessment, state the new reason(s) by placing
a cross or crosses in one or more of boxes D–G below Ø
D The person is unable to understand the information relevant to the decision.
E The person is unable to retain the information relevant to the decision.
F The person is unable to use or weigh that information as part of the process of
making the decision.
G The person is unable to communicate their decision (whether by talking, using
sign language or any other means).
GFSB-Liberty Form 22.indd 3 19/2/09 13:26:38
4
C3 NO REFUSALS REQUIREMENT
Place a cross in box A, B or C. Where C applies, give the new reason immediately below Ø
A A no refusals review assessment was not carried out.
B The reason(s) why the person meets the no refusals requirement IS/ARE the
reason(s) stated in the standard authorisation.
C The reason(s) why the person meets the no refusals requirement IS NOT/ARE
NOT the reason(s) stated in the standard authorisation.
New Reason
The standard authorisation is hereby varied so that the reason(s) given in it as to why the person meets the
no refusals requirement is/are now as stated below.
Place a cross in box D or E below Ø
D The person has 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.
E Any advance decision they have made does not prevent them from being given the
treatment proposed, and any decisions made by their donee of a lasting power of attorney
or deputy do not con ict with these proposals for their accommodation, treatment and care.
C4 ELIGIBILITY REQUIREMENT
Place a cross in box A, B or C. Where C applies, take action as in the ‘New Reason’ note below Ø
A An eligibility review assessment was not carried out.
B The reason(s) why the person meets the eligibility requirement IS/ARE the
reason(s) stated in the standard authorisation.
C The reason(s) why the person meets the eligibility requirement IS NOT/ARE
NOT the reason(s) stated in the standard authorisation.
New Reason
The standard authorisation is hereby varied so that the reason(s) given in it as to why the person meets the
eligibility requirement is/are now as stated in the eligibility review assessment attached to this form.
GFSB-Liberty Form 22.indd 4 19/2/09 13:26:38
5
C5 BEST INTERESTS REQUIREMENT
Place a cross in box A, B or C. Where C applies, complete the rest of this section (C5) Ø
A A best interests review assessment was not carried out.
B The reason(s) why the person meets the best interests requirement IS/ARE the
reason(s) stated in the standard authorisation.
C The reason(s) why the person meets the best interests requirement IS NOT/ARE
NOT the reason(s) stated in the standard authorisation.
If you placed a cross in box C above, indicate which of the reasons have changed by placing a cross
or crosses in one or more of boxes D–F below:
D The reason(s) why the arrangements authorised by the standard authorisation
are in the person’s best interests HAS/HAVE changed.
E The reason(s) why the arrangements authorised by the standard authorisation
are necessary in order to prevent harm to the person HAS/HAVE changed.
F The reason(s) why the arrangements authorised by the standard authorisation
are a proportionate response to the likelihood of the person otherwise suffering
harm, and the seriousness of that harm, HAS/HAVE changed.
New Reason
Where one or more reasons has/have changed (see rows D–F immediately above), the standard
authorisation is hereby varied so that the reason(s) given in it as to why the person meets the best interests
requirement is/are now as stated in the best interests review assessment attached to this form.
PART D — VARYING THE CONDITIONS OF THE STANDARD AUTHORISATION
Note: Part F4 of the bests interests review assessment form (Form10) sets out the assessors
opinion as to whether or not the existing conditions should be varied. If the assessor has
recommended their variation, they will have set out there the new recommended conditions.
Place a cross in box A or B or C Ø
A There HAS BEEN a signi cant change in the person’s circumstances. The supervisory body
MUST therefore vary the conditions to which the standard authorisation is subject.
In the circumstances it is appropriate to vary the conditions in the way shown in Part E.
Now complete Part E of this form.
GFSB-Liberty Form 22.indd 5 19/2/09 13:26:39
6
B There HAS NOT BEEN a signi cant change in the person’s circumstances. However, the
supervisory body has decided that in the circumstances it is appropriate to vary
the conditions to which the standard authorisation is subject.
Now complete Part E of this form.
C There HAS NOT BEEN a signi cant change in the person’s circumstances. Having regard to
any changes there have been, the supervisory body has decided that in the
circumstances it is not appropriate to vary the conditions to which the standard
authorisation is subject. The existing conditions therefore remain in force.
The supervisory body’s reasons for not varying any conditions that it was asked to vary are as follows:
Do not complete Part E of this form. Proceed to Part F instead.
PART E — THE NEW VARIED CONDITIONS
Only complete Part E if you placed a cross in box A or B of Part D of this form.
The conditions to which the standard authorisation is subject are hereby varied. The person is now subject
to the following conditions and to no others:
1
2
3
4
5
6
GFSB-Liberty Form 22.indd 6 19/2/09 13:26:39
Please Use Continuation Sheet
7
PART F — PROVIDING COPIES OF THIS DECISION AND THE REVIEW ASSESSMENTS
The supervisory body has completed its review of this standard authorisation.
Any review assessments that were carried out are attached to this form.
If you have received copies of this notice, and copies of the review assessments that were carried out, it is
because the supervisory body is required to give them to the following persons:
(a) the managing authority of the hospital or care home
(b) the person who is the subject of the standard authorisation
(c) the person’s representative
(d) any section 39D IMCA.
Signed
(on behalf of the supervisory body)
Dated
Signature
Print name
Position
Date
GFSB-Liberty Form 22.indd 7 19/2/09 13:26:39
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome