Before you start
This is a demonstration tool with sample data. Do not enter patient names, NHS numbers, hospital numbers, full dates of birth, addresses or other direct identifiers. It supports local audit and quality improvement — it does not replace clinical judgement, the Mental Capacity Act 2005, safeguarding processes or legal advice.
1
Project setup
Confirm organisation, site, wards, departments, leads and local MCA/best interests/safeguarding policy references.
2
Team
Add the audit lead, MCA lead, safeguarding lead and other contributors.
3
Inclusion / exclusion & criteria
Review who is in scope (adult inpatients with a capacity question) and the 32 documentation criteria aligned with the MCA 2005, Code of Practice and NICE NG108.
4
Data collection
For each eligible case, complete the 4-step form: case details, the 32 criteria (Yes/No/N/A/Unable), best interests & safety outcome, then review and submit.
5
Dashboard
Review overall compliance, functional element completion, best interests documentation, and ward/department/decision-type comparisons.
6
Findings
Read the narrative summary, strongest/weakest criteria, safety concerns and good practice.
7
Improvement
Identify gaps and causes, plan actions and PDSA cycles, and document a sustainability plan.
8
Re-audit
Set the parameters for the next cycle and compare baseline vs re-audit criterion-by-criterion.
9
Resources
Browse the guidance underpinning the audit criteria.
10
Export centre
Generate an editable Word report, executive summary, ARCP evidence, presentation, Excel workbook, CSV or plain-text summary.