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Registration Number: {{org_field_registration_no}}


Consent to Care and Treatment Policy

1. Purpose

At {{org_field_name}}, we are dedicated to ensuring that all service users receive care and treatment that respects their rights, autonomy, and individual preferences. This policy sets out our commitment to obtaining valid consent before providing care or treatment, ensuring that decisions are made in the best interests of the individual and in line with legal and regulatory requirements.

1.1 Upholding Service Users’ Rights to Make Informed Decisions

Every individual has the fundamental right to make informed decisions about their own care and treatment. This policy ensures that:

1.2 Compliance with Legal and Regulatory Requirements

This policy ensures that the organisation complies with all relevant legislation and best practice guidelines, including:

By aligning with these legal frameworks, {{org_field_name}} ensures that all staff act lawfully, ethically, and in the best interests of the individuals they support.

1.3 Commitment to Person-Centred Care

At the core of our approach is person-centred care, meaning that each service user is treated as an individual with unique needs, preferences, and values. This policy supports this commitment by ensuring that:

2. Scope

This policy applies to all employees and representatives of {{org_field_name}} who are involved in the provision of Supported Living services. It ensures that every staff member understands their role in obtaining, documenting, and respecting service users’ consent before providing care or treatment.

The policy applies to:

2.1 Care Workers and Support Staff

Care workers are responsible for:

2.2 Managers and Senior Staff

The registered manager and senior management have an essential role in ensuring that staff understand and comply with consent policies. Their responsibilities include:

2.3 Administrative and Office Staff

While administrative staff may not provide direct care, they may handle consent-related documentation and communications. Their role includes:

2.4 Other Professionals and External Partners

This policy also applies to any external professionals working with {{org_field_name}}, including:

3. Legal and Regulatory Framework

This policy aligns with:

4. Principles of Consent

At {{org_field_name}}, we recognise that obtaining valid and meaningful consent is fundamental to providing safe, ethical, and person-centred care. The following principles guide our approach to obtaining and managing consent:

4.1 Consent Must Be Voluntary

Service users must give consent freely, without coercion, undue pressure, or manipulation from staff, family members, or others.

Staff must create a supportive environment where individuals feel comfortable making their own decisions.

If there are concerns about undue influence (e.g., family members pressuring a service user), staff must take steps to ensure the person’s autonomy is respected.

4.4 Consent Must Be Informed

Service users must receive sufficient, relevant, and accessible information to make an informed decision about their care.

Information should include:

Staff must ensure that information is provided in a way the service user can understand, using:

4.3 Consent Must Be Specific and Time-Limited

Consent applies only to the specific care, treatment, or intervention agreed upon at that time.

If new treatments or changes in care arise, fresh consent must be obtained.

Consent must be regularly reviewed and updated, especially if:

4.4 Capacity Must Be Assessed When Necessary

If there is any doubt about a service user’s ability to consent, staff must follow the Mental Capacity Act 2005 (MCA) two-stage test:

Stage 1: Does the person have an impairment or disturbance in the functioning of their mind or brain (e.g., dementia, learning disability, mental illness)?

Stage 2: Does this impairment prevent them from:

Understanding the relevant information?

Retaining the information long enough to make a decision?

Weighing up the options and consequences?

Communicating their decision (verbally, in writing, or through gestures)?

If the person lacks capacity, a best interests decision must be made following the MCA guidelines.

4.5 Consent Is Ongoing and Can Be Withdrawn at Any Time

A service user has the right to change their mind and withdraw consent at any time.

If consent is withdrawn:

5. Decision-Making Procedures for Service Users

At {{org_field_name}}, we are committed to supporting service users in making informed decisions about their care and treatment. Decision-making must always prioritise the individual’s rights, preferences, and legal safeguards. This section outlines the steps taken to ensure decisions are made appropriately, particularly when a service user has difficulties in understanding, retaining, or communicating their choices.

5.1 Supporting Decision-Making with Accessible Information

To empower service users to make informed choices, staff must:

5.2 Assessing Capacity Using the Mental Capacity Act (MCA) Two-Stage Test

If there is any doubt about a service user’s ability to consent, staff must conduct a Mental Capacity Assessment following the two-stage test under the Mental Capacity Act 2005:

Stage 1: Is there an impairment or disturbance in the functioning of the mind or brain?

Stage 2: Does this impairment prevent the person from making a specific decision?

The service user is considered to lack capacity if they cannot:

Important Notes:

5.3 Best Interests Decision-Making When Necessary

If a service user lacks capacity, staff must ensure that any decisions made on their behalf are in their best interests. This process follows the MCA best interests checklist, including:

If the decision relates to significant care restrictions (e.g., continuous supervision), a Deprivation of Liberty Safeguards (DoLS) authorisation may be required.

5.4 Involvement of Legal Representatives (LPA or Court-Appointed Deputy)

If a service user has a legal representative responsible for health and welfare decisions, staff must:

Important Notes:

5.5 Right to Refuse Care and Associated Procedures

Service users with capacity have the absolute right to refuse care or treatment, even if their decision may result in harm. Staff must:

Exception: If a person lacks capacity and refusing care would cause significant harm, a best interests decision must be made, and safeguarding procedures may apply.

Summary of the Decision-Making Process:

StepAction
1. Support Decision-MakingProvide clear, accessible, and relevant information to help the person decide.
2. Assess CapacityIf in doubt, conduct the MCA two-stage test to determine capacity.
3. Best Interests DecisionIf the person lacks capacity, make decisions following the MCA best interests framework.
4. Involve Legal RepresentativesConsult LPAs or Court-Appointed Deputies if applicable.
5. Respect the Right to Refuse CareIf the person has capacity, their decision must be respected and recorded.

6. Obtaining and Documenting Consent

Consent must be appropriately obtained, clearly recorded, and regularly reviewed to ensure it remains valid and reflects the service user’s current wishes and needs.

6.1 Explanation of Care, Risks, and Alternatives

Before obtaining consent, staff must ensure that the service user has received a full explanation of their care, support, or treatment, including:

a. Nature of the Care or Treatment

b. Potential Benefits and Risks

c. Available Alternatives

Staff must ensure that:
✔ The information is provided in a clear, jargon-free, and accessible format.
✔ The service user has the opportunity to ask questions and receive further clarification.
✔ Consent is obtained voluntarily, without pressure or undue influence.

6.2 Types of Consent: Verbal, Written, and Implied

Consent can be expressed in different ways, and the method of obtaining it depends on the type of care being provided.

a. Verbal Consent

b. Written Consent

c. Implied Consent

Important Considerations:

6.3 Regular Review of Consent

Consent is not a one-time event; it must be regularly reviewed and updated to reflect changes in the service user’s health, preferences, or capacity.

a. When to Review Consent

Changes in health condition – If a service user develops new health issues or deteriorates, their ability to consent may change.
New treatments or interventions – If a new form of care is introduced, fresh consent must be obtained.
Fluctuating capacity – If a service user has a condition like dementia or a mental health disorder, their capacity to consent may vary over time.
Withdrawal of consent – If a service user decides to withdraw their consent, this must be documented, and alternative solutions discussed.
Annual or routine care plan reviews – As part of ongoing care planning, consent should be reviewed to ensure it still reflects the person’s wishes.

b. Documentation of Consent Reviews

6.4 Best Practices for Documenting Consent

All staff must follow best practice guidelines when documenting consent to ensure compliance and accountability.

Clearly state what the person has consented to.
Record the date and time when consent was given.
Specify the type of consent (verbal, written, or implied).
Note any discussions about risks, benefits, and alternatives.
Document any withdrawal of consent, including the reason (if provided) and any actions taken.
If the person lacks capacity, record the results of the Mental Capacity Assessment and the Best Interests decision-making process.

By following these procedures, {{org_field_name}} ensures that service users’ rights are protected, care is delivered ethically, and legal compliance is maintained.

7. Consent and Data Protection

At {{org_field_name}}, we recognise that obtaining and managing consent extends beyond care and treatment—it also applies to the handling of personal and sensitive health data. Protecting service users’ confidentiality and ensuring compliance with data protection laws are fundamental to ethical and legal care practices.

This section outlines how personal and health data must be obtained, stored, shared, and processed in accordance with the General Data Protection Regulation (GDPR) and the Data Protection Act 2018.

7.1 Sharing Personal and Health Data Only with Consent

Under GDPR and the Data Protection Act 2018, personal data must only be shared when:
The service user has given explicit consent for their information to be shared.
There is a legal requirement to share the data (e.g., safeguarding concerns, court orders).
Sharing is necessary to protect the vital interests of the service user or others (e.g., medical emergencies).

a. Types of Data Covered

The following types of service user information are protected under data protection laws:

b. How Consent for Data Sharing is Obtained

Before sharing a service user’s information, staff must:
Explain why the information needs to be shared, who it will be shared with, and how it will be used.
Obtain written consent wherever possible, especially for sharing medical information with external agencies (e.g., GPs, social workers).
Allow service users to ask questions and ensure they fully understand their rights.
Document the consent in the service user’s records, including what data is being shared and for what purpose.

7.2 Compliance with GDPR and the Data Protection Act 2018

All handling of personal and health data must follow GDPR principles, ensuring that data is:

PrincipleHow It Applies to Consent in Domiciliary Care
Lawfulness, fairness, and transparencyService users must be informed of how their data is used, and consent must be freely given.
Purpose limitationData can only be collected and used for a specific, legitimate reason (e.g., care provision, safeguarding).
Data minimisationOnly the necessary information should be collected and processed.
AccuracyData must be kept up to date and corrected if inaccurate.
Storage limitationData should not be kept longer than necessary—records must be securely disposed of when no longer needed.
Integrity and confidentiality (security)Data must be kept secure and protected from unauthorised access, loss, or theft.

a. Service Users’ Rights Under GDPR

Service users have the right to:
Access their data – They can request a copy of the information held about them.
Rectify incorrect data – They can request corrections if their data is inaccurate.
Withdraw consent – They can change their mind and withdraw permission for data sharing.
Restrict processing – They can request limits on how their data is used.
Be forgotten – In some cases, they can request that their data is erased.

Staff must ensure that service users understand these rights and know how to exercise them.

7.3 Data Security and Confidentiality

To ensure compliance with GDPR and protect service users’ personal information, staff must:

Store paper-based records securely in locked cabinets with restricted access.
Ensure electronic records are password-protected and only accessible by authorised personnel.
Use encrypted emails and secure online systems when transmitting sensitive data.
Never share personal information via unsecured channels (e.g., personal emails, text messages, social media).
Report any data breaches immediately following the organisation’s incident reporting procedure.

7.4 Exceptions: When Data Can Be Shared Without Consent

In some situations, data protection laws allow information to be shared without the service user’s consent if it is necessary for:

Safeguarding: If there is a serious risk of harm to the service user or others, staff have a duty to share information with appropriate agencies (e.g., local authority safeguarding teams).
Medical emergencies: If a person is unconscious or unable to provide consent, relevant medical information may be shared with healthcare professionals to provide urgent care.
Legal requirements: If ordered by a court or required by law (e.g., under the Mental Capacity Act 2005, Deprivation of Liberty Safeguards).

In all cases where consent is overridden, the decision must be justified, recorded, and reported to senior management.

575 Staff Responsibilities and Training

To ensure compliance with GDPR and data protection regulations:
All staff must receive training on data protection, confidentiality, and obtaining consent.
Managers must monitor compliance and address any breaches or concerns.
A Data Protection Officer (DPO) (if applicable) should oversee data management and ensure the organisation adheres to legal requirements.

Summary of Key Actions for Staff

ActionRequirement
Explain data useInform service users why their data is collected and how it will be used.
Obtain valid consentSecure written/verbal consent before sharing personal or health data.
Document consentRecord what data is shared, with whom, and for what purpose.
Ensure securityProtect records (paper and digital) from unauthorised access.
Allow access to dataFacilitate service users’ rights to access or correct their data.
Report breachesImmediately report any unauthorised data disclosures.

By following these procedures, {{org_field_name}} ensures that service users’ personal information is handled lawfully, securely, and in line with best practice standards.

8. Training and Staff Responsibilities

At {{org_field_name}}, we recognise that staff training and clear responsibilities are essential to ensuring compliance with consent policies, the Mental Capacity Act 2005 (MCA), and best practice guidelines in Supported Living. All staff must have a thorough understanding of how to obtain, document, and review consent while ensuring that service users’ rights are upheld.

This section outlines the mandatory training requirements for staff and the managerial responsibilities for ensuring compliance with consent policies.

8.1 Mandatory Training on Consent and the Mental Capacity Act (MCA)

All staff involved in care provision must receive mandatory training on the following key topics:

a. Understanding Consent in Care

The legal and ethical importance of obtaining consent.
The different types of consent (verbal, written, implied) and when each is appropriate.
How to provide service users with clear and accessible information to support informed decision-making.
How to respect the right to refuse care and manage refusals appropriately.
Procedures for documenting consent accurately in care records.

b. Mental Capacity Act (MCA) and Best Interests Decision-Making

The five key principles of the Mental Capacity Act 2005:

c. GDPR, Data Protection, and Confidentiality

How to obtain explicit consent before sharing personal and health data.
Understanding service users’ rights under the Data Protection Act 2018 and GDPR.
Secure storage and management of paper and electronic consent records.
When and how data can be shared without consent (e.g., safeguarding situations, medical emergencies).

d. Handling Complex Consent Scenarios

How to support service users with communication difficulties in decision-making (e.g., using interpreters, visual aids, speech-generating devices).
Managing family and advocate involvement while prioritising the service user’s wishes.
Identifying and addressing potential coercion or undue influence in consent decisions.
When to escalate cases where consent or capacity is disputed.

All staff must complete refresher training annually to stay updated on legal changes and best practices.

8.2 Managerial Responsibility for Compliance

Managers and senior staff play a critical role in ensuring that the organisation remains compliant with consent and MCA regulations. Their responsibilities include:

a. Ensuring Staff Are Trained and Competent

Deliver or arrange mandatory training sessions for all care staff.
Monitor staff understanding of consent procedures through supervision and competency assessments.
Ensure new employees receive consent training as part of their induction process.
Provide ongoing coaching and refresher training to keep staff up to date.

b. Monitoring and Auditing Compliance

✔ Conduct regular audits of care records to ensure that consent is:

c. Supporting Decision-Making and Risk Management

Provide guidance to staff when service users refuse care or withdraw consent.
Ensure that Mental Capacity Assessments and best interests decisions are completed correctly when required.
Escalate complex cases (e.g., safeguarding concerns, legal disputes) to external professionals, such as social workers or the Court of Protection.

d. Ensuring Organisational Compliance

Keep up to date with changes in CQC regulations, the Mental Capacity Act, and GDPR requirements.
Ensure all policies related to consent, data protection, and capacity are reviewed annually and updated as needed.
Encourage a culture of respect and person-centred decision-making among staff.

8.3 Compliance Monitoring and Performance Evaluation

To ensure effective implementation of this policy:

Regular Spot-Checks & Supervision

Consent Record Audits

Feedback from Service Users and Families

Performance Reviews and Staff Accountability

4. Summary of Key Responsibilities by Role

RoleKey Responsibilities
Care WorkersObtain and document consent before providing care. Respect refusals and escalate concerns if necessary.
Senior Carers/SupervisorsSupport junior staff in complex consent cases. Assist in Mental Capacity Assessments.
ManagersEnsure all staff receive training. Monitor compliance, conduct audits, and address non-compliance.
Data Protection Officer (if applicable)Oversee GDPR compliance. Ensure data security and proper documentation of consent.
Training Coordinator (if applicable)Organise consent and MCA training. Maintain staff training records.

By ensuring that all staff are trained and managers enforce compliance, {{org_field_name}} guarantees that consent is obtained ethically, legally, and in a way that respects the dignity and autonomy of service users.

9. Monitoring and Review


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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.

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