BEST INTEREST ASSESSOR COURSE
There are 2 cases studies and you are required to choose ONLY 1 OR USE A SHADOWING EXPERIENCE OR USE A CASE STUDY you have been provided with as long as a DOL has been authorised.
Case studies to refer to for VIVA exam MOCK AND SUMMATIVE ASESSMENT.
Case study 1 ME
Full name of the person being assessed – ME
Date of birth (or estimated age if unknown) 09/06/1929 Est. Age 86
In carrying out this assessment I have met or consulted with the following people
NAME ADDRESS CONNECTION TO PERSON BEING ASSESSED
Home Representative RGN
Son MR GE
The following interested persons have not been consulted for the following reasons
NAME REASON CONNECTION TO THE PERSON BEING ASSESSED
I have considered the following documents (e.g. current care plan, medical notes, daily record sheets, risk assessments)
DOCUMENT NAME DATED
Care notes and care plan from nursing home
Urgent and Standard Authorisation
Care plans, risk assessments, daily recordings, incident logs, medical information and background history kept in records held at the care home (All documentation was up to date)
Mental Health and Eligibility forms completed by sec 12 doctor
Mental Capacity Assessment
The following practicable steps have been taken to enable and support the person to participate in the decision making process:
In line with Principle 2 of the MCA (section 1(3)), I took practicable steps to enable Mrs. ME to make a decision in relation to her care, treatment and accommodation.
Prior to the assessment I established from the Home Representative RGN Mrs ME’s communication needs in order to optimise her involvement. I was informed that Mrs ME who had vascular dementia spoke English and that she tended to be most alert during early afternoon. She was reported to be supported by her son Mr GE in complex decisions. I telephoned Mr GE who confirmed his mother’s communication needs. He advised that his mother had little short term memory and sometimes needed information repeated. I acknowledged that Mrs ME would be meeting me for the first time and may have felt apprehensive about speaking openly. I subsequently arranged for Mr GE to be present to provide support and reassurance to his mother for the purpose of this assessment. In addition I gleaned information from Mrs ME’s care notes on barriers to communication such as disorientation and occasional verbal aggression.
Mrs ME was assessed during two interviews on 9/12/15 and 11/12/15.
On arrival at the first assessment on the afternoon of 9/12/15 I initially met Mrs ME’s son and then with Mrs ME who was sitting in the dining area. In order to enable her to feel more at ease I asked her whether she would like to speak with me with the support of her son in a private room. She agreed to this. A further assessment was necessary as Mrs ME seemed to be somewhat disoriented. A second assessment took place two days later. Mrs ME declined support from a staff member during this assessment. Mrs ME was interviewed in a quiet area of the corridor of the unit at her choice. Photographs of her at her former home and CB Care Home were used to help engage and communicate with her whilst also providing context for the purpose of the assessment.
Providing relevant information is essential in all decision making (para 3.7 MCA COP). On both occasions I took time to give Mrs ME information relevant to the decision about her accommodation, care and treatment and the fact that she was not free to leave. I was mindful not to provide Mrs ME with overly detailed information in accordance with Chapter 3 of the MCA which may confuse her. In accordance with the directions given by Maccur J in LBL v RYJ, I provided Mrs ME with the ‘salient details’ of the decision to be made as follows
She had been living at CB Care Home since 25/5/13. She was there to receive care and treatment Care staff supported her to ensure all her daily needs were met including personal care, dressing and undressing, eating and drinking, taking medication and support with mobility and transfers. She is subject to restrictions as she is constantly supervised and is not free to leave the nursing home as the home had a locked door and staff would return her to the home if she left.
During the assessment I sat near Mrs ME so that she could see and hear me. I spoke slowly at an appropriate volume using simple and jargon free language. I gave her information in bite sized chunks, paused to check her understanding of the options and associated risks and allowed time for her to respond to questions. I also repeated information and questions where necessary.
In my opinion the person LACKS capacity to decide whether or not they should be accommodated in this hospital or care home for the purpose of being given the proposed care and/or treatment, and the person is unable to make this decision because of an impairment of, or a disturbance in the functioning of, the mind or brain.
X
In my opinion the person HAS capacity to decide whether or not they should be accommodated in this hospital or care home for the purpose of being given the proposed care and/or treatment
Stage One: What is the impairment of, or disturbance in the functioning of the mind or brain?
Mrs ME has Vascular Dementia which causes and impairment of, or disturbance of the functioning of the mind or brain.
Stage Two: Functional test a. The person is unable to understand the information relevant to the decision Record how you have tested whether the person can understand the information, the questions used, how you presented the information and your findings.
Decision to be made
I assessed Mrs ME’s capacity in relation to the specific decision on whether or not she was able to give valid consent to be accommodated to receive care and treatment in her placement at CB Care Home Nursing Home and to the relevant restrictions associated with her present deprivation.
In seeking to identify Mrs ME’s understanding of where she was, she stated she thought she lived “in a home” but she was unable to identify the name of the home or what led her to be where she was. In asking Mrs ME whether she had carers visiting her when she was at home to help her she stated “I can’t remember I was only a kid”. When Mrs ME was asked what she understood by a ‘home’, she responded with “it’s just somewhere where you sit” and did not elaborate on this, despite my rephrasing the question. In response to a question over what care Mrs ME needed she replied “I have food’, I don’t get it… I don’t know if I get the proper amount or who does it …” Mrs ME was asked what help carers gave her in the home. She did not identify any of her other health or care needs but responded with “I’m fine, I do it all myself’…’I don’t want to be dependent on others… it wouldn’t feel right. I’ve done it alone since being a kid”. Mrs ME was asked specifically if she had any help with having a shower, Mrs ME replied she did not have any help. Evidence from care notes and staff confirmed that Mrs ME did require assistance from care staff with showering. Mrs ME was informed again of the support that the carers provide her with and then asked what would happen if the carers were not in place. Mrs ME said “I don’t know, we’d just have to see”.. When Mrs ME was asked who other people in the home were, she replied “I don’t know”. Mrs ME was asked whether she understood that she was not free to leave. Mrs ME, however, maintained that she had only recently arrived “here” and that although she knew she had to stay in the home, she had been “out of the home” on her own “at times”. The latter was confirmed by the home representative and her care plan to be incorrect. In response to asking Mrs ME what it was like living at CB Care Home Mrs ME replied “I just get on with things I have to do as I always have”.
Mrs ME was disoriented in terms of time as despite just having had her lunch she believed it was evening time.
This provides evidence of Mrs ME’s inability to understand information in order to make a decision regarding her care, treatment and accommodation at CB Care Home.
b. The person is unable to retain the information relevant to the decision Record how you tested whether the person could retain the information and your findings. Note that a person’s ability to retain the information for only a short period does not prevent them from being able to make the decision.
Despite giving and repeating salient information to Mrs ME such as where she was living, why she came to be where she was and the care and support that she received, Mrs ME was unable to retain this information.
This provides evidence of Mrs ME’s inability to retain information in order for her to make a decision regarding her care, treatment and accommodation at CB Care Home.
x
c. The person is unable to use or weigh that information as part of the process of making the decision Record how you tested whether the person could use and weigh the information and your findings.
Mrs ME was not able to understand and retain information about the options and was thus unable to weigh up information in order to make a decision. Mrs ME’s statement that she was able to carry out her own care needs despite being given information to the contrary highlighted that she was unrealistic about the expectations that she had of herself.
This provides evidence that Mrs ME is unable to use or weigh up information in order for her to make a decision regarding her care, treatment and accommodation at CB Care Home.
d. The person is unable to communicate their decision (whether by talking, using sign language or any other means) Record your findings about whether the person can communicate the decision.
In the first interview she expressed a preference to be at home, then pointing to her son she said she wanted to go home with him (without recognising that he was her son). She then said she did not want to take a ‘chance on him’. In the second interview Mrs ME was able to speak and articulate that she was ‘alright’ where she was. Her response however was not based on any rational decision which was informed by understanding, retaining and weighing up the information pertaining to her needs.
This provides evidence that Mrs ME was therefore not able to communicate a decision about her care, treatment and accommodation at CB Care Home.
x
Stage Three: Explain why the person is unable to make the specific decision because of the impairment of, or disturbance in the functioning of, the mind or brain.
In accordance with s. 2(1) MCA 2005 Mrs ME has Vascular Dementia which causes an impairment or disturbance in the functioning of the mind or brain. Her resultant cognitive impairment and short term memory loss provides the ‘causal nexus’ for her lack of capacity with regards to her care, treatment and accommodation at the material time that this assessment was carried out.
NO REFUSALS ASSESSMENT To the best of my knowledge and belief the requested Standard Authorisation would not conflict with an Advance Decision to refuse medical treatment or a decision by a Lasting Power of Attorney, or Deputy, for Health and Welfare.
To the best of my knowledge and belief the requested Standard Authorisation would conflict with an Advance Decision to refuse medical treatment or a decision by a Lasting Power of Attorney, or Deputy, for Health and Welfare.
Please describe further
There is not a valid Advance Decision, Lasting Power of Attorney or Deputy for Health and Welfare in place X
BEST INTERESTS ASSESSMENT MATTERS THAT I HAVE CONSIDERED AND TAKEN INTO ACCOUNT I have considered and taken into account the views of the relevant person X
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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
X
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 being deprived of liberty
X
I have taken into account any assessments of the person’s needs in connection with accommodating the person in the hospital or care home X
I have taken into account any care plan that sets out how the person’s needs are to be metwhile the person is accommodated in the hospital or care home
X
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 donee of a Lasting Power of Attorney or Deputy (c) any IMCA instructed for the person in relation to their current or proposed deprivation of liberty
X
BACKGROUND INFORMATION Background and historical information relating to the current or potential deprivation of liberty. For a review look at previous conditions and include comments on previous conditions set.
Mrs ME has been a resident of CB Care Home since 25/5/13. Historical electronic social care records indicate that Mrs ME was diagnosed with moderate vascular dementia on the 24/10/12 and was assessed as not having capacity 2/11/12 by Dr Hayer from the Little Bromwich Community Mental Health Team on 2/11/12. Mrs ME’s husband AB had a number of hospital admissions due to his ill-health and he was eventually placed in CB Care Home on 31/1/2013.
What else has been tried and failed and why Mrs ME is in CB Care Home and requiring nursing care
As Mrs MEs health continued to deteriorate in the community, concerns were raised in relation to her poor food intake, unintentional self-neglect, wandering and deteriorating mental health.
A package of care of approximately three calls a day was set up to support her with tasks and activities of daily living and a pendant alarm was put in situ. Mrs ME was described by her son to be frequently disoriented and verbally aggressive often raising her stick to carers. He reports that her electric heater caught fire on one occasion and was fortunately extinguished in time by home carers. Mrs ME had been unable to use her pendant alarm. Social care records indicate Mrs ME was returned home by neighbours on at least one occasion after wandering out. Mrs ME’s children provided daily support often staying with her at night during this period.
Following a hospital admission due to reduced mobility and general ill-health the discharge planning team in consultation with the family proceeded to consider a number of options for discharge under her best interests. Mrs ME’s husband who was alive at the time had significant input in to the decision. Mrs ME’s son states that options such as supported living or indeed anything short of 24 hour care would have raised significant risks for Mrs ME
between calls and at night as she could not alert assistance.
Discussions thus culminated in a decision to place her at CB Care Home initially in a residential placement. Her deterioration in her health whilst in placement led to her having a Continuing Health Care Assessment and her qualifying for the nursing level of care. Significant People and Events Mrs ME was born in Birmingham and was one of seven siblings who are now all deceased. Mrs ME lived with her late husband AB at her former property for approximately 46 years. She had two children G… and C..l. C…. sadly died earlier this year. Mrs ME was said to have worked in an Office and her hobbies included crochet, knitting for charities and singing in a choir. In recent years her late husband was her main carer and was said by her son to have shielded the children from the onset and resultant symptoms of her dementia.
Care at CB Care Home Mrs ME requires 24 hour nursing care and supervision. She is supported with washing, dressing and assistance with medication. Carers encourage and monitor Mrs ME’s dietary intake as “she is a very picky eater”. Evidence from care notes and the RGN indicate Mrs ME’s weight dropped to 39.7kg on 21/1/15 and has fluctuated significantly since then. Her weight has now increased to 54.5kg as of 16/11/15. Mrs ME remains under the CH Community Dietician. She is recorded in ‘professional notes ‘to have been directed to take a high calorie diet and fortisips x 3 prescribed by the GP. Her weight has now (16/11/15) passed target range and her BMI is 20.7. She is due to be reviewed again shortly.
Mrs ME walks using a Zimmer frame; however, she needs supervision with regards to her mobility and transfers. Mrs ME is at high risk of falls and has sustained a number of falls which have necessitated hospitalisation. An incident form on her care notes recorded an unwitnessed fall on the 17/10/15 which led to her having a lump on her head and a fracture to her right NOF. A further fall on the 9/11/15 evidenced her having had a fall on the 9/11/15 when she was found on the floor with a skin tear to her left elbow. It was noted that a falls plan and risk assessment was in situ and that staff were required to check and monitor her to ensure where she was within the home at all times whilst also checking on her every two hours at night. Apart from Mrs ME being able to address her continence needs in the main (with only the occasional accident of slight ‘leakages of urine’), she is largely reliant on staff to anticipate and address her health and social care needs.
Mrs ME was also noted to require assistance with her medication with staff having to cajole her at times and return to administer her medication to aid her compliance.
Mrs ME was noted to engage in social activities at times but was also said to spend long periods of time sometimes up to two days when she chooses to remain in her room.
VIEWS OF THE RELEVANT PERSON Provide details of their past and present wishes, values, beliefs and matters they would consider if able to do so:
During my consultations with Mrs ME, she gave inconsistent view of where she would like to live, sometimes saying she would like to ‘go home’ without any concept of where or what this would entail and at other times that she is ‘happy’ where she is. Mrs ME raises no objection over remaining in the home. It was however very apparent that Mrs ME valued her independence as she stated in response to a question on what help she needed with her care: ’I don’t want to be dependent on others… it wouldn’t feel right. I’ve done it alone since being a
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kid”.
Mrs ME was noted to present as cheerful and broke out with singing from time to time during the assessment. She talked about how much people around her ‘loved’ to hear her sing. She was observed to have a good rapport with both staff and some of the other service users with whom she made passing conversation.
I understood from Mr GE that when Mrs ME was mentally capable, She expressed no particular objection to be placed for long term placement in care home and wanted to move in as her husband was there.
It was noted in her care plan that She likes going into the community and in the past enjoyed music and dancing and would sit in the garden when the weather is fine. She also enjoys visits from her son.
Her son reported that he did not think his mother was a particularly religious person and although she was a member of the Church of England, she was not observed to be attending Church regularly.
Given that she wished to be non-dependent on others I would think that Mrs ME would have continued to remain at home as long as possible, if she was given the choice to do so but assessments clearly indicate that it was too unsafe for her to continue to remain at home.
VIEWS OF OTHERS
GE (Son) Mrs ME’s son stated that Mrs ME was agreeable to going in to CB Care Home as she was joining her husband and at the time her cat was able to move to the home with her. Mr GE stated that it was his belief that she would not have wanted to remain at home in the long term. He stated that owning a home had been very important to his mother and that she was a very homely person. He stated that in his opinion his mother’s dementia had now deteriorated to a point where he felt that she remembered very little about her former home and had come to view CB Care Home where she had settled as her home.
Mr GE further stated that his mother’s combined physical and mental health needs were now of such a high degree that she could not be managed in any environment other than one that provided 24 hour care with her daily and night time needs. He stated that the high risks of falls, poor nutrition and her inability to manage her day to day activities due to the deterioration in her dementia were among some of the reasons why he felt it was necessary for her to remain in CB Care Home and be deprived of her liberty. He stated that he visited his mother every week and was actively involved in her care. He stated that he felt that the CB Care Home was in the main very proactive in responding to his mother’s needs in an appropriate and sensitive manner. He raised concern about a one off incident where a tap in her room was dripping and that a delay of a week in getting it fixed. He commented that this incident was a one of incident and that his concerns were satisfactorily addressed.
Mr GE was noted to have Deputyship for managing Mrs ME’s finances only. There was also a mental capacity assessment on file which had been completed by Dr R Edwards 21/12/14 which outlined that Mrs ME had ‘end stages of dementia’. She was recorded by Dr Edwards not to have mental capacity in relation to ‘finances, medication, safety or to give consent to treatment’. Mrs ME’s son confirmed that Mrs ME did not make any advance decisions about her care or welfare.
CH (RGN) CH stated that Mrs ME was admitted to CB Care Home on 25/5/15 with her cat TG. Mrs ME was said to be happy to join her husband AB who was already in residence at CB Care Home when she came in to placement.
Mrs ME was described as being a fairly sociable woman who enjoyed singing but had periods of low mood. The RGN outlined that Mrs ME required support with some aspects of her personal care, nutrition and medication needs. There were additional concerns in relation to her needing supervision with her mobility and transfers to prevent falls and fall related injuries. Mrs ME was noted to get confused with her walking aids and often clutter her room with a number of walking Zimmer frames and walking sticks. In doing this she not only presented risks to herself as she wandered around the home but that she also presented risks to other residents whose walking aids she had taken. Mrs ME was also reported to be under the nutritionist as her weight had fluctuated considerably. She was noted to have gained weight more recently. The home representative stated that it was her view that Mrs ME need to be deprived of her liberty due to the risk of harm that she would experience if she did not have the care and supervision that she had at the present time at CB Care Home. The RGN further stated that although Mrs ME had not made any attempts to leave CB Care Home unaccompanied, if she were to try to leave she would be prevent from doing so by staff. If she did manage to leave she would be returned to the home in the interests of her safety.
N B (Psychiatrist and Mental Health Assessor) N B carried out a Mental Health assessment on the 16/12/15 and is quoted as saying:
‘The above named lady has a diagnosis of Dementia. On assessment today she was sitting in the lounge. She smiled at me when I introduced myself. She was very pleasant. She said this was not her home and knew it was a nursing home. She said she came this morning to the nursing home. She said she comes and goes from this nursing home. She said she came this morning to this nursing home. There was evidence of poor short term memory and severe cognitive impairment. There was no history of challenging behaviour’.
N B further stated in terms of impact of the Deprivation of Liberty on Mrs ME:
‘Deprivation of liberty will have minimal effect on the mental health of this lady. She has been living in this care home for the last few years. She walks freely in the care home with her Zimmer frame. She has not been trying to leave the care home and not been expressing any desire either’.
I have considered the mental health assessment of Mrs ME and concur with the assessment of the Doctor that depriving Mrs ME of her liberty in delivering the care treatment is unlikely to affect her mental health adversely. I have also considered the eligibility assessment in making decisions about Mrs ME’s deprivation of liberty under the DoLS Procedure. It is clear from the assessment that deprivation of liberty under DoLS procedure do not conflict with a requirement under the Mental Health Act.
THE PERSON IS DEPRIVED OF THEIR LIBERTY In my opinion the person is, or is to be, kept in the hospital or care home for the purpose of being given the relevant care or treatment in circumstances that deprive them of liberty Note: if the answer is No then the person does not satisfy this requirement
YES
X
NO
The reasons for my opinion: Note: Consider the concrete situation of the person including type, duration, effects and manner of implementation of the measures in question in order to determine whether they meet the acid test of continuous (or complete) supervision AND control AND are not free to leave.
Objective: Applying the acid test should provide evidence of confinement in a particular restricted space for more than a negligible period of time. Refer to the descriptors in the DoLS Code of Practice in light of the acid test.
THE ACID TEST OF DEPRIVATION
The acid test for deprivation of liberty as outlined by Lady Hale and handed down by the Supreme Court on 19/3/14 in reference to Cheshire West and Chester Council v P (2014) is fulfilled as follows:
The Concrete Situation
Supervision Mrs ME is under continuous supervision. Mrs ME is monitored and supervised throughout the day in CB Care Home with care staff being aware of her whereabouts. She is also checked every two hours at night. When Mrs ME is taken out on rare occasions into the garden with a wheelchair she is escorted by staff.
During the day, staff monitor and prompt Mr ME with activities of daily living. She has general observation throughout the day and 1:1 support to complete essential activities of daily living. She is supervised and guided by staff with activities such as: personal care, meal preparation, accessing activities or appointments in the community. Staff monitor Mrs ME’s medication intake. Her mood is monitored and regular reassurance is provided throughout the day. Staff record observations/incidents in Mrs ME’s notes. Her blood sugar is regularly checked at the GP surgery. There are care plans, guidelines and risk assessments about various aspects of Mrs ME’s daily activities. On that basis, I am of the opinion that Mrs ME is under continuous supervision.
Control Personal Care Mrs ME is accommodated or confined for the purpose of providing all-day care and managing activities of daily living in CB Care Home for a significant period of time. Evidence from care notes indicate that her personal care, nutritional, medication, mobility and transfers need to be anticipated by staff on a 24hr basis. Mrs ME also needs to be monitored for pressure areas and UTIs. To a large extent Mrs ME is subject to the routines and regimes prescribed by the nursing home although the home strives balance their responsibilities by enabling choices. Meals for example can be provided in her room if necessary at a time when she wishes to eat.
The Environment Mrs ME is in an environment with locked doors with codes that she is unable to access. The home also has locked windows. Limits on Movements or Contacts Although generally compliant Mrs ME can be resistant to interventions such as personal care. Staff strive to encourage her compliance using a range of methods, approaches and interventions. The latter can include returning to interventions after a period of time, distracting by talking to her, offering her a cup of tea or giving her reassurance. In the garden Mrs ME’s right to liberty is further controlled or breached whilst being escorted in a wheelchair. Mrs ME is escorted to appointments outside the home. The home has an open door policy for visitors with a general exception for meal times. In my view, Mrs ME has no control over most aspects of his life and is not free to leave CB Care Home.
This therefore provides evidence of continuous supervision and control.
Not free to leave Mrs ME has not attempted to leave the home although she wanders about the home. If she could physically leave the home which is unlikely due to her decreased mobility she would be unable to operate the doors of the unit, lift or the entrance as she would not remember the process or relevant codes.
In line with the Supreme Court Cheshire West Judgement as referred to above, however, whether someone is physically able to leave the home is immaterial. What is, however, important is what staff would do if she were to leave. The RGN has stated that if Mrs ME did leave staff would prevent her from leaving and return her to the home immediately if she did leave.
This therefore provides evidence that she would not be free to leave.
Mrs ME is confined to the home for a not negligible length of time for the purpose of receiving care and treatment.
The impact of the type, duration, effect and manner of implementation of the supervision and control and the inability to leave outlined above over a 24hr basis evidences the essential elements of the acid test and hence a Deprivation of Liberty.
Again in line with the Supreme Court Judgement in Cheshire West, compliance or lack of objection or the relative normality of the placement or the purpose behind this much needed placement are irrelevant to the acid test.
Mrs ME currently lives in an environment where she is under supervision and control on a 24hr basis, the cumulative effect of which is to cause the acid test to be met. Hence in my professional opinion Mrs ME is deprived of her liberty.
Subjective: Evidence that the person lacks capacity to consent to being kept in the hospital or care home for the purpose of being given the relevant care or treatment.
As already identified Mrs ME does not have mental capacity in regards to making decisions about her accommodation, care and treatment and there is therefore no valid consent on these matters.
She is unable to understand his medical condition and therefore, I am of the view that she has accepted that she is receiving care and treatment rather than understanding why she is receiving these. She lacks safety awareness, has no abilities to structure any activities independently and staff provide effective supervision and control over all aspects of her daily living.
Based on the issues described above, I concluded that Mrs ME does not have capacity to make decisions in relation to her accommodation, care or treatment. In my view, the above factors satisfy the subjective element for deprivation of her liberty. The confinement is without valid consent as outlined in the Mental Capacity Assessment.
The placement is imputable to the State because:
The placement is imputable to the state as although the Local Authority had not made the arrangements for this confinement, CB Care Home is in fact regularly inspected and regulated by the CQC. It is not relevant that Mrs MEs placement is privately funded. Further Mrs ME now receives a nursing contribution for her care via the CCG.
It is necessary to deprive the person of their liberty in this way in order to prevent harm to the person. The reasons for my opinion are:
YES X
NO Describe the risks of harm to the person that could arise which make the deprivation of liberty necessary. Support this with examples and dates where possible. Include severity of any actual harm and the likelihood of this happening again.
Taking into consideration section 4.61 of the DoL CoP it is my view that harm (the nature of which is outlined below) could arise if the DoL is not in place.
Harm that could be avoided includes:
Mrs ME’s communication ability is now impaired as a result of her cognitive impairment such that she would be vulnerable to harm occurring to her without the continuous supervision and monitoring which she is in receipt of at present from the staff at the care home as she would be unable to call or ask for help as at present the staff have to anticipate her needs through continuously monitoring and observing her.
-Falls and fall related injuries and hospital admissions ,the high risk of which has been evidenced by her being unrealistic about her functional abilities, being at high risk of UTIs and having had falls within the home necessitating hospital admissions in the past twelve months. As evidenced in her care notes, Mrs ME also in her confusion and disorientation frequently collects walking frames and sticks in her room which present a tripping hazard.
-Self-neglect. The moderate risk of which is evidenced by her occasional non-compliance and resistance as evidenced in her care notes and her own inability to manage her own needs fully.
-Malnutrition. The high risk of which is evidenced by periods in the last twelve months when her weight has reduced and dieticians have needed to be engaged by the home to direct a plan of action and monitoring of weight has been required thereafter as evidenced within this assessment.
-Health Deterioration. The medium risk of which is evidenced by her occasional noncompliance necessitating staff to cajole her or return to give her medication to her at a later time.
-Reducing social isolation. The high risk of which is identified by her staying in her room for long periods of time when feeling low.
Preventing Abuse – Mrs ME would be at risk of being taken advantage of or being abused without staff support to safeguard her from abuse and maintain her safety. She relies on staff monitoring her continuously in order to do this.
Overall Mrs ME has deteriorated significantly in both her physical and cognitive functioning levels. She requires assistance with all aspects of daily living on an ongoing and continuous basis such that without that support she would be at risk of some serious harm occurring to her such that it is necessary to deprive her of her liberty.
Depriving the person of their liberty in this way is a proportionate response to the likelihood that the person will otherwise suffer harm and to the seriousness of that harm. The reasons for my opinion are:
YES X
NO With reference to the risks of harm described above explain why deprivation of liberty is justified. Detail how likely it is that harm will arise (i.e. is the level of risk sufficient to justify a step as serious as depriving a person of liberty?). Why is there no less restrictive option? What else has been explored? Why is depriving the person of liberty a proportionate response to the risks of harm described above?
The risk of harm and seriousness of the harm justifies the deprivation of liberty and is a proportionate response (in line with CoP 4.58) because the risks and seriousness of the potential harm are of such a high degree that they outweigh the burdens imposed by the deprivation of liberty and cannot be mitigated by any alternative less restrictive option in line with para 2.7 DoL COP.
-I have considered whether any restrictions to the care plan could be made but have been unable to make any recommendations. Any reduction in restrictions such as supervision within the home with her mobility would place her at significant risk of harm through for example falls and fall related injuries.
-Consideration has been given to Mrs ME returning to the community with a care package and assistive technology, however this has been tried prior to her admission and evidenced not to be a viable option.
-Alternative forms of accommodation including Supported Living with access to domicillary care have been considered (as Mrs ME’s house has now been sold following a COP application). This would not be a viable option as it would again present Mrs ME with risks between calls during the day and at night.
-Mrs ME’s is unable to use a pendant alarm reliably particularly whilst wandering around which renders her at high risk of significant risk of falls and fall related injuries when she is on her own which in the extreme could be fatal.
-Son GE is of the view that it is beyond his capability to provided sustained support for Mrs ME within the community due to her deteriorating health and the competing commitments and demands of his own family.
It is therefore my professional judgement, having weighed up all the relevant factors that it is necessary to deprive Mrs ME of her liberty at CB Care Home and that the deprivation is a proportionate response to the seriousness of harm that could otherwise be caused as outlined above.
This is in the person’s best interests. Note: you should consider 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 can be provided effectively in a way that is less restrictive of their rights and freedom of action. You should provide evidence of the options considered. In line with best practice this should consider not just health related matters but also emotional, social and psychological wellbeing.
YES
X
NO
The reasons for my opinion are:
In considering whether the deprivation of liberty is in Mrs ME’s best interests, I have been guided by the checklist in section 4 of the MCA 2005, Chapter 5 of the MCA Code of Practice and para 4.61 of the DoLS Code of Practice the best interest’s checklist has also been followed:
-Participation of Mrs ME has been encouraged as evidenced in this assessment through addressing for example potential barriers to communication.
-All relevant circumstances have been considered through consulting with a range of key stakeholders and consideration of all appropriate documentation as outlined within this assessment.
-I have identified Mrs MEs view as far as is practicable including her past and present wishes feelings and views. Although Mrs ME valued living in the community and is likely to have wanted to remain at home as opposed to going into care according to her son Mr ME, Mr ME and her carers have indicate that Mrs ME is stable and appears settled in her placement. Mrs ME is noted not to have made any requests or attempts to leave the home. My own observations during the assessment indicated that Mrs ME presented as happy and content.
-No assumptions have been made in relation to age, appearance, condition, eccentricity, or idiosyncratic behaviours. Rather her best interests were determined by taking a needs-led approach. In doing this discrimination has been avoided.
-Consultation has been undertaken with relevant key stakeholders as outlined in this assessment. I have avoided restricting Mrs ME’s rights by considering each aspect of her care and treatment at CB Care Home and have concluded that the care and accommodation currently in place is the least restrictive option which meets her needs.
Mrs ME has a diagnosis of vascular dementia and her short term memory is impaired. She has a lack of insight to her health and the dangers she faces. Thus based on the information and evidence I have collated in this assessment the care at CB Care Home is in Mrs ME’s best interests and is the least restrictive option available to meet her health and social care needs.
If Mrs ME is questioned she sometimes states she would like to return to her former home but she is not consistent in that resolve. Evidence from her presentation during the assessment indicates that she is content in CB Care Home. Evidence from staff and her son confirms that she appears to be well-settled. Dr N B (DoLS Mental Health Assessor) has confirmed that Mrs ME’s deprivation of liberty and confinement to the home is not likely to have any adverse impact on her health and well-being.
The following is an account of the options I have considered and includes the burdens and benefits of each option.
After giving your reasons above you should now carry out analysis of the benefits and burdens or each option identified.
Option 1: Remaining at CB Care Home Benefits:
Regular Social Care and Health Support -24hr support and supervision enables Mrs ME to maintain her personal safety and to address her social care and health needs including prevent the risk of self-neglect, falls, malnutrition, dehydration, pressure areas from arising, health deterioration due to an inability to selfmedicate and preventing UTI’s. -Care plans are reviewed so that any changes in Mrs ME’s needs are identified and addressed promptly -Anxiety that Mrs ME may experience is addressed by staff on a 24hr basis by staff know her well and are able to respond to her needs in an appropriate, sensitive and responsive manner. -Staff including nursing staff are be available 24/7 to deal with Mrs ME’s needs and any crisis that may arise. Improve dignity -Care and treatment may slow Mrs MEs decline. -There would be less need potential need for the emergency services to be contacted. Improving psychological, social and emotional health -The quality of Mrs ME’s psychological and emotional health is improved as she has opportunities to socialise and stimulate her. -Mrs ME is being afforded quality time from her son who lives locally. He is now able to visit her at regularly and who helps to maintain her psychological and emotional well-being.
Burdens:
-Mrs ME lives in a home with a locked door policy and she is not free to leave unaccompanied. -Mrs ME has less control, choice and autonomy/independence over the manner in which she lives her life as there are regimes and structures in situ over the manner in which she lives her life, who she lives. Further structures are in place around care and support both within the home and when going out. -Emotional and psychological health may deteriorate due to her being away from her home/community environment. There would be a low risk of this as she has little memory of her former home prior to her admission to CB Care Home. -Mrs ME would have reduced contact with the community
Option 2: Returning to the Community with Domiciliary Support and Assistive Technology
Benefits: -Mrs ME may have a greater sense of belonging if she was in community environment that she had familiarity with. -Mrs ME would not be in a locked environment and thus more independent -Mrs ME would have more choices and control although her choices may be unwise or uninformed -Mrs ME may find it easier to maintain community contacts.
Burdens: -Community/family support combined with a domiciliary care package and assistive technology has failed in the past due to Mrs MEs deteriorating condition. Mrs ME has been susceptible to innumerable risks including; malnutrition, deteriorating personal hygiene, falls, health deterioration due to an inability to manage medication and social, emotional and psychological deterioration, -Mrs ME has been unable to summons assistance when in crisis due to her Dementia thus this would compounding danger and risk in living in environments – A supported living environment with domiciliary care for Mrs ME could potentially give rise to risks at night and in between calls.
I do not believe there is a viable alternative to Mrs ME residing in CB Care Home. She is well settled and appears to accept the care provided by the staff within the home environment. She has regular visits from her family. Mrs ME’s needs cannot be met safely with a care package in the community and besides any similar care would amount to a deprivation of liberty at home thus resulting in community DoL. The only other option would be for Mrs ME to remain in her current placement without the legal framework, which is not lawful as it does not give her the right to challenge her detention.
Having considered the benefits and burdens of both options it is my view that remaining at CB Care Home is in Mrs ME’s best interests.
BEST INTERESTS REQUIREMENT IS NOT MET This section must be completed if you decided that the best interests requirement is not met.
March 2015 – V4 – Final Deprivation of Liberty Safeguards Form 3 Page 18 of 21 Combined Age, Mental Capacity, No Refusals and Best Interests
For the reasons given above, it appears to me that the person IS, OR IS LIKELY TO BE, deprived of liberty but this is not in their best interests.
In my view, the deprivation of liberty under the Mental Capacity Act 2005 is not appropriate. Consequently, unless the deprivation of liberty is authorised by the Court of Protection or under another statute, the person is, or is likely to be, subject to an unauthorised deprivation of liberty.
A Safeguarding Adult enquiry must be considered for any unauthorised deprivation of liberty. Please place a cross in the box if a referral has been made.
Date of Referral:
Please offer any suggestions that may be beneficial to the Safeguarding Adult process, commissioners and / or providers of services in deciding on their future actions or any others involved in the resolution process.
BEST INTERESTS REQUIREMENT IS MET The maximum authorisation period must not exceed one year In my opinion, the maximum period it is appropriate for the person to be deprived of liberty under this Standard Authorisation is:
The reasons for choosing this period of time are: Please explain your reason(s)
Mrs ME has a progressively deteriorating condition, namely dementia. Her condition is unlikely to improve. She is therefore unlikely to regain mental capacity to enable her to make a decision regarding her care and accommodation. I therefore recommend authorisation for the maximum period of 12 months.
DATE WHEN THE STANDARD AUTHORISATION SHOULD COME INTO FORCE I recommend that the Standard Authorisation should come into force on:
RECOMMENDATIONS AS TO CONDITIONS (Not applicable for review) Choose ONE option only I have no recommendations to make as to the conditions to which any Standard Authorisation should or should not be subject (proceed to the Any Other Relevant information section of this form).
X
I recommend that any Standard Authorisation should be subject to the following conditions
