Report 70: The Mental Capacity Act (MCA) and care planning
Care planning, involvement and person-centred care
This section explores two key themes that are central to care planning within the MCA framework: involvement, and keeping the wishes of the person at the centre of their care and support. It emphasises that building relationships and good communication are critical to meaningful involvement.
Involving people in decisions about them
Involving people in decisions about their care is intrinsic to the principles of the MCA and should be evident in every care and support plan. Research on mental health and wellbeing demonstrates that involvement leads to improved service outcomes and enhances mental wellbeing.  People who use services and their carers are experts by experience. By bringing their knowledge and ideas, they give a fresh perspective on how their particular needs for care and support can best be met.
Providers and commissioners must challenge assumptions about how care plans are developed and the level of active involvement by the user. Supporting people to be involved in decisions about their care and treatment should be reflected in the ethos, management, policies and care practice of each service. All services should be able to show how they do this.
Meaningful involvement is based on a sharing of power between the person using the service and the provider. Involving people in designing their care plans means:
- having a conversation among equals who are working together to help one of them make a decision about their care and support
- that the person is considered as a whole in all aspects of their life
- that the plan belongs to the person, keeping them in control
- that the plan is only implemented or shared with others if the person gives consent (where they have capacity to do so).
Harvey  identifies these as key elements in person-centred care planning for people with long-term conditions. They are, however, equally applicable to care planning for all adults in need of care and support:
… care planning is a conversation between the person and the healthcare practitioner about the impact their condition has on their life, and how they can be supported to best meet their health and wellbeing needs in a whole-life way. The care plan is owned by the individual, and shared with others with their consent. It is important that a discussion takes place, there is a record of it, and people know they have a plan.
Producing a shared written record of how the person will be cared for tells them (and others whom they wish to involve) what to expect. Giving this information clearly maintains the accountability of the service provider and enables people to raise any concerns about the care plan or its delivery.
What to look for
- The person or their family/friends are able to tell you how they were involved in developing the care and support plan and that they felt (and feel) listened to.
- The person and their chosen representative are aware of the care and support plan and have seen a copy.
- The care and support plan clearly explains how care and support will be delivered.
The next section considers how to create a care and support plan that follows the MCA principles.
Person-centred care and support plans
Each person’s needs and choices will be unique to them. This means that staff must do all they can to help the person convey their personal aspirations and goals, and the support they need. Creating the care plan with the person or their chosen representative will keep the focus on what is important to that individual and will enable their care and support to reflect this.
Designing an MCA-compliant care and support plan requires a cultural shift from ‘traditional’ models of care planning to person-centred care planning. The key differences between the two are summarised in the table below (Table 1).
Traditional care planning
Person-centred, MCA-compliant care planning
The professional assesses the person’s needs.
Care and support plans are developed with the person. The conversation is led by the person who knows best about their needs and preferences.
Care planning follows a medical model of disability.
Care planning follows a social model of disability.
There is a focus on what the person is unable to do.
There is a focus on goals and aspirations, what the person would like to achieve with their care and support.
There is a static view of the person’s ability or capacity.
Care planning explores potential for change, opportunities to develop capacity and ability.
The professional writes the care plan with little or no input from the person or their representative.
The person is supported to express how they would like their care and support to be delivered. The professional provides information about what the service can offer. They agree what will be in the care and support plan. A copy of the plan is made available to the person and/or their representative.
The emphasis is on protecting the person from risk.
The emphasis is on safe care that respects a person’s right to take risks that they understand.
The process takes place when it is convenient for the professional.
The care planning conversation takes place at a time when the person is most or more likely to have capacity.
Power is with the professionals.
Power is equally shared.
Promoting involvement may mean orientating the person to the decision. For example, helping to orientate a person with dementia to the time and place relevant to the decision and filling in the gaps of their understanding. It might also include orientating a person’s beliefs concerning a decision. For example, helping someone who is depressed to hold onto positive values that were important to them when they were not so depressed. Ongoing work to reduce the effects of mental health conditions and maintain independence and control is vital to maximising a person’s capacity to make a decision.
Each aspect of care and support needs to fit a person’s life story. This means actively involving others who are part of that person’s life. Linking into a person’s existing support network will bring together all the information about them, so that their care and support are tailored to meet their specific needs and preferences. This will help to improve the user’s experience and promote their wellbeing, rather than merely responding to problems as they arise: ‘Being truly person centred is about recognising people within the full context of their lives and how they live them and not just focusing on their health conditions’.  The person’s wishes, thoughts and feelings should be routinely prioritised together with input from families and carers. Objective decision-making should only be used as a last resort.
What to look for in the care and support plan and other records
- What the person would like to achieve with their care and support, their goals and aspirations for the future.
- What is important to the person about how they live their life now. For example, what they enjoy doing, their interests, likes and dislikes, who is important to them, who they like to see, where they like to go, their preferred routines (such as when they like to get up and go to bed, whether they like a bath or a shower, etc.).
- Details of key life events and dates to assist with chronological orientation.
- How best to support and involve the person in decision-making.
- Essential information for continuity of care and for use in emergencies.
- Roles and responsibilities so that the person receives coordinated care and support to meet their needs.
- Where a person lacks capacity to express their choices, how their families and others who are interested in their welfare have been consulted.
- What outcome the person wants and any other options considered.
- The associated benefits and risks of each option.
The case of M,  from the Court of Protection, clearly illustrates the importance of care planning that takes account of the full context of a person’s life.
Practice example: the case of M
M, a 67-year-old woman, had a mild mental health problem and lacked capacity to decide where to live. She had substantial medical needs including diabetes, which was not well controlled. M was placed in a care home by the clinical commissioning group (CCG). It considered this to be in her best interests because of the significant risks to her health if she returned home. However, M hated living in the care home and said that she wanted to leave or she would take her own life. While acknowledging these risks, the Court of Protection said that if M remained in the care home, she was entitled to ask, what for? The right to life and the state’s obligation to protect it is not absolute and the Court must have regard to the person’s own assessment of their quality of life. In M’s case, there was little to be said for a solution that attempted to preserve her daily life without meaning or happiness.
Involvement in the cycle of care and support planning
Involvement is not an isolated activity. Ongoing communication between commissioners, providers, users and their families/carers is fundamental to taking the right decisions at the right time. It enables decisions to be altered over time to reflect people’s changing needs.
Services must make sure that their staff have the knowledge and skills to maximise involvement as part of an ongoing conversation that takes place at all stages of the care and support planning process. For example:
- at the outset, when developing the plan of care for each person
- as part of the risk management process, including safeguarding
- each and every time care and support are provided
- when carrying out reviews
- through regular feedback about people’s experience of the service they receive.
What to look for
- Evidence that staff ask people about their preferences each time they provide care or support – for example, whether they want to take their medicines now, whether they would like a cup of tea, coffee or a cold drink.
- Evidence that staff regularly ask the views of people using the service and/or their families about the care and support they receive and listen to what they say.
- Evidence of systems for reviewing care and support plans and obtaining feedback.
Involvement in the care and support planning cycle is underpinned by the quality of the relationship between the person using the service and the social care professional:  ‘People who use services have emphasized the support that they gain from relationships based on warmth, empathy, reliability and respect’. 
Having the right care staff with sufficient time and the right training in communication skills is critical to building effective relationships. 
What to look for
- Care staff talk to people in a respectful way.
- People say that staff are caring towards them and always treat them with respect.
Assumptions are often made about the capacity of people who have limited communication skills or other sensory impairments. Yet we know that it is quite possible to discern what a person feels or wants from their gestures and facial expressions, tone and volume of voice, or body language and behaviours. Care staff may need to observe a person’s responses over a period of time to understand these non-verbal signals.
A communication chart is a good example of a person-centred approach that carefully looks for what each individual is trying to communicate, rather than making blanket assumptions. The authors of ‘Person centred thinking with older people’  provide a useful worked example about eating, based on four questions:
- What is happening? Food is being prepared.
- What is the person doing? Shutting their lips tightly.
- What do we think this means? Best guess – the person does not want food at the moment or wants a drink first.
- What should we do? Offer a drink, gently encourage the person to eat, try shifting their mealtime to later in the day, maintain a record of food consumed and monitor.
Other ways to help a person communicate include the following:
- Making time to listen, to ask enough questions, to create opportunities for the person to tell their story in their own time, in their own way.
- Researching their previous wishes and finding out about their values.
- Providing all the relevant information in an accessible way – for example, in plain English, in clear writing, in Braille, in alternative languages, in pictures or in photographs, or a combination of these.
- Using a translator or other person/professional who understands the person’s communication style best.
- Addressing any sensory needs – does the person use a hearing aid, glasses, dentures; do they understand sign language?
- Involving family, friends or an advocate to provide support and reassurance.
- Choosing the right setting and time of day, considering whether the person may gain or regain capacity at a later date.
- Meeting with the person informally to explain the options and possible outcomes.
- Talking clearly, slowly, using straightforward, jargon-free language.
In order for care staff to successfully support people’s dignity and choices, they must do all they practically can to understand the meaning that users are trying to convey: ‘Having the power to communicate and to be understood is central to older people being able to have choice and control in their life – in fact, to have any quality of life at all’. 
What to look for in the care and support plan and other records
- A description of any communication needs and how these will be met.
- Where the person has limited communication ability, other non-verbal communication methods that the person may use.
- How the person was supported to be involved in decisions about their care and support.
What else to look for
- Users have clean spectacles, dentures are fitted and hearing aids are working.
- Staff use different communication tools to meet people’s needs.
- Staff explain what is happening each time they offer care and support.
- Staff take time to listen to what people are trying to convey.