Herefordshire Safeguarding AdultsBoard

MENTALCAPACITYACT2005(MCA)POLICY,PROCEDUREANDGUIDANCE

DATE:January 2018

Version 2

It is suggestedthatthispolicyis read inconjunctionwithHerefordshireSafeguardingAdultsBoard’sDeprivationofLiberty Safeguards2007(DoLS)policyandwith theMentalCapacityAct2005CodeofPracticeandDeprivationofLiberty SafeguardsCodeofPractice.

These CodesofPracticecanbedownloadedfrom:

MCA 2005 CodeofPractice:

DoLSCodeofPractice: safeguards

Contents

1 INTRODUCTION………………………………………………………………………………………………….

2.PURPOSE ………………………………………………………………………………………………………..

3.SCOPE ……………………………………………………………………………………………………………

4.POLICY STATEMENT …………………………………………………………………………………………..

5.DEFINITIONS……………………………………………………………………………………………………..

6.LEGALCONTEXTANDCARE QUALITYCOMMISSION(CQC)…………………………………………..7.ASSESSMENT…………………………………………………………………………………………………...8.BESTINTERESTDECISION MAKING………………………………………………………………………..

9.CONSULTATIONANDFURTHERADVICE………………………………………………………………….

10.QUALITY, ACCOUNTABILITY ANDRECORDING………………………………………………………..

11.INDEPENDENTMENTALCAPACITYADVOCATE(IMCA)………………………………………………12.ADVANCE DECISIONS……………………………………………………………………………………….13.RESTRAINT–MCA ANDDOLS……………………………………………………………………………..

14.FINANCES, POWEROF ATTORNEY ANDDEPUTIES………………………………………………….

15.COURTOF PROTECTIONANDOFFICEOFTHE PUBLICGUARDIAN………………………………16.CONSENTANDCAPACITY………………………………………………………………………………….17.STAFFLIABILITY………………………………………………………………………………………………18.INTERFACE OF MHA 1983ANDMCA2005……………………………………………………………….

19.CONVEYANCE TO HOSPITAL ORCAREHOME…………………………………………………………

20.HOSPITAL

21.POLICE……

22.AMBULANCE SERVICE…………………………………………………………………………………………………….

23.RESEARCH…………………………………………………………………………………………………….

24.CHILDRENANDYOUNGPEOPLE………………………………………………………………………….

25.CARERS…………………………………………………………………………………………………………

26.PERSONALISATION…………………………………………………………………………………………..

27.TRAINING……………………………………………………………………………………………………….

28.INFORMATIONGOVERNANCE……………………………………………………………………………..

29.RELATEDPOLICY ANDPROCEDURES…………………………………………………………………...

30.FURTHERINFORMATIONANDRESOURCES……………………………………………………………31.MONITORINGANDREVIEW…………………………………………………………………………………

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32.IMPLEMENTATION…………………………………………………………………………………………….

1.INTRODUCTION

1.1The Mental CapacityAct (MCA) 2005provides alegalframework for acting andmaking decisionsonbehalfofindividualswho lack themental capacityto makeparticular decisionsfor themselves.Theaimis to assistandsupport a personwhomaylack capacityand discourageanyonewho isinvolved in caringfor somebodywho lackscapacityfrom being overlyrestrictive.

1.2The Actprovideslegalprotectionfor staffandothersandprotectionfor peoplewho are assessedas lacking capacitybysetting out amandatoryprocedureformakingdecisionson theirbehalf. Itprovidesthreefundamentalpowersin relationtohealthandwelfaredecisions:

  • Opportunitiesfor peoplewhohavecapacitytoplanfor atimewhentheymaylackcapacity;
  • Alegalframework forpeoplewith capacitytorecord theirwishes for futuretreatment,especiallythe refusaloftreatment;and
  • Alegalframework for staffandothers tomakeaBestInterestsdecisiononbehalfofanotherpersonwho is assessedaslackingcapacitytomakethatdecisionat thattime.

1.3ThisPolicy,Procedures andGuidancehasbeendevelopedonbehalfofHerefordshireSafeguarding Adults BoardforadherenceandimplementationbyallagenciesandservicesoperatingwithinHerefordshire.

1.4Theoverall aimof thepolicyand guidance inHerefordshire isto ensuregoodpractice anda coherentapproachacrossorganisations.

1.5The keymessagesofthe Mental CapacityAct (MCA)2005:

  • The Actapplies toeveryoneinvolved in the care,treatmentandsupportofpeopleaged16andoverlivingin EnglandandWales who areunable tomake allor some decisionsfor themselves.
  • The Actis designed toprotectandempowervulnerablepeoplewho lackcapacity.

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  • The Actsupports thoseover theageof 18who have capacityandchoose toplanfor theirfuturebycreating aLastingPower of Attorney.
  • The Actprovideslegalprotection inpracticeforhealthandsocialcarestaffandcarers.
  • The Actis supportedbyaCode of Practice,withwhich all professionalshave adutyto comply.

1.5.1TheActprovides five statutoryprincipleswhich are thebenchmarkoftheMCAandmustunderpin allacts carried outanddecisionstaken in relation totheAct.Theyare asfollows:

Principle One

A personmustbeassumedtohavecapacityunless it isestablishedthattheylackcapacity.

PrincipleTwo

A person is nottobetreated asunableto make a decisionunlessall practicablestepstohelphavebeentakenwithoutsuccess.

Principle Three

A person is nottobetreated asunableto make a decisionmerelybecausetheymakean unwisedecision.

Principle Four

An actdone,or decisionmade,onbehalfof aperson who lackscapacity, must bedoneor made,in theirbestinterests.

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PrincipleFive

Beforethe actis done,or thedecision ismade,regardmustbehadas to whetherthepurposeofthe actor thedecisioncanbeaseffectivelyachieved ina waythat is lessrestrictive oftheperson’srights andfreedom ofaction.

1.5.2 TheAct provides a twostageprocessfor theassessmentofcapacity.

1.5.3 The Act emphasisesthatassessmentofcapacityand BestInterestsdecisionmakingis integral todayto daypractice.

1.5.4 The Actprovides a BestInterestschecklist tobe implementedbyanyonemakingbest interestsdecisions for peoplewho lack capacity.

1.5.5 The Actunderlinestheimportanceof theappropriateinvolvementof theindividual, carers andfamilies in capacityassessmentsandBestInterestdecisionmaking.

1.5.6 The Actestablishesacriminal offenceofilltreatment orneglectof apersonwholacks capacity.

2.PURPOSE

2.1Thisdocumentprovides aguide for anyoneinvolved in theassessmentofcapacityandrelatedactivities in healthandsocial carepractice.Theprincipleswithinthedocumentare applicabletoanyoneaged16 yearsandabovewhomaylackcapacity.Guidelinesanddocumentationrelating to theassessmentsofcapacityofChildren & YoungPeople(CYP) under theageof 16are availableinthe HerefordshireSafeguardingChildren BoardInterAgencyChildProtectionProceduresforSafeguardingChildren.

2.2Staffoftenhave akeyrole in helpingandsupportingpeopleto understandwhatdecisionsneedtobemadeandwhy, and whattheconsequencesofthosedecisionsare.Theyare sometimestheonlypeople in a position toprovideinformationtoindividualsabouttheoptionsavailable to them,or where theycan getotherhelpand/oradvice.Staffshouldensurethatsupport is provided to enablepeopletomaketheirowndecisionswheneverpossible.This guidanceshouldincreasestaffawarenesswhendiscussingthedifferentoptionsavailableto peopletohelpthemwheretheymaylackcapacity, nowor in thefuture.

2.3Everyoneprovidingcare andsupporttoa person who lacksmentalcapacitymusthaveregard tothe MentalCapacityAct andits CodeofPracticeandact inaccordancewith it unless there are validreasonsfrom acting otherwise.

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3.SCOPE

3.1Thepolicyapplies toallstaffwhowork for agencieswhoarepartof theHerefordshireSafeguarding Adult BoardinHerefordshire asoutlined in thepolicystatementbelow.

4.POLICYSTATEMENT

4.1The issueofwhether apersonaged16 yearsor over has thementalcapacitytomakea decisionregarding his or hercare commonlyarises in healthand social caresettings. All healthandsocial careprofessionalswillpotentiallybe insituationswheretheyare requiredtoassessthementalcapacityof an individual to make a particulardecisionandtomakeBest Interests decisions.Everyoneworkingwithor caringfor anadult whomaylack capacityto makedecisions must comply with the MCA2005whenmaking decisions or whenactingfor suchpersons.

4.2Professionalstaffhave adutyand commitment to protectadultsatrisk. Theyneed towork onthebasisofanassumptionof capacityandshouldconsiderpeople’scapacityto takedecisions aspartoftheirnormalassessmentandcareplanningarrangements.Where therearedoubtsaboutan individual’s abilityto make a specificdecision,aformalassessmentofcapacitymaybe necessaryto determinecapacity.Specificdecisionsor actionsmayneedtobetakenwhere anadultmaynothavecapacity.Whereanadult maybe deemedtobe atriskandmaybebeing abused,theHerefordshireSafeguarding Adults MultiagencyPolicyand Proceduresmustbefollowed.

4.3TheMCA2005hasimplicationsfor all aspectsoftheworkwithadultswho maylack capacityandfor allpolicies. All existing policies andproceduresneedtobeMCAcompliant.

5.DEFINITIONS Advancedecision:

This isa writtenandwitnesseddecisionmadebyan adultwithcapacityto refusespecific medicaltreatment inadvance.Thedecisionwill applyat afuture datewhentheperson lacksthecapacityto consenttoor refusethetreatmentspecified in theadvancedecision.Ithas thesameeffect asa contemporaneousrefusalofthespecifiedmedicaltreatment. Anadvancedecision is legallybinding.

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Adult:

Schedule3 oftheMCA hasbeenamended(with some exceptionswithregard to legalprocessesfor 16/17year olds) andtheterm ‘adult’nowmeans a personwho:

(a)as aresultof animpairment or insufficiencyof his personalfaculties,cannotprotecthis interests,and

(b)hasreached the age of 16.

Attorney:

This isapersonwhohasbeenappointedunder eithera LastingPowerofAttorneyor(prior to October2007) anEnduringPower of Attorney. An attorneyhas thelegalright tomakedecisionsonbehalfof thedonor,providingthesedecisions arewithin the scopeoftheirauthorityandhavebeenregisteredwith the CourtofProtection. Thereare twotypesofLastingPowersofAttorney–personalwelfareandpropertyandfinancialaffairs.

Best Interests:

Anyact doneor decisionmadeonbehalfof apersonwho lacks capacitymust bedoneor madeintheirBestInterests.Section4 oftheMCA2005setsouta non-exhaustivechecklist.

Carer:

A Carer is someoneof anyagewhoprovidesunpaidsupporttofamilyor friendswhocouldnotmanagewithoutthishelpduetoillness,disability,mentalill-healthor asubstancemisuseproblem.

Children:

WithintheMCA this refers to peoplewho arebelowthe ageof 16 years. This is differentfromthedefinitionwithintheChildrenAct1989andthe lawmoregenerallywhere theterm ‘child’ isusedto refer topeopleagedunder 18 yearsofage.

CQC:

The CareQualityCommission(CQC) is anon-departmentalpublic bodyofthe UKgovernmentestablished to regulate andinspecthealthandsocial careservices inEngland.This includesservicescurrentlyprovided bythe NHS, localauthorities,privatecompaniesandvoluntaryorganisations–whether inhospitals,carehomesor people’sown homes–dentistandGPs.

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Decision-maker:

This isa personwho isresponsiblefor decidingwhat is in theBestInterestsof a personwho lacks capacity.Whothis is, is dependenton thedecisionthatneedstobemadeand sometimeswill be aprofessionalandatothertimesafamilymember,Carer orclose friend. Itis likelyto bethepersonwhoiscarrying out theactionrequired toimplementthedecision.

Deprivation ofLiberty:

This isa termusedintheEuropeanConventiononHumanRightsaboutcircumstanceswhen aperson’sfreedomis takenaway. Caselaw(includingthatfrom the CourtofProtectionandSupremeCourt) continuestodefineitsmeaningin practice.There isnosimpledefinitionofdeprivationofliberty. SeeChapter 2 oftheDoLSCodeofPracticeandtheLawSocietyGuidance services/advice/articles/deprivation-of-liberty, for amoredetailedunderstanding.

Deputy:

This isa person appointedbythe CourtofProtectionwithongoing legalauthoritytomakeparticulardecisions onbehalfofthepersonwho lacks capacity.Deputiesforpersonalwelfare(including healthcare)decisionswill onlybe required in themostcomplexcases whereimportantandnecessaryactions cannotbe carriedout withoutthe court’s’authorityor there isnootherwayofsettling thematter intheBestInterestsofthepersonwholacks capacitytomakeparticularwelfaredecisions.

Donor:

This isa personwhomakesaLastingPowerofAttorney(LPA) toappoint aperson tomanagetheirfinancialandpropertyaffairs ortomakepersonalhealthandwelfaredecisionsor (prior to October2007) an EnduringPower of Attorney.

Enduring Power ofAttorney(EPA):

This isa power of attorneycreatedundertheEnduringPowers ofAttorneyAct 1985todeal withpropertyandfinancialaffairs.Existing EPAs continue tobevalid ifregisteredwith the officeofthepublicguardian.

IndependentMentalCapacityAdvocate(IMCA):

This isa personwhosupportsandrepresents apersonwho lacks capacitytomake aspecificdecision,wherethatperson hasnooneelsewho can support them.Theymakesure thatmajordecisionsfor apersonwholacks capacityaremadein accordancewiththe MentalCapacityAct2005.IMCAsappointedunder DoLSare required to have

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additionalDoLSspecifictraining.SeeDoLSCodeofPractice7.34–7.41for detailsonthe roleof theDoLSIMCA.

Lasting PowerofAttorney(LPA):

This isa power of attorneycreatedundertheMental CapacityAct 2005.Itenables aperson,initiallywith capacity, toappointanotherpersontoact ontheirbehalfin relationtodecisionsaboutthedonor’sfinancialandpropertyaffairs and/orpersonalwelfare(including healthcare)at atimewhentheynolongerhavecapacity. An LPAmustberegisteredwith the Officeof thePublicGuardianbeforeit canbeusedandceasesonthedeath ofthedonor.

ManagingAuthority:

Theperson or bodywithmanagementresponsibilityfor thehospitalor care home inwhich a personis, ormaybecomedeprivedoftheirliberty.

MCAand DoLS Lead:

This is thenamedindividualresponsibleforensuringthe qualityandefficacyoftheservicesprovided to adultswho maylack capacitywithin theirAgency. Theyshouldprovideacontactpointfor otheragenciesandare responsiblefor sharinginformationandprovidingspecialist advice.

Mediation:

A voluntary,facilitative process thatassists parties toreacha mutuallyacceptableoutcome.Mediation is a non-adversarialandvoluntaryprocess. Amediator isindependentandactsas afacilitator.Amediatorworkswith the parties to identifytheirconcernsandhelpsthem toresolve areas ofdisagreement.Partieswho take part inmediationhave arealstakeintheprocessand a mediatorempowersthemtoresolvethedisputethemselves.

MentalCapacity:

Thisdescribesa person’sabilityto makea decisionabouta particularmatter atthetimeit needstobemade. Alegaldefinition is containedin Section2oftheMental CapacityAct 2005.

Restraint:

Theuse or threatofforce toundertakean actwhich the personresists, or therestrictionoftheperson’slibertyofmovement,whetheror nottheyresist. Restraint mayonlybeused where it isnecessaryto protecttheperson from harmand is proportionate totherisk of harm.Restraintcan includephysicalrestraint e.g. moving thepersonor blocking

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theirmovementtostopthemleaving,mechanicalrestraintinvolving theuseofequipmentsuchas usingabeltto stopthepersongettingoutoftheirchairor bedrailstostop thepersonfromgetting outofbed,chemicalrestrainte.g. using medication torestrainandpsychologicalrestrainte.g.tellingaperson nottodo something ordeprivingaperson oflifestyle choicesbytellingthemwhattime to go to bedor getup.

StandardAuthorisation:

This is theformalagreementtodeprive apersonoftheirlibertyin therelevanthospitalor care home.It is givenbytheSupervisoryBody, after completionof thestatutoryassessmentprocess.

Statementofwishesand feelings:

A personwith capacitymayexpresstheirwishesandfeelingsabouttheirfuturemedicaltreatment,wheretheywould chooseto live,howtheywouldwish tobe caredfor, in theeventtheylose capacityin thefuture.Theseare not legallybindingbut shouldbeusedbyrelevantprofessionalsfor considerationwhenmakingBest Interestsdecisionsfor aperson who lackscapacity.

SupervisoryBody:

A local authoritythat isresponsiblefor consideringadeprivationoflibertyrequest,commissioning theassessmentsand,wherealltheassessmentsagree,authorisingdeprivationofliberty.Which localauthoritywill be responsiblewilldependupon wheretheadultis ordinarilyresident.This will be the areain whichtheadultwas ordinarilyresident immediatelybefore theybegantobeaccommodatedin thecare home orhospital, or iftheadultwas of no settledresidenceimmediatelybefore theywereaccommodatedinthecare home or hospital,it will be thearea in which theadultwaspresentatthattime.Within Herefordshire,theSupervisoryBodyis HerefordshireCouncil.

UrgentAuthorisation:

An authorisationgivenbyaManaging Authorityfor amaximum ofsevendays,whichmaybeextended bya maximumof afurthersevendays byaSupervisoryBody, thatgives the Managing Authoritylawfulauthorityto deprive apersonoftheirlibertyin ahospital or carehomewhile the standarddeprivationof libertyauthorisationprocess isundertaken.

Adult:

Theadult inneedofcare andsupportwhohas aphysical/mentalimpairmentor illness.Thetermreplacesthepreviouslyused term‘adultat risk’

Young Carer:

YoungCarers are childrenandyoungpeoplewholook aftersomeone in theirfamilywho has anillness,a disability, or is affectedbymental ill-healthorsubstancemisuse.YoungCarers oftentake onpracticaland/oremotionalcaringresponsibilitiesthatwouldnormallybe expectedofanadult.Thetasksundertakencanvaryaccordingto thenatureof theillness ordisability, the levelandfrequencyofneedforcare andthestructureofthefamilyas awhole.

Young Person:

WithintheMCA this refers to peopleaged 16-18 years to whom mostoftheActapplies(but note amendmenttoSection3 oftheMCA re definitionofadult).

6.LEGAL CONTEXTANDCARE QUALITYCOMMISSION (CQC)

6.1SomeofthemostrelevantLegislation,CodesofPracticeandStatutoryInstrumentsare asfollows:

  • Care Act2014
  • Mental HealthAct1983
  • HumanRights Act1998
  • TheEuropeanConventiononHumanRightsand itsfiveprinciples
  • DisabilityDiscrimination Act1998
  • General Data Protection Regulations 2017
  • Care Standards Act2000
  • HumanTissueAct2004
  • Mental CapacityAct 2005
  • Mental CapacityAct CodeofPractice2007
  • Mental HealthActCodeof Practice2015
  • Deprivationof LibertySafeguards(DoLS)2007
  • Deprivationof LibertySafeguardsCodeofPractice2008

6.2The CareQualityCommission(CQC) hasdevelopedEssentialStandardsofQualityandSafetywhichhealthandsocial careorganisations,dentistsand GPsmustreach tobecompliantwith the MCA2005and toavoidsanctions.Furtherdetailsareavailable at:

6.3CQC states in‘EssentialStandardsofQualityandSafety’(March2010)that allpeoplewho useservicesshouldbeprotectedfrom abuse,or the risk ofabuse,andtheir

humanrightsberespectedandupheld.Specifically, CQC outcome 7statesthat allagenciesmust:

6.4.Make surethattheuseofrestraint is alwaysappropriate,reasonable,proportionateandjustifiabletothatindividual;

6.4.1 Whereapplicable,onlyuse DoLSwhen itis intheBestInterestsofthepersonwho uses theserviceandinaccordancewith the MCA2005.

6.5CQC havea dutytomonitortheoperationof DoLS inEnglandandto reportontheoperationofDoLStotheSecretaryofHealth.TheCommissionmaycancelaregistrationin respectofacaresetting in EnglandwhereDoLSlegislationhasnotbeencarriedout in accordancewithrequirementsof theenactment.

7.ASSESSMENT

7.1Agenciesshouldconsideridentifying anamedMCALeadacrosstheirteamstructures whowill be responsiblefor ensuringthe qualityandefficacyoftheservicesprovided toadultswho maylack capacity.

7.2ThenamedMCALeadwillprovideacontactpointfor otheragencies andberesponsiblefor sharinginformationandprovidingspecialist advicewhererequiredtootheragencies inrespectofservices or informationprovided bytheagency.

7.3Individualassessmentsofcapacityare theresponsibilityofeveryhealth andsocial care worker.

7.4Definingalackofcapacity(MCA Code ofPracticeChapter 4):

Anyquestion asto whethera person lackscapacitymustbedecided onthe balanceofprobabilities:

7.4.1A person lacks capacityin relation toamatterif at thematerialtimes/he isunable tomakea decision forher/himself inrelationtothematter becauseof animpairment, or adisturbance in thefunctioning, of themindor brain.

7.4.2It doesnotmatter whethertheimpairment ispermanent or temporary, althoughiftemporary,considerationshouldbe given astowhethermaking thedecisioncanwaituntil theperson has regainedcapacity.

7.4.3A lack ofcapacitycannotbe establishedmerelybyreferenceto:

  • A person’sage orappearance;
  • Acondition or an aspectoftheirbehaviour,whichmightleadotherstomakeunjustifiedassumptionsabouttheircapacity.

7.5Assessing capacity

7.5.1Mental capacityis theabilityto makean informeddecision.Consequentlythereare two basic questions to beconsideredonce a decision(ordecisions) hasbeendefinedandneedstobemade:

  • Is thereanimpairmentof, ora disturbance in,theperson’smind orbrain?Examplesofanimpairment ordisturbance includeBrainInjury,LearningDisability,Dementia,Physical or Medical conditions thatcancausedrowsiness,deliriumor lossofconsciousness,ifso:
  • Is theimpairmentor disturbancesufficientthatthepersonlacksthecapacitytomakethatparticulardecision atthetime it needs tobemade?
  1. Theperson assessingcapacitymustensurethattheyare providingthe personwith sufficient relevantinformationon whichto make theirdecision,making everyefforttoprovidethatinformationinawaythat is mostappropriate tohelpthepersonunderstand.
  2. A personis assessedas having thementalcapacitytomakethedecisioniftheyare:
  3. Able tounderstandinformationrelevanttothedecision
  • Able toretaintheinformationrelatedtothedecision whichneedstobemade
  • Able touse or weighthatinformationas partof thedecision-makingprocess
  • Able tocommunicate thedecision by any means

7.5.4If theyare unabletodoanyofthefourpoints,theywill be assessed asnothaving the mentalcapacityto makethedecision.Anindividual’scapacitymayfluctuateduringthedayor over the courseoftime.It isimportanttoallowforthis in anyassessmentandtorepeattheassessment asappropriate tothe situation.SeeAPPENDIX1AssessingCapacity–Flowchart.

7.6TheMCA2005identifiestheneedfor allpractitionerstocarryout situationandtime specificassessmentsof mental capacitywhere thereare doubtsabouta person’smental capacity.The kindsofdecisionwhichare covered bytheMCA2005rangefrom

day-to-daydecisions tosignificantdecisions.More seriousdecisionshave greaterconsequencesfor theperson who, itis thought,maylack capacityand justifyamoreformalassessmentofcapacity. Decisions relatingtoprovidinghealthcare ortreatmentincludesprovidingnursingand social care,carrying out diagnosticexaminationsandtests,providingprofessionalmedicaltreatment,giving medication, providingemergencycare, carrying out other necessarymedicalproceduresandtherapies andarranging torefer someoneto hospitalfor anassessmentorfor treatment.Somedecisionscannever betakenonsomeone else’sbehalfegmarriage,divorce,voting,sexualrelationships.

7.7All assessmentsofcapacitymust beconducted bythedecision-maker who is thepersonresponsiblefordecidingwhat is in theBest Interestsofthepersonwho lackscapacity. Thereare timeswhen a numberofpeoplemaybe involved in makingrecommendations inrelationto a decision. Itis thedecision-makersresponsibilitytowork out whatwouldbe in theBestInterestsofthepersonwholackscapacity.Thedecisionmaker is thepersonwho is decidingwhether or nottotakeaction inconnectionwith the careor treatmentofanadultwholacks capacityor who is contemplatingmakingadecisionontheirbehalf.Forexample:

7.7.1Wherethedecisioninvolves medicaltreatment,thedoctorproposingthetreatment is thedecision-maker;

7.7.2Wherenursingcareisprovided,thenurse is the decision-maker;

7.7.3Wherethedecisioninvolves social care oraccommodation,theSocialWorkerorotherprofessionalproposing and responsiblefor thearrangementswill be thedecision-maker;

7.7.4For moreday-to-daydecisions,thedecision-maker will be theperson mostdirectlyinvolved with the personat thetimeusuallyafamilymember, paidcarer, carerorfriend;

7.7.5The holder of avalid LastingPowerofAttorneyor a deputywill be the decision-makerfor decisionswithinthescopeoftheirauthoritybutonlyin relationtodecisionswhere the person lackscapacity.

7.8Assessmentsofcapacityin simple dayto daydecisionmakingmaybe madesolelybythe decision-makerand maybe documentedwithintheperson’scase records.

7.9A major decision is being madefor exampleif thereare concernsthatanindividual maynothavethecapacityto:

7.9.1Consent to ‘SeriousMedicalTreatment’(seeMCA Code ofPractice,Sections6.15–6.19,);

7.9.2Consent toaninformaladmission (tohospital,nursingor carehome);

7.9.3Consent toachangeofaccommodation;

7.9.4Request aTribunalHearingwhen detainedundertheMHA(1983);

7.9.5Managetheirpropertyorfinancial affairs,health or welfare.

Theabove list is notexhaustiveandprofessionaljudgementmustbeused.

7.10Best practiceindicatesassessments ofcapacity/ Best Interestdecisionswhere amajordecision isbeingtakenshould, ifpossible, betakenbyamultidisciplinaryteamincludingthedecision-maker.Oneofthesepeopleshouldideallyhave an establishedrelationshipwith the individualwhosecapacityis beingassessedforexamplea carer,close friend orfamilymember or professionalwith alongstandingrelationshipwith theindividual.Considerationshouldalsobe given as towhether thepersonthemselvesshouldbepresentfor someor all ofthemeeting.However, there willbea numberofsituationswhenonlyone person,thedecision-makercompletestheassessment.Sec

5.39of theMCA CodeofPractice makes itclear thatlearning aboutaperson’spastandpresentviews dependsoncircumstancesandthatwhat is availablein anemergencywill be differenttowhatis available in anon-emergency.However ‘...even in anemergencythere maystill be anopportunityto tryto communicatewith the personor hisfriends,familyor carers’.

7.11Considerationoftheskills and experienceofthoseconductingtheassessmentmustoccur,for examplewhere theindividualhas significantlearningdisabilities theassessor shouldhaveexperienceandexpertise in thatarea.

7.12All assessmentsofcapacityin respectofsignificantdecisionsmustberecordedon a capacityform andfullydocumentedonaperson’s casenotes.Thetwostagesofthe testmustberecorded,withthestepstaken toestablishthattheperson doesnotlack capacityto make relevantdecisionsabout theircare or treatmentandtheoutcomeoftheassessment.

7.13It MUST benotedthatall assessmentsofcapacityare TIMEAND ISSUESPECIFIC; it isthusprobablethatan individual mayhaveseveraldifferentassessmentsofcapacityin respectofdifferentissuesanddecisionsdocumentedboth on theelectronic recordandintheircasenotes.

7.13.1Itshouldalso be notedthatsomepeoplemayhavefluctuatingcapacity. Inthesecases ifthepersonlacks capacityformostof the time,andhaveonlyfleetingperiodswhere theyhavecapacitythen on balanceit is likelythat theywill be assessed aslackingcapacitytomake specificdecisions.Wherethebalance is the other wayand the

personhas capacityfor themajorityofthetime attempts shouldbemadetogetthemtomakedecisionsatthetimeswhentheyhavecapacity.

7.14If someonewantstochallengeanassessor’sor decisionmaker’sconclusions,thereare severaloptions:

7.14.1Involve an advocate toact onbehalfofthepersonwho is deemedtolackcapacitytomakethedecision

7.14.2Get asecondopinion

7.14.3Hold aformalor informal bestinterestscaseconference

7.14.4Attemptsomeformofmediation

7.14.5Pursuea complaintthroughtheorganisation’sformalprocedure

7.14.6Ultimately, if all otherattemptstoresolve thedisputehavefailed,anapproachtothe CourtofProtectionmustbe considered.

8.BESTINTEREST DECISIONMAKING

8.1The Actsetsoutachecklistof factors tobeconsidered bythedecisionmakerwhilstconsideringthebest interestsoftheperson.If anindividual isassessed aslackingcapacitytomake a decision,oneofthe keyprinciplesofthelegislation is thatanyact donefor,or anydecision madeonbehalfoftheperson,must bedone intheperson’sbest interests(Code ofPracticeChapter 5)

8.2Factors tobeconsidered:

8.2.1Asfar aspossibleencouragetheperson themselves toparticipateinthedecisionmaking process.

8.2.2Identifythe relevantcircumstanceswhich theperson themselveswouldtakeintoaccountiftheywere makingthedecisionthemselves.

8.2.3Identifythe person’spastandpresentwishes andfeelings,beliefsandvalues.

8.2.4No decisionis tobemadesolelyon thebasisoftheperson’sage,appearanceorotheraspects of behaviourthatmight leadother to makeunjustifiedassumptions.

8.2.5Likelihoodofregainingcapacity. Doesthedecisionneedtobemadenow?Ifitislikelythat capacitymaybe regained, canthedecisionmakingbe delayed?

8.2.6If thedecisionconcerns life-sustainingtreatmentthenthedecisionmustnotbemotivatedbyadesiretobringabouttheperson’sdeath.

8.2.7Ensuretheviews of others–inparticular,anyonenamed bythepersontobeconsulted,thoseinvolvedin caringfor theperson, those interestedintheirwelfare,anyoneappointed asPower ofAttorneyor anyCourt Deputy–aretakenintoconsiderationtoinformdecisionmaking.

8.2.8Consult with theIndependentMentalCapacityAdvocate(IMCA) if onehasbeenappointed.

8.2.9Consider whetherthere areanyother optionswhere theoutcomemaybe lessrestrictivefortheperson’srights.

8.3Thenweigh upall ofthesefactors inorder to work out what is in theperson’sbest interests.Thereis nohierarchyof factorsin determiningwhatis in a person’sbestinterests.Although Courts are now giving greater weight to the Person’s wishes. Partofthedecisionmaking processwill be toestablishwhatare themostimportantissuesgiven the circumstancesandapplying the statutorychecklist.

8.4Decisions mustbe clearlyrecorded in thecase records.See Appendix2DeterminingBestInterests. NB:A decisionnot tomake,or todelaymaking, adecisionalso needstobe recorded.

9.CONSULTATIONANDFURTHERADVICE

9.1Within Herefordshirenot all professionalswillroutinelycome into contact withadults whomaylack capacity. All staff,however, should befamiliarwith the MentalCapacityAct CodeofPractice (2007)and have access totheirmanager shouldtheyhave anyconcerns. Allmanagers areexpected tohave agoodlevelofawarenesswithregard to theMCA,regardlessof howoftentheyare usingtheActand must beabletosupporttheirstaffwhereappropriate.

9.2Whereconsultationor guidance is requiredorsoughtregarding anassessmentofcapacityor BestInterests’decision, this shouldbe soughtfromthestaffmember’slinemanager,anexperiencedcolleague,namedProfessionalMCALeadorOrganisationalMCALead.Iftheissue isnotresolved the staff member shouldtakeadvicefrom theagency’s own LegalServices in linewithagencyprocedures.

10.QUALITY,ACCOUNTABILITYANDRECORDING

10.1All assessmentsof an individual’s capacitymust berecorded intheindividual’scase records.

10.2TheCodeofPracticegives guidance onwhenprofessionalsshouldbeinvolvedand when,byimplication,there isa needforclearlydocumentedassessmentie:

10.2.1A decisionhas major consequences(e.g. a decisiontomoveaccommodation,decisiontoaccept/declinesupportat home,decisionwhethertoreport a criminal orabusive actetc).

10.2.2Theremaybea disputewith theperson,theirfamilyor the careteamastothecapacityoftheindividual.

10.2.3Theperson’scapacitymaybe subjectto challenge.

10.2.4Theremaybe legalconsequencesof afindingofcapacity(e.g. as aresult of aclaimforpersonalinjury).

10.2.5Theperson ismakingdecisionsthatputher /himself or othersat risk or thatresult in preventablesufferingor damage.

10.2.6Theseexamplesarenotexhaustive andeachcircumstanceneedstobejudgedon itsmerit,usingprofessional judgementwithsupportfrom theline manager orrelevant leadsasappropriate.Theanticipation is thatstaffwill use theirorganisation’srecording methodstodocumentclearlywhen mental capacityassessmentsandassociatedbestinterestdecisions arebeingmade.

10.3Eachagencyis expectedtohavetheirownqualityassurancesprocesses inplace.

11.INDEPENDENTMENTALCAPACITYADVOCATE(IMCA)

11.1TheIMCAservicecommencedinApril2007in England.ThecurrentIMCAandDoLS IMCAprovider in Herefordshireis OnsideAdvocacy

11.2An IMCA is someoneappointedtosupport apersonwho lacks capacityand hasno onetospeakfor them,such asfamilyor friends.SeeAPPENDIX3IndependentMental CapacityAdvocate.There isa statutorydutyto appointanIMCAwhere thedecision isanyofthefollowing:

11.2.1ChangeofAccommodation:AnIMCA mustbeinstructedwhere a decision isproposedabouta move toor a changeinaccommodationwherethepersonlacks

capacitytomakethedecisionandtherearenofamilyor friendswhoare willingandable tosupporttheperson.This includesmoving to acarehomefor8 weeks or more,or admissiontohospitalwhere admissionis likelyto last 28days ormore.

11.2.2SeriousMedicalTreatment: NHSbodiesmust instructandthentake into accountinformationfrom anIMCAwhere decisionsare proposedabout‘seriousmedicaltreatment’where theperson lacksthecapacityto makethedecisionandtherearenofamilyorfriends whoarewillingand ableto supporttheperson.

11.2.3SafeguardingAdults(Adultprotection):LAsandtheNHS havepowers to instructandmustconsideranIMCA tosupportandrepresentapersonwholackscapacitytoconsenttotheproposedmeasureswhere it isallegedthat:

i)Theperson isbeingorhas beenabused or neglected byanotherperson;and/or

ii)Theperson isabusingor hasabusedanotherperson.

11.3Insafeguarding adultcases,access toIMCAsis not restrictedto peoplewhohave nooneelsetosupportor representthem.Peoplewho lack capacitywho do havefamilyandfriendsarestillentitledto have anIMCA to supportthem in safeguardingadultprocedures.Thedecision-makermustbe satisfied thathaving an IMCAwill benefittheperson.

11.3.1Care Reviews: A responsible bodycan instructand must consider an IMCA tosupportandrepresenta personwho lacks capacitywhen:

i)Theyhavearrangedaccommodationforthatperson

ii)Theyaimtoreviewthe arrangements (aspartofacareplanor otherwise)

iii)Therearenofamilyor friendswhomitwouldbe appropriatetoconsult.

11.3.2Deprivationof LibertySafeguards(DoLS):TheMCA2005introducedtheDeprivationof LibertySafeguards(DoLS)via the MentalHealthAct2007,which hasamendedtheMCA2005.Theyprovidelegalprotectionfor peoplewhomaybedeprivedoftheirlibertyin ahospital(otherthanunderthe MentalHealthAct1983) or carehome,whetherplacedthereunderpublicorprivatearrangements.Incertaincircumstances, aperson who is subjectto DoLSmusthave anIMCA instructedto supportthem.TheDoLS CodeofPracticeprovidesdetailsofwhenanIMCAshouldbeinstructed–sections3.22–3.28and 7.34 –7.41.SeeHSABDoLSPolicy.

11.4TheIMCAmakesrepresentationsabouttheperson’s wishes,feelings,beliefsand values,atthesametime asbringing to theattentionofthedecision-maker all

factorsthatare relevant tothedecision.TheIMCA can challengethe decision-maker onbehalfofthepersonlacking capacityif necessary. Thedecisionmakermusttakethe

IMCA report into accountbutdoesnotnecessarilyhave to accepttheproposedsuggestion or conclusion.Ifthedecisionmaker’s decision rejectstheIMCA conclusion,thenthewrittenresponse totheIMCAserviceshouldinclude a statementindicatinghowthe informationhasbeenconsideredandgiving cogentreasoningto supportwhyitwasdisregarded.

11.5TheIMCAmustgive supportingevidence intheirfinal report thatunderpinstheirsuggestions.Toensureappropriateconsultationhasoccurred in theeventof achallengethefollowingstageswill be followed to achieve asatisfactoryoutcome:

11.5.1Informaldiscussionwiththedecisionmaker

11.5.2RequestandattendaBest Interestsmeetingwithrelevant peopleinvited toattend

11.5.3Write aletterofconcern tothedecisionmakerhighlightingthe concerns. Copythe relevantAssistantDirector andIMCAManager intothecommunication

11.5.4Senior Managersto discussandrespond

11.5.5Officialcomplaintprocessinitiated

11.5.6ApproachCourtofProtection

11.6For furtherdetails seeGoodPracticeGuidance:

12.ADVANCE DECISIONS

12.1The Actcreatesstatutoryrules with clear safeguards sothatpeoplemaymakeadecision in advance torefuse treatmentiftheyshould lack capacityin thefuture.TheAct setsouttwo important safeguardsofvalidityand applicabilityin relationtoAdvanceDecisions:

12.1.1WhereanAdvanceDecisionconcernstreatmentthatis necessaryto sustainlife,strict formalitiesmustbecompliedwith in order for theAdvanceDecisiontobeapplicable.

12.1.2Theseformalities arethatthedecisionmustbe in writing,signedandwitnessed.Inaddition,theremustbe anexpressstatementthatthedecisionstands‘eveniflifeisat risk’which mustalso bein writing,signed and witnessed.

13.RESTRAINT–MCA AND DOLS

13.1Restraint is onlypermittedif thepersonusingit reasonablybelieves it isnecessaryto preventharmtothepersonwholacks capacity, and iftherestraintused isa proportionateresponse tothelikelihoodandseriousnessoftheharm.Section 6 oftheMCA sets outlimitations on theuseofrestraintwhen taking action inconnectionwithcare andtreatment. Itdefines restraintas theuseor threatofforcewhere apersonwholacks capacityresists, andanyrestrictionoflibertyor movementwhetheror nottheperson resists.

13.2Manydifferentactionscanconstituterestraint;physicalintervention e.g.holdingaperson,mechanicalrestrainte.g.lapbelts,chemicalrestrainte.g.medicationandenvironmentalrestrainte.g. lockeddoors.

13.3TheDeprivationofLibertySafeguards(DoLS) 2007is anamendment to theMental CapacityAct (MCA) 2005andareadditionalsafeguardsforpeople who lackcapacityandaredeprivedoftheirliberty, butare notsubjecttotheMental HealthAct1983.TheDoLSCodeofPractice is asupplement to theoverarchingMCA Code ofPractice.Theyprovidealegalframework to protectthosewho maylack the capacitytoconsenttothearrangementsfortheirtreatment or careandwherelevels ofrestriction orrestraint used indeliveringthat careare soextensive as tobedeprivingthepersonoftheirlibertyandusingSection6 oftheMCAis no longer sufficient.TheseCodesofPractice shouldremainthemainpointofreferencefor staffworkingwithdeprivationoflibertyissues.

13.4The issueofcovertmedication is aBestInterestsspecificdecisionwithsignificantimplications.For a decisiontobemadetoadminister prescribedmedicationcovertly,e.g.withinfood or drinkunknown to theperson,it wouldfirst needtobeestablishedthatthepersonconcernedlackedcapacityto consenttothemedication.Following areviewof themedication,considerationwouldneedtobegiven as towhether it mightbeacceptabletothepersonin analternative form (e.g. a liquid).Priortochanging the state of anymedication,egbycrushingor splittingacapsuleopen,consultationwith apharmacistis essential.The decisionmaker i.e.thepersonadministeringthemedication,would be requiredtoconfirmthatthemedicationwas intheirBest Interestsat thattimeandwouldfollowthe careplanto ensure it was the leastrestrictive option.

13.5Healthand social carepractitionersshouldnot administermedicinestoaresidentwithout theirknowledge(covertadministration) if theresidenthascapacitytomakedecisionsabouttheirtreatmentandcare.

13.6Healthandsocial care practitionersshouldensurethat covert administrationonlytakes place inthecontextofexisting legal and goodpracticeframeworks to protectboth theresidentwhoisreceiving the medicine(s)andthecarehomestaffinvolved inadministeringthemedicines.

13.7Healthandsocial care practitionersshouldensurethattheprocessfor covertadministration ofmedicines toadultresidentsin carehomesincludes:

  • Assessingmental capacity
  • Holdingabestinterestmeetinginvolvingcare home staff,thehealthprofessionalprescribing the medicine(s),pharmacistandfamilymemberor advocatetoagreewhetheradministeringmedicineswithouttheresidentknowing (covertly) is in theresident'sbestinterests.
  • Recording thereasonsfor presumingmental incapacityand theproposedmanagementplan
  • Planning howmedicineswill be administeredwithouttheresidentknowing
  • Regularlyreviewingwhether covertadministration is still needed.

14.FINANCES, POWEROFATTORNEYANDDEPUTIES

14.1An importantchangethatthemental capacitylegislationbrought inwas enablingindividuals tobeabletochoosesomeonetotakeboth propertyandaffairsandpersonalwelfaredecisionsontheirbehalfshouldtheylose capacitytodo sofor themselves. ALastingPowerofAttorney(LPA) replacedtheprevious systemofEnduringPowersofAttorney(EPA), which couldonlybe usedfordecisionsonpropertyandfinancialaffairs.