Determining Deprivation of Liberty : Risk Matrix (1)

Transcription

1 Determining Deprivation of Liberty : Risk Matrix (1) The Matrix Definitions and Considerations of Risk Assessment: Consider the person against the following factors. If the physical location and type of restrictions in place are similar to those cited, consider the likelihood and severity scales (pages 3 & 4). Mark off the statements that apply to the person s situation (NB if you are assessing a situation that is proposed, rather than one which is occurring, adjust the language to reflect that, e.g. rather than the person being described as having no known difficulties within the last 6 months, rephrase, to state is unlikely to have difficulties within the next 6 months ). The highest level of applicable statements; even if there is only one in that level, indicates the likelihood and severity; e.g. Highly Likely (H) and Extreme (E) are the highest risk ratings. Once you have established likelihood and severity ratings, cross tabulate these on the matrix on the final page to arrive at the level of risk e.g. H and E will cross tabulate to 4 Level 4. Concrete Situation Physical Location Concrete Situation Type of Restriction Follow the guidance at the bottom of the final page indicating whether authorisation is required. This is the physical location where the person is or will be and may fit one of the following, or similar, descriptions: Older people: Residential care, often with nursing. Units with locked doors specifically designed to keep people in, rather than to keep undesirables out (it is intent that is important here). The purpose would usually be to prevent people wandering from the unit and placing themselves in danger. Such services usually provide care for people with dementia in old age. Frequently termed EMI Residential, or EMI Nursing. Possibly with electronic safety systems triggering alarms if people approach a door. Learning Disabilities/Autistic Spectrum Disorders: Residential care, sometimes with nursing, sometimes Independent Hospitals (where the person is not detained under the Mental Health Act 1983). Again, units with locked doors specifically to prevent people leaving. Often very high staffing ratios relying on staff to prevent the person leaving rather than, or in addition to, a locked door. Possibly geographically isolated settings preventing the person leaving. Learning Disabilities/Autistic Spectrum Disorders & other complex needs: Supported living projects with locked doors specifically to prevent people leaving. Situations where people do not have, or are unable to use, door keys. Often very high staffing ratios relying on staff to prevent the person leaving rather than, or in addition to, a locked door. NB an Order under s16 Mental Capacity Act 2005 is required to deprive a person of their liberty in these settings. Similarly styled units for people with other complex needs such as acquired brain injuries, alcohol related dementias and degenerative conditions that affect the functioning of the mind or brain where the characteristics of the physical caring environment relate to those given above - locked doors and/or high staffing ratios. Acute Medical Wards/Units in Hospitals. These may be dealing with alcohol related dementia, acquired brain injuries and other situations where a person may need acute medical treatment. The characteristics of the physical environment here are likely to include some of these; cot sides designed to keep the person in bed, sedation, frequent calls to security staff to return the person, locked doors designed to keep the person in rather than maintain the security of the ward from undesirable visitors. NB no detention under MHA 1983 Rehabilitation Units and Acute Mental Health facilities where physical characteristics are similar to the above If the location fits the above continue with the risk assessment for Deprivation of Liberty by first noting the actual type of restrictions or control measures (below) that are in place or are to be put in place; together these are referred to as the restriction for the remainder of the risk assessment. This is the type of restriction in place, or which will be put in place around the person and may fit one of the following, or similar, descriptions: Environmental restraint: The home or hospital has been designed in such a way as to restrict movement; locked doors, coded key pads, stairways without handrails, poor lighting & heating Certain rooms, i.e. training or rehab kitchens, rehab laundry, craft rooms, activity rooms are locked with a key or coded lock to prevent access Chemical restraint: (use of drugs and prescriptions to sedate, change or moderate people's behaviour Prescribed medication has a sedative side effect but is not prescribed for sedation Risk Matrix: Page 1 of 6

2 Likelihood Severity Deprivation of Liberty Control Measure Deprivation of Liberty Risk Matrix (5) October 2008 Forced care: Forcing, or coercing someone to receive food or medication or to get dressed Threats & Verbal Intimidation: The person has been threatened or intimidated in order to prevent them doing something or to make them do something. Threats may involve the threatened withholding of food, outings, pleasurable activity, or conversely the threatened isolation, time out, or eviction of the person. Threats may come from paid staff or others including relatives. This may include misleading the person as in DE & JE v SCC where DE and JE were both told the police would return DE to the home if he left with JE. Electronic surveillance: e.g. electronic tags, CCTV, exit alarms, pressure pads or similar used to monitor or restrict movement within the home or hospital Medical restraint: Medical intervention used to deliberately restrict movement or freedom; e.g. Catheters Continuous supervision: In place for most waking hours and possibly at night time too. High staffing levels, e.g. 1:1 or higher will indicate continuous supervision. Physical or any other form of restraint to prevent the person leaving or to maintain their safety. Restriction of contact with friends or family members This is the conclusion reached after considering the potential for deprivation of liberty occurring The likelihood scale assists the assessor in an evaluation regarding whether the impact could be realised, e.g. if a person is in one of the above care settings with some restrictions in place and has a fluctuating mental state requiring the restriction to be relied on constantly; it is highly likely that they are being deprived of their liberty if the restriction results in a severe or extreme impact upon the person. This is the conclusion reached after positively considering the level of impact on the person s liberty that would be sustained if the restriction is in place or put in place. The more extreme the severity the more potential exists for a deprivation of liberty occurring. This matrix assists the assessor to determine whether or not an authorisation for deprivation of liberty should be sought. The scale may have its uses for Best Interests Assessors; however, its primary purpose is to establish the need for a best interests assessment. A level 4 risk does not mean that deprivation of liberty is actually taking place; it simply means that the risk level is at its highest and authorisation should be sought. It does not mean that authorisation must or will be given. The systems put in place to eliminate or minimise the risk of deprivation of liberty - this may include the provision of services, advice, or equipment. For example, a programme of supported activity outside of the care home may remove some restrictions on a person s liberty. Control measures should be included in any care plan Assessing Risks of Deprivation of Liberty Mental Capacity Act 2005 & Community Care Legislation The assessment tool used should have the capacity to identify and evaluate the risk of deprivation taking place. Prior to either seeking authorisation or granting authorisation those providing care must ensure that their duties under the Mental Capacity Act 2005 have been carried out. There must be a Capacity Test in relation to all aspects of the person s decision making where capacity is believed to be in doubt. This must include a capacity test that relates specifically to the person s decision to remain at the care setting and accept the care regime provided 2 separate tests. The best interests of the person in respect of the above issues must be recorded. Associated community care assessments, care plans, and risk assessments should be in place. Where there are no relatives or friends there must be evidence of someone other than the staff of the care setting being involved in the decision making process, for admissions since October 2006 an IMCA. Where there are relatives and friends there must be evidence of their involvement in assessments, care plans and the decision making process. If close relatives and friends disagree with the placement and or subsequent deprivation of liberty they must be advised of their rights to approach the Court of Protection. Staff training and supervision must be in place around the specific restrictions on the person s liberty The absence of any of the above must result in an action plan to rectify these issues. They must not remain absent longer than absolutely necessary during any period of deprivation, or restriction on liberty. Capacity and best interests assessments will be carried out as part of the authorisation process but their absence prior to authorisation indicates bad practice. Bad or poor practice is not an acceptable reason for authorising deprivation of liberty. Risk Matrix: Page 2 of 6

3 Identifying Deprivation of Liberty : Risk Matrix (2) Likelihood This is the conclusion reached after considering the potential for the restriction being used and its surrounding support structures Unlikely U The person has no known history of difficulties requiring the use of the restriction in the last six months The mental state of the person, and those around them is considered to be stable Support Staff: Training is provided and repeated, supervision is provided, maintenance is in place The person has some insight into their situation and is taking their own reasonable and appropriate control measures Quite Unlikely Q The person has an intermittent history of difficulties within the last six months and the restriction has been used at these times, but not within the last 4 weeks. Control measures are not dependent on an individual e.g. specific staff being available The mental state of the person, and those around them is considered to be stable Support Staff: Training has been provided, supervision is provided, maintenance is in place. Likely L The restriction is planned for with protocols in place but has not been used within the past 4 weeks The mental state of the person or any or those around them is thought to be deteriorating on a month by month basis Control measures that are not classed as restrictions are dependent on specific staff but can break down, be easily removed or defeated Support Staff: Training and supervision is, or has been, minimal The person s condition is fluctuating Highly Likely H The restriction is constantly in place and used on a weekly or more frequent basis The mental state of the person or another person around them is thought to be deteriorating on a daily/weekly basis Support Staff: Training and supervision is minimal The person s condition is fluctuating and unpredictable Risk assessments are not up to date or are not being followed There is a history of life threatening situations or conditions Risk Matrix: Page 3 of 6

4 Identifying Deprivation of Liberty : Risk Matrix (3) Severity This is the conclusion reached after positively considering the actual result of the restriction on the person Negligible N As a result of the restriction involvement in activity outside of the care setting is occurring at least once per week There are no restrictions on visits from family or friends The person is able to go out and about with family and friends if they and the person wish Minor M As a result of the restriction involvement in activity outside of the care setting is occurring only intermittently but more than once per month There are some limitations on visits by family and friends There are some limitations on going out of the care setting with family or friends Severe S As a result of the restriction the person has only partial choice and control over the immediate environment, e.g. movement around the care setting, access and egress to the care setting, when to dress, what to eat As a result of the restriction involvement in care planned activity outside of the care setting is occurring but less than once per month As a result of the restriction some social support systems and relationships, other than those vitally important to the person, cannot be sustained community relationships such as social outings pubs, clubs, social gatherings The person is supervised by staff frequently to ensure the restriction and maintain their safety or the safety of others Extreme E As a result of the restriction the person has little or no choice and control over vital aspects of the immediate environment, e.g. movement around the care setting, access and egress to the care setting, when to dress, what to eat As a result of the restriction involvement in activity outside of the care setting is not occurring As a result of the restriction the person is being prevented from leaving the care setting with family or friends in relation to social activity As a result of the restriction vital social support systems and relationships cannot be sustained with close family, partners and close friends As a result of the restriction the person is being prevented from being discharged from the care setting to the care of family or friends The person is supervised by staff continuously throughout waking hours The person expresses a wish to leave the care setting and return to an alternative setting or person that is a concrete reality; e.g. an address that still exists and is owned/rented by the person, rather than a place where the person lived 40 years ago or returning home to partner or friend who is alive and well, and able to care for them, rather than a deceased, ill or unwilling partner or friend. Risk Matrix: Page 4 of 6

5 Identifying Deprivation of Liberty : Risk Matrix (4) Use the risk matrix to calculate the potential for deprivation of liberty. Negligible N Severity Minor M Severe S Extreme E Unlikely U Quite Unlikely Q Likely L Highly Likely H DOL Status Guidance 4 Level 4 With the current restriction in place there is the highest risk of depriving the person of their liberty. Check that the restriction is in the best interests of the person and the same outcome cannot be achieved without this restriction within the next 7-28 days. Seek authorisation of Deprivation of Liberty 3 Level 3 With the current restriction in place there is a substantial risk of depriving the person of their liberty. Check that the restriction is in the best interests of the person and the same outcome cannot be achieved without this restriction within the next 7-28 days. Consider seeking authorisation of Deprivation of Liberty and keep the situation under weekly review if no authorisation is sought. 2 Level 2 With the current restriction in place there is a moderate risk of depriving the person of their liberty. Check that the restriction is in the best interests of the person and the same outcome cannot be achieved without this restriction. Monitor the situation weekly and minimise restrictions. 1 Level 1 With the current restriction in place there is a low risk of depriving the person of their liberty. Check that the restriction is in the best interests of the person and the same outcome cannot be achieved without this restriction. Monitor the situation monthly and minimize restrictions. Risk Matrix: Page 5 of 6

6 Using the Matrix The Care Planning & Practice Environment Check that person centred assessment & care plans are in place Check that care plans are outcome focussed Check that adequate resources are being deployed by the provider to deliver the identified outcomes Care plans must identify capacity and best interests issues Care plans must identify any restrictions on liberty and why they are the least restrictive that are in the person s best interests Check that staff implementing restrictions are adequately trained and supported YES NO The Restrictions(s) Clearly identify the restriction(s) Check again that they are both the least restrictive and in the person s best interests. Consider less restrictive alternatives to each restriction identified and evidence why these were not in the person s best interests Poor Practice A deprivation of liberty may be taking place for reasons of poor practice, rather than in the best interests of the person. Revisit care plans, capacity and best interests. This must be carried out immediately. Authorisation cannot be granted if capacity cannot be determined and there is no clear evidence that a restriction is both the least restrictive on the person s human rights and freedoms and in the person s best interests. Any deprivation of liberty at this stage is unlawful The Likelihood Scale Establish the level of likelihood and frequency that the restrictions will be used. This scale considers frequency of need for the restrictions and the stability of the person s condition NB Consider the frequency of need for the restriction only do not confuse this with the frequency that the person s health, illness of frailty restricts their human rights and freedoms in itself. The Severity Scale Establish the impact of the restrictions on the person when they are used. This scale considers the results of the restrictions and how the person s human rights and freedoms are affected. NB Ensure that only the impact of the restriction is considered and not the impact of the person s health, illness or frailty. Be careful to distinguish between planned restrictions implemented in the best interests of the person and poor practice where restrictions occur outside of the care planning framework The Matrix Cross reference the results of the likelihood scale and the severity scale using the matrix to produce an overall rating for the level of risk to liberty. Follow the DOL Status Guidance Risk Matrix: Page 6 of 6