Planned re-audit
Set the parameters for the next audit cycle to measure improvement.
Baseline vs re-audit — all 32 criteria
| Criterion | Baseline | Target | Re-audit |
|---|---|---|---|
C01 The specific decision being assessed was clearly documented. | 90.4% | 90% | — |
C02 The assessment was decision-specific. | 92.5% | 90% | — |
C03 The assessment was time-specific. | 81.8% | 90% | — |
C04 The presumption of capacity was reflected unless there was evidence requiring assessment. | 88.7% | 90% | — |
C05 Evidence prompting the capacity assessment was documented. | 88.2% | 90% | — |
C06 Impairment or disturbance of mind or brain was documented where capacity was questioned. | 80.4% | 90% | — |
C07 The relevant information for the decision was documented. | 87.3% | 90% | — |
C08 Practical support to help the person make the decision was documented. | 70.2% | 90% | — |
C09 Communication support, interpreter, advocate or communication aid was used or considered where relevant. | 60.8% | 90% | — |
C10 The person's ability to understand relevant information was assessed. | 86% | 90% | — |
C11 The person's ability to retain relevant information was assessed. | 84.2% | 90% | — |
C12 The person's ability to use or weigh relevant information was assessed. | 78.2% | 90% | — |
C13 The person's ability to communicate the decision was assessed. | 89.1% | 90% | — |
C14 A clear conclusion about capacity for the specific decision was documented. | 78.9% | 90% | — |
C15 Fluctuating capacity or need for reassessment was considered where relevant. | 71.7% | 90% | — |
C16 The person's wishes, feelings, values, beliefs or preferences were documented where possible. | 93% | 90% | — |
C17 Risks, benefits and reasonable alternatives were documented where relevant. | 88.7% | 90% | — |
C18 Best interests decision-making was documented where the person lacked capacity. | 85.7% | 90% | — |
C19 Options considered as part of best interests decision-making were documented where relevant. | 96.4% | 90% | — |
C20 Least restrictive option was considered where relevant. | 83.9% | 90% | — |
C21 Family, carer or important-person consultation was documented where appropriate. | 86% | 90% | — |
C22 IMCA referral was considered or completed where required. | 67.3% | 90% | — |
C23 LPA, deputy, ADRT or advance statement status was considered where relevant. | 76.4% | 90% | — |
C24 Safeguarding concern was considered or escalated where relevant. | 83.7% | 90% | — |
C25 DoLS or deprivation of liberty concern was considered or escalated where relevant. | 56% | 90% | — |
C26 Disagreement, conflict, uncertainty or unresolved legal concern was escalated where relevant. | 86.3% | 90% | — |
C27 Outcome, decision or action plan was clearly documented. | 82.1% | 90% | — |
C28 The decision was communicated to the MDT, ward team or relevant professionals where appropriate. | 88% | 90% | — |
C29 Review date, expiry date or reassessment plan was documented where local policy requires it. | 54.4% | 90% | — |
C30 Reason for delayed, missing or incomplete assessment was documented where applicable. | 86.2% | 90% | — |
C31 Documentation was clear enough for another clinician or professional to understand the capacity assessment, conclusion and next actions. | 80.4% | 90% | — |
C32 Any mental capacity, consent, safeguarding or best interests safety concern was escalated or actioned where identified. | 82.7% | 100% | — |