Improvement plan

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.