Report 70: The Mental Capacity Act (MCA) and care planning
Monitoring MCA implementation
This section sets out the role of providers and commissioners in monitoring and assessing quality. It offers a set of standards against which evidence gathered about care planning can be measured.
Example quality standards and prompts
A set of standards is produced below for monitoring officers to use with either domiciliary care agencies or care homes. Providers may also wish to use these as part of their own quality management processes. Beneath each standard is a list of the types of evidence that would demonstrate whether or not that standard is being achieved. These prompts are not designed to be used as a tick-box set of criteria. They represent suggested areas for enquiry, and the monitoring officer or provider may choose to use them to build their own tools.
Person-centred care and support
Quality standard: care and support plans promote people’s liberty – the freedom to make decisions about their care and support.
People’s choices are recorded including:
- the person’s preferred style of address
- what the person would like to achieve from their care and support, their goals and aspirations for the future
- what is important to the person about their lifestyle, what they enjoy, dislike, etc.
- any other specific lifestyle choices that may affect the way their care and support are provided – for example, sexual orientation, spiritual rituals, special diets, etc.
- historical and social information to help staff get to know the person better, such as their family circumstances, social situation, significant events past and present, key achievements
- any statement of wishes or future preferences for their care and support should they lose capacity to express these (including end of life wishes)
- any advance decision to refuse treatment.
Quality standard: people and their chosen representatives are supported to be involved in their care planning and to make decisions about their care and support.
How people are supported to be involved in their care and support planning is recorded, including:
- how to communicate well, whether the person has any special communication needs, and how these can be understood and met
- information about who is important to the person and the level of their involvement – for example, family member or a friend who helps with shopping, etc.
- details of any attorneys (lasting or enduring)
- anyone else the person wants to be involved in decisions about their care and support and the information that can be shared with each named person
- how the person and their chosen representative are involved
- the person’s informed consent to their care and support plan or, where they lack capacity to do so, and they have a personal welfare attorney or court- appointed deputy, that person’s consent.
Assessment of mental capacity
Quality standard: there is a clearly recorded assessment of capacity with supporting evidence for people who lack capacity to consent to their care and support plan.
The evidence includes:
- the decision to be made
- how the person was assisted to understand the decision about their care and support
- the impairment or disturbance in the functioning of the mind or brain
- how this affects the person’s capacity to make the decision about their care and support (see Assessing capacity to consent for details about what evidence is required in the capacity assessment)
- whether the decision can be delayed
- a reasonable belief (i.e. more likely than not) that the person lacks capacity to make a decision about this specific aspect of their care and support plan
- a referral to the commissioning body if there is a dispute about the capacity assessment.
Best-interests decision-making process
Quality standard: care planning documents demonstrate that any act performed for, or any decisions made on behalf of, people who lack capacity is performed, or made, in their best interests.
Documents should show:
- how the decision was in the person’s best interests
- the person’s health, care and support needs
- if the decision is about medical treatment, whether the person made an advance decision to refuse this treatment while they had capacity to do so
- how the person and their family were encouraged to be involved
- what attempts were made to find out about the person’s past and present wishes and feelings (e.g. any relevant religious, cultural or moral beliefs and values)
- who was consulted
- options considered and risk assessment of each option
- reason for choosing a particular option and whether there were other less restrictive options that were discounted, and why
- if restraint is included in the plan, evidence that this is necessary to prevent harm to the person, that the amount and type is proportionate to the likelihood and seriousness of harm, and that there is the minimum amount of force for the shortest time possible
- how the best-interests decision was shared with the person and their significant others where appropriate.
Quality standard: care and support plans are regularly reviewed to make sure that they continue to meet people’s changing needs and choices.
Reviews should ensure that:
- the person is involved in the review of their care and support plan as far as they are able
- the person receives the necessary support to take part in the review and their wishes are taken into account in future planning
- the person’s chosen representatives are involved in the review
- changes to the person’s capacity and best-interests decision are considered
- any less restrictive options to meet the need have been considered.
Deprivation of Liberty Safeguards
Quality standard: people who are deprived of their liberty have their rights protected.
The following questions should be asked:
- Has the care home taken all practical steps to avoid depriving the person of their liberty? Is there a less restrictive option that will meet the person’s needs?
- Has the deprivation been authorised by the supervisory body?
- If not, has the care home requested authorisation?
- Have they notified the Care Quality Commission that they have requested an authorisation and the outcome?
- Is information about the relevant person’s representative recorded in the care and support plan?
- Does the care and support plan take account of any conditions attached to the authorisation?
- Does the care and support plan clearly record the purpose of the restrictions, how they are to be used, by whom and when?
- Do the care and support plan or case notes describe the steps that the care home has taken to help the relevant person understand the effects of the authorisation and their rights?
- Does the care and support plan include a mechanism for keeping the measures under regular review and who will be involved?
- Does the care and support plan clearly state when the Deprivation of Liberty Safeguards authorisation will expire and a review date to assess whether a further application will need to be made?
- If the request for authorisation to deprive the person of their liberty was refused, does the care and support plan take account of the best-interests’ assessor’s recommendations?