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Mental Capacity Act Implementation Policy

1. Purpose The purpose of this policy is to ensure that {{org_field_name}} fully complies with the Mental Capacity Act 2005 (MCA) and its associated Deprivation of Liberty Safeguards (DoLS), ensuring that people we support are empowered to make their own decisions wherever possible and that any interventions are made lawfully, ethically, and in their best interests. This policy aligns with:

• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 11 – Need for Consent
• Regulation 13 – Safeguarding Service Users from Abuse and Improper Treatment
• The Care Act 2014
• The Human Rights Act 1998
• The Equality Act 2010
• CQC Key Lines of Enquiry (KLOEs) on Effective, Caring, and Responsive Services This policy ensures that all staff understand their responsibilities under the MCA and that decision-making is structured, documented, and consistently applied to safeguard the rights and dignity of the people we support.

2. Scope This policy applies to all employees, agency workers, volunteers, and external healthcare professionals providing care within {{org_field_name}}. It covers all people we support aged 16 and over who may have impaired mental capacity due to conditions such as dementia, learning disabilities, acquired brain injuries, or mental health disorders. It also applies to family members, advocates, and legal representatives involved in decision-making processes.

3. Policy Statement {{org_field_name}} is committed to ensuring that:

• People we support are assumed to have capacity unless proven otherwise.
• All practical steps are taken to support individuals in making their own decisions.
• Any decision made on behalf of a person lacking capacity is in their best interests and least restrictive.
• Mental capacity is assessed and recorded appropriately.
• Advance Decisions, Lasting Power of Attorneys (LPAs), and Court of Protection orders are respected.
• Staff receive ongoing MCA training and support to apply the Act correctly.

4. The Five Principles of the Mental Capacity Act

1. Assumption of Capacity – Every adult has the right to make their own decisions unless proven otherwise.
2. Right to Make Unwise Decisions – Individuals have the right to make choices that others may perceive as unwise.
3. Support to Make Decisions – Every effort must be made to help a person make their own decisions before assuming they lack capacity.
4. Best Interests Decision-Making – When a person lacks capacity, decisions must be made in their best interests, considering their past and present wishes.
5. Least Restrictive Option – Any intervention must be the least restrictive of the person’s rights and freedoms.

5. Assessing Mental Capacity Capacity assessments must be decision-specific and carried out by a trained professional when there is doubt about a person’s ability to make a particular decision. The two-stage test applies:

• Stage 1: Is there an impairment or disturbance in the person’s mind or brain affecting their ability to decide?
• Stage 2: Can the person understand, retain, use, or weigh the relevant information, and communicate their decision? If a person fails any part of Stage 2, they are deemed to lack capacity for that specific decision.

6. Best Interests Decision-Making When a person lacks capacity, all decisions must follow the Best Interests Checklist:

• Consider the person’s past and present wishes.
• Consult with family members, advocates, or attorneys.
• Avoid making assumptions based on age, disability, or appearance.
• Consider the least restrictive option. Where necessary, multi-disciplinary meetings must be held to determine the best course of action.

7. Lasting Power of Attorney (LPA) and Court of Protection

• If a person has an LPA for Health and Welfare, they have the legal authority to make healthcare decisions.
• If no LPA exists and major decisions are required, the Court of Protection may need to appoint a Deputy.
• Advance Decisions to Refuse Treatment (ADRTs) must be respected if valid and applicable.

8. Deprivation of Liberty Safeguards (DoLS) DoLS applies to people in care homes or hospitals who lack capacity and are subject to continuous control and supervision. Key steps include:

• Identifying when a person is deprived of their liberty.
• Applying for a Standard or Urgent DoLS Authorisation.
• Ensuring all restrictions are proportionate, necessary, and regularly reviewed.
• Working with Local Authorities and Best Interests Assessors (BIAs) to ensure compliance.

9. Role of Staff in Implementing the MCA

• Care staff must support people to make their own decisions, document capacity assessments, and apply best interests decision-making.
• Senior staff must oversee complex cases, ensure compliance, and liaise with healthcare professionals and legal representatives.
• Managers must provide ongoing training, monitor adherence, and review DoLS applications.
• All staff must respect LPAs, ADRTs, and ensure decisions made on behalf of others are lawful and justified.

10. Recording and Documentation

• All capacity assessments and best interests decisions must be recorded in the care plan.
• Advance Decisions, LPAs, and DoLS authorisations must be kept on file.
• Decisions must be reviewed regularly and updated as necessary.
• Any disputes regarding mental capacity must be escalated to the Registered Manager.

11. Training and Competency All staff must complete annual MCA training covering:

• The five principles of the MCA.
• How to conduct capacity assessments.
• Best interests decision-making processes.
• DoLS authorisation process and legal responsibilities. Competency is assessed through case studies, scenario-based discussions, and audits.

12. Safeguarding and Complaints

• Any misuse of restrictive practices or failure to follow the MCA must be reported as a safeguarding concern.
• People we support, families, and staff must have access to a clear complaints procedure.
• The Registered Manager must investigate all concerns and escalate where necessary.

13. Policy Review This policy will be reviewed annually or sooner if legislation or CQC guidance changes, significant concerns arise, or audit findings indicate improvements are required.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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