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Mental Capacity and Deprivation of Liberty Safeguards (DoLS) Policy

1. Introduction

Our Home Care business is committed to ensuring that the rights of individuals who may lack mental capacity are respected and upheld in line with the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). We ensure that all service users are supported in making decisions about their care and that any restrictions to their freedom are legally authorised. This policy applies to all staff and is designed to ensure compliance with Care Inspectorate Wales (CIW) regulations, the Social Services and Well-being (Wales) Act 2014, and Social Care Wales (SCW) Code of Practice.

This policy provides guidance on how we manage Mental Capacity Assessments and Deprivation of Liberty Safeguards (DoLS) effectively and fairly, ensuring the well-being, dignity, and rights of all service users. It also serves as a compliance guide for CIW inspectors.

2. Key Principles of Mental Capacity and DoLS Management

• Presumption of Capacity: Every individual is presumed to have the capacity to make decisions unless it is proven otherwise.
• Support to Make Decisions: Service users must be given appropriate support to make decisions, considering their ability to understand and retain information.
• Best Interests: Any decisions made on behalf of individuals lacking capacity must be in their best interests and consider their wishes, feelings, values, and beliefs.
• Least Restrictive Option: Any decision or intervention must be the least restrictive option that protects the individual’s rights and freedom.
• Safeguarding from Unlawful Deprivation of Liberty: We ensure that individuals are not deprived of their liberty unless a DoLS authorisation has been obtained and all legal procedures are followed.

3. How We Manage Mental Capacity and Deprivation of Liberty Safeguards Efficiently

A. Assessing Mental Capacity

We conduct a Mental Capacity Assessment (MCA) whenever there is doubt about a service user’s ability to make specific decisions regarding their care or treatment.

For Staff:

• Step 1: Assess capacity on a decision-specific basis, considering whether the person can understand, retain, and weigh the information involved in the decision.
• Step 2: Provide appropriate support and information to enable the individual to make an informed decision.
• Step 3: If the individual is unable to make a specific decision, a best interests decision-making process is implemented.
• Step 4: Complete a Mental Capacity Assessment (MCA) Report (MCA-R) to document findings and decisions.

For CIW Inspectors:

• MCA assessments are recorded in the Care Management System (CMS), ensuring that each decision about capacity is clearly documented.
• There is evidence that appropriate support is provided to service users to enable them to make decisions.

B. Deprivation of Liberty Safeguards (DoLS)

If a service user lacks capacity and may be subject to restrictions that amount to a deprivation of liberty, we follow the legal process to ensure that the deprivation is authorised.

For Staff:

• Step 1: If a service user’s care involves restrictions (e.g., medication that requires restraint or the use of locked doors to prevent exit), assess whether it amounts to a deprivation of liberty.
• Step 2: If there is any doubt, notify the Registered Manager immediately to initiate a DoLS application.
• Step 3: If a DoLS authorisation is needed, the manager will complete the DoLS Referral (DRF) to the Local Authority for assessment and approval.
• Step 4: Ensure that any deprivation of liberty is reviewed regularly to ensure that it remains lawful and necessary.

For CIW Inspectors:

• DoLS referrals and authorisations are documented and available for review.
• DoLS assessments are made by the relevant Local Authority and must be kept up to date.
• Staff must demonstrate that restrictions are proportionate, documented, and legally authorised.

C. Best Interests Decision-Making

When a service user lacks mental capacity to make a specific decision, we ensure that a best interests decision is made, involving relevant individuals and professionals.

For Staff:

• Identify and consult with relevant people (e.g., family members, advocates, care team, or healthcare professionals) to make decisions in the service user’s best interests.
• Document all decisions made in the service user’s Best Interests Decision Record (BIDR).
• Ensure that any decision made is the least restrictive and in the best interest of the individual.

For CIW Inspectors:

• Best interests decisions are documented and demonstrate that the person’s rights, preferences, and views were considered.
• Family involvement and consent are recorded, where appropriate.

D. Recording and Documentation

We ensure that all mental capacity assessments and DoLS-related records are accurately documented and easily accessible for review by managers, staff, and CIW inspectors.

For Staff:

• Complete a Mental Capacity Assessment (MCA) form for each service user who may lack capacity.
• Maintain records of DoLS referrals, assessments, and authorisations in the Care Management System (CMS).
• Keep a Best Interests Decision Record for each decision made on behalf of a service user.

For CIW Inspectors:

• All MCA, DoLS, and best interests decisions are available for inspection and demonstrate legal compliance with all relevant regulations.
• Audits confirm that records are reviewed regularly to ensure accuracy and appropriateness.

E. Staff Training and Competency in MCA and DoLS

We ensure that all staff are fully trained and competent in managing Mental Capacity and Deprivation of Liberty Safeguards in compliance with CIW regulations.

For Staff:

• Complete Mental Capacity Act and DoLS Training (MCAT) during induction and annual refresher training.
• Participate in case reviews and discussions on best interests decision-making and DoLS implementation.
• Ensure that any staff member involved in making capacity-related decisions is competent in legal frameworks and ethical considerations.

For CIW Inspectors:

• Training logs confirm that all relevant staff receive up-to-date training in Mental Capacity and DoLS.
• Staff appraisals ensure that competence in this area is regularly assessed and maintained.

F. Safeguarding and Reporting

If we are concerned that a service user is being unlawfully deprived of their liberty, we follow the safeguarding procedures and report the concern to the relevant authorities.

For Staff:

• Follow the Safeguarding Referral Process (SRP) if there are concerns that a service user is being deprived of liberty without proper authorisation.
• Report any suspected breach of DoLS immediately to the Registered Manager for escalation.
• Cooperate with external agencies such as the Local Authority and Safeguarding Boards if necessary.

For CIW Inspectors:

• Safeguarding logs demonstrate that concerns related to DoLS breaches are reported and investigated promptly.
• DoLS-related issues are tracked through the incident reporting system (IRS) to ensure timely resolution.

4. Governance and Continuous Improvement

We ensure high standards of mental capacity and DoLS management through regular audits, reviews, and staff training.

What We Do:

• Conduct Quarterly MCA and DoLS Audits (MDA) to monitor compliance and effectiveness.
• Hold Annual Service User and Family Feedback Sessions (ASUFS) to improve care planning and DoLS practices.
• Review and update policies and procedures regularly to reflect changes in legislation and best practice.

For CIW Inspectors:

• Audit reports demonstrate regular monitoring of MCA and DoLS processes.
• Action plans are developed and implemented based on audit findings.

5. Compliance Monitoring and Audit Procedures

• Internal Audits: Conducted quarterly to ensure compliance with CIW, MCA, and DoLS regulations.
• Annual Reviews: Full compliance check against MCA and DoLS legislation and CIW standards.
• Staff Supervisions & Appraisals: Carried out every six months to ensure ongoing staff competence in these areas.

6. Conclusion

We are committed to upholding the rights and dignity of individuals who may lack mental capacity, ensuring that all Deprivation of Liberty Safeguards are legally implemented and regularly reviewed. This policy ensures that mental capacity assessments and DoLS procedures are managed effectively, in compliance with CIW regulations, MCA 2005, and best practice guidelines.

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