Findings — Mental Capacity Assessment Documentation Audit

Summary narrative

Mental Capacity Assessment Documentation Audit reviewed 60 cases against 32 documentation criteria aligned with the Mental Capacity Act 2005, the MCA Code of Practice, NICE NG108 and local trust policy. Overall documentation compliance across all criteria was 81.4% against a target of 90%. Best interests decision-making was required in 27 cases; of these, an IMCA referral was required in 11 cases and completed in 2. 4 case(s) had an identified safety concern requiring escalation or action. The lowest-performing criteria were: Review date, expiry date or reassessment plan was documented where local policy requires it. (54.4%); DoLS or deprivation of liberty concern was considered or escalated where relevant. (56%); Communication support, interpreter, advocate or communication aid was used or considered where relevant. (60.8%). The strongest areas of documented practice were: Options considered as part of best interests decision-making were documented where relevant. (96.4%); The person's wishes, feelings, values, beliefs or preferences were documented where possible. (93%); The assessment was decision-specific. (92.5%). Recommended next steps include targeted teaching on the weakest criteria, embedding structured capacity assessment prompts in the electronic record, and a planned re-audit to assess improvement.

Lowest 5 criteria

54.4%
Review date, expiry date or reassessment plan was documented where local policy requires it.
56%
DoLS or deprivation of liberty concern was considered or escalated where relevant.
60.8%
Communication support, interpreter, advocate or communication aid was used or considered where relevant.
67.3%
IMCA referral was considered or completed where required.
70.2%
Practical support to help the person make the decision was documented.

Highest 5 criteria

96.4%
Options considered as part of best interests decision-making were documented where relevant.
93%
The person's wishes, feelings, values, beliefs or preferences were documented where possible.
92.5%
The assessment was decision-specific.
90.4%
The specific decision being assessed was clearly documented.
89.1%
The person's ability to communicate the decision was assessed.

Safety concerns

4 case(s) flagged for escalation or action.

DEMO-MCA-04 — Respiratory Ward

DEMO — Patient refusing NIV; functional capacity elements incompletely documented; escalated to consultant for review.

DEMO-MCA-109 — Respiratory Ward

Safety concern flagged; see notes.

DEMO-MCA-114 — Acute Medical Unit

Safety concern flagged; see notes.

DEMO-MCA-149 — Care of the Elderly Ward

Safety concern flagged; see notes.

Functional elements gap

Cases where at least one of the four functional elements (understand, retain, use/weigh, communicate) was not documented as met.

of 60 cases reviewed

Notable good practice

96.4%
Options considered as part of best interests decision-making were documented where relevant.
93%
The person's wishes, feelings, values, beliefs or preferences were documented where possible.
92.5%
The assessment was decision-specific.
90.4%
The specific decision being assessed was clearly documented.
89.1%
The person's ability to communicate the decision was assessed.
88.7%
Risks, benefits and reasonable alternatives were documented where relevant.

DEMO-MCA-01

DEMO — Delirium admission: decision-specific, time-specific capacity assessment for IV fluid consent; four functional elements documented.

DEMO-MCA-03

DEMO — Best interests decision documented clearly with family consultation and least restrictive option considered.

DEMO-MCA-06

DEMO — Exemplar: specific decision, support offered, four functional elements, clear conclusion, best interests reasoning where required, communicated to MDT with review plan.