Mental Capacity Assessment Documentation Audit

DEMO DATA

Audit whether mental capacity assessments are decision-specific, time-specific, supported, clearly documented and linked to appropriate best interests decision-making where required.

OverviewHow to useProject setupTeamInclusion / exclusionData collectionDashboardSubmissionsFindingsImprovementRe-auditResourcesExport centreSettings
Cases reviewed
60
Sample data
Overall MCA documentation compliance
81.4%
Target ≥ 90%
Four functional elements fully documented
41.7%
Understand, retain, use/weigh, communicate
Best interests documented where required
63%
Of cases where capacity was lacking
Aim
To assess whether mental capacity assessments are completed and documented in line with local policy, the Mental Capacity Act 2005, NICE NG108 and relevant professional standards, and to identify improvement priorities for capacity documentation, best interests decision-making and escalation.
Standards
Mental Capacity Act 2005 · MCA Code of Practice · NICE NG108 · Local Trust MCA & Best Interests policy — target 90% compliance across criteria
Sample
Target sample 60 adult inpatients (≥ 16y) where a mental capacity question arose during the current admission. Pseudonymised only — no direct patient identifiers.

Tool workflow

    Step 1
    Project setup
    Confirm scope, wards, leads, local policy references and guidance sources.
    Step 2
    Team
    Add supervisors, contributors, safeguarding and MCA leads.
    Step 3
    Inclusion / exclusion
    Review who is in scope and the 32 audit criteria.
    Step 4
    Collect data
    Structured form for each eligible mental capacity assessment.
    Step 5
    Dashboard
    Compliance, best interests, ward comparison and safety concerns.
    Step 6
    Findings
    Interpret results, good practice and gaps.
    Step 7
    Improvement
    Plan actions, PDSA cycles and re-audit.
    Step 8
    Resources
    MCA 2005, Code of Practice, NICE NG108 and local policy references.
    Step 9
    Export centre
    Editable Word, PowerPoint, Excel, CSV and ARCP outputs.
Add a case
Open the structured data collection form.
Plan improvement
PDSA cycles, actions and re-audit plan.
Generate outputs
Word, PowerPoint, Excel, CSV and ARCP evidence.
Clinical safety note
This tool supports local audit, quality improvement and governance review. It does not replace clinical judgement, the Mental Capacity Act 2005, the MCA Code of Practice, local safeguarding, legal advice, best interests processes or urgent escalation pathways. Do not enter patient names, NHS numbers, hospital numbers, full dates of birth, addresses or other direct identifiers.