Audit tool for mental capacity assessments - BPS Beta · PDF fileAudit Tool for Mental...

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Professional Practice Board and

Social Care Institute for Excellence

Audit Tool for Mental Capacity Assessments

ISBN 978-1-85433-703-0 © The British Psychological Society 2010.

St Andrews House, 48 Princess Road East, Leicester LE1 7DR, UK

Tel: 0116 254 9568 Fax: 0116 247 0787 E-mail [email protected] Website www.bps.org.ukIncorporated by Royal Charter Registered Charity No 229642

Contributors

Catherine Dooley Project Manager, Mental Capacity Act Audit Tool, The British Psychological Society

Karen Banford Clinical Lead Speech and Language Therapy, South BirminghamCommunity Healthcare Speech and Language Therapy

Karen Brooks MCA Coordinator – Luton Borough Council/Luton PCT

E.A. Carmody Leeds PFT

Liz Chesters Consultant Clinical Psychologist, Coventry and Warwickshire Trust

Indrani Choudhury Chartered Educational Psychologist in independent practice

Susan Ellsmore Social Care Institute for Excellence

Bruce Gilmer Consultant Clinical Psychologist, Head of Psychological Services,Forensic Directorate (Learning Disability), Northumberland Tyne & Wear NHS Foundation Trust

Mary Hill Forensic neuropsychologist in independent practice

Corrie Meesters Clinical psychologist and neuropsychologist, Making Sense

Brenda Noel Clinical Coordinator, St Andrews Healthcare

Dawn Owen Collated responses from LD Psychology across North Wales on behalf of BCUHB

Kate Parker Speech and language therapist, East London Foundation Trust

Alison Picton Social Care Institute for Excellence

Graham Powell Chartered psychologist

Genevieve Smyth College of Occupational Therapists

Alison Stansfield Leeds PFT

Sue Tye Clinical Lead O.T. Chelmsford Learning Disabilities Team

The British Psychological Society Ethics Committee

College of Occupational Therapists

The Royal College of Psychiatrist Old Age Faculty

The Royal College of Psychiatrist Learning Disability Faculty

INF166/05.2010

Audit Tool for Mental Capacity Assessments 1

Contents

Contributors

Foreword

1. Introduction 42. Rationale for the project 5

3. Purpose of the guidance 6

4. Development of the audit tool – methodology 8

4.1 Establishing standards

4.2 Identification of the sources for the standards

4.3 Detailed commentary on each standard

4.4 Matters to note

4.4.1 The assessor’s skills and competency

4.4.2 Standards for audit

4.4.3 Consent

5. Status of this publication 9

6. Standards for an Assessment under the MCA (2005) 10

7. References 16

Appendix 1: Example of an audit 17

Appendix 2: Audit Tool Questionnaire 23

If you have problems reading this document and would like it in adifferent format, please contact us with your specific requirements.

Tel: 0116 252 9523; E-mail: [email protected].

FOREWORD

Scie is delighted to welcome the BPS Audit Tool for Mental Capacity Assessments. Thispublication is one of a series of audit tools commissioned to test the impact of the MentalCapacity Act, given implementation remains in its infancy.

This publication has high aims: to set standards and to guide and enhance practice withinprofessions and organisations in assessing mental capacity. In use, the tool will assesscompliance against the Act, but also provide benchmarks to test future provision. It buildson the earlier guidance published by the Society to promote awareness and good practicein the assessment of capacity in adults.

Originally for applied psychologists, the development process has included consultationwith a wider audience, and the Society is to be congratulated for producing a tool suitablefor professionals practising beyond psychology, in psychiatry, occupational therapy, andspeech and language therapy, and in the widest variety of settings from the community tomental health or acute general hospital wards.

Susan Elsmore

Scie MCA Consultant


1. Introduction

The Mental Capacity Act came into law in 2005 and has been implemented in stages overthe following years in England and Wales. It is recognised that while there now is astatutory framework to protect and empower people who may lack capacity or who are atrisk of compromised capacity, it nevertheless requires widespread cultural change andalteration to practices in a wide range of care settings to fully ensure that the aims of theAct are met.

The Code of Practice for the MCA was published in 2006; this is generally regarded as anexceptionally well written and useful document to guide people through the procedures ofthe Act. It uses a range of case scenarios to illustrate how issues are dealt with; however, itdoes not fully address some of the complexities that arise.

A range of publications has provided additional guidance. There has been detailed guidancefrom lawyers, for instance Dimond’s guide to the legal aspects of the Act (Dimond, 2008);Jones’ Mental Capacity Act Manual (Jones, 2009); guidance for doctors and lawyers (BMA &The Law Society, 2004); social work (Brown & Barber, 2008; Barber et al., 2009) as well asmore focused publications such as for Guidance for End of Life Care (Chapman, 2008) or forspecific areas of capacity, e.g. financial decision making (Suto et al., 2007).

The British Psychological Society has had an active role in contributing to the developmentof expertise in the area of Mental Capacity; the Interim Guidance on the Assessment of Capacitywas published in 2006; this was followed in 2007 by a short reference guide producedjointly with the Royal College of Psychiatrists on the assessment of capacity, funded by theDepartment of Health. The Society has also gained funding for the production of Guidanceon Best Interest Assessments (2008) and Research Guidance (2008).

The Society’s present contribution is an audit tool that is designed primarily for evaluatingformal assessments of capacity likely to be carried out by applied psychologists, speech andlanguage therapists and other professional groups, often working in specialist services. It issuggested that this might represent the ‘gold standard’ to support and guide developingexpertise as the Mental Capacity Act enters fully into the culture of services for clientgroups where capacity may be impaired.

Clinical audit is defined as ‘a quality improvement process that seeks to improve patientcare and outcomes through systematic review of care against explicit criteria and theimplementation of change’ (NICE, 2002).

The key component of clinical audit is that performance is reviewed to ensure that whatshould be done is being done, and if not it provides a framework to enable improvements tobe made. A key component is establishing standards against which practice can be compared.

The goal of this work is to ensure that practitioners are utilising, as much as possible,evidence based decision making in their capacity assessments by:

n clarifying standards within capacity assessments; n identifying the sources of advice and expertise; n assisting in ways of addressing complexity, and n drawing this together in a user friendly way.

4 Professional Practice Board/Social Care Institute for Excellence

2. Rationale for the project

Applied psychologists have generally engaged well with the Mental Capacity Act and haveviewed it as a useful means to empower and protect vulnerable groups.

However, there has also been considerable anxiety about what constitutes a ‘good enough’capacity assessment and what assessment approaches might be included. One importantquestion is how much reliance should be put on neuro-psychological assessments (or otherformal assessment tools), and whether these are the sole basis of psychological assessmentsor whether a wider range of approaches could be used.

The Society’s Interim Guidance provided a range of case scenarios giving illustrations of howcapacity assessments might be approached and also addressed other areas – such asprofessional issues and team approaches. However, this was written before the Act cameinto force and in the two years since the Act applied psychologists have developed furtherexperience and considerable expertise, both within the profession and as part of teamsand services.

This seems a good time to bring this expertise together to generate and embed standardsfor the field. However, the MCA covers a wide range of clients groups: people sufferingfrom dementia, people with learning disabilities, those with physical disabilities andacquired brain injury as well those with mental health problems. The decisions are alsowide ranging, covering many areas of health and well-being. These standards are thereforebased around the core requirements of the Act and professional standards of assessmentrather than specifying any particular approaches.

Applied psychology assessments are likely to be more formal, more detailed and can belengthy. Psychologists and other professional staff, such as speech and language therapistsand psychiatrists, tend to be called in for more specialist assessments in cases where othersfeel unable to make the decision without additional specialist opinion (Code of Practice, 4.51).

Some psychologists work in specialist units, most typically for those with acquired braininjury, where an essential part of the ongoing work of the unit, for all staff, is to assess andenhance capacity to enable people to return to life in the community with adequatesupport. In these settings there has been the development of expertise which can usefullybe disseminated more widely.

The experience of psychologists in Scotland, where a Mental Incapacity Act came intoforce in 2002, has been invaluable in assisting this. The audit tool is designed specifically inrelation to the MCA for England and Wales although the principles would apply widely.


3. Purpose of the guidance

This document aims to set standards and to guide and enhance practice within professionsand organisations.

Within this there are three functions this guidance aims to fulfil:

1. For the individual practitioner it provides a statement of the expected standardagainst which to review their own work, either on their own or with their clinicalsupervisor. It can also be incorporated as part of the evidence base for DevelopmentReviews (within the NHS as part of the KSF). In addition, it can be utilised as atraining tool to target specific areas where practice needs to be improved.

2. It is also intended that this could be used within teams and/or services as part of theclinical governance to identify strengths and weaknesses of procedures andimplementation.


Jenny Sheldon is a Speech and Language Therapist and has started work in a generalhospital where she is expected to assess capacity for those people on a stroke unit wherethey showed communication problems. As part of supervision of her work the audit toolwas used to evaluate her assessments; these came out as generally at a very high standard.

But for B.11 Has the person had sufficient time to assimilate issues that have arisen? Havepsychological aspects of adjustment to change been taken into account in their responses?and Section C Enhancing Capacity there were usually very limited responses. Jenny saidthat she had not thought that this was part of her role but also admitted that she feltunder pressure from the service to give a definitive opinion quickly.

It was agreed that she would start to build these elements into her assessments and discussthe implications of this with the clinical team.

Raj Shah is an Occupational Therapist in a Learning Disability Team which is regularlyrequired to help assess capacity to enter into sexual relationships.

In his supervision he talks about the difficulty of addressing A.7 The assessment should bemade against clear criteria for the expected level of knowledge/decision making requiredto demonstrate the required capacity. Has this been stipulated in advance?

He agrees with his supervisor that this could be a project he works on within the team toset clear standards and expectations in this area. This includes consulting with bothservice users and their families; once result is in, providing better guidance for the teamin their assessments but also helps to deal with some of family concerns about this area.

3. For professions involved in capacity assessments it provides a consensus statement ofexpected standards.


An acute admission ward had a high number of people admitted for detoxification andwould assess capacity (on various possible issues), but if people were judged to havecapacity, the ward would discharge them rapidly. After two people died soon afterdischarge the unit reviewed various aspects of care, including their approach to assessingcapacity. They realised that they needed a more specialist input to how they dealt withB.10 Was there any assessment of whether the person demonstrated that they couldidentify and weigh risks and benefits for the specific issue? and worked with the drug andalcohol team to develop ways to assess this in more depth. They also identified that theirresponses to F.2 If the person is judged to have capacity are there recommendations foractions to provide support to empower and protect the person? needed improvement.

A ward for older people in a general hospital in an ethnically diverse area was concernedabout the extreme distress showed by some people who were judged to lack capacity andthen, after Best Interest meetings, were moved into residential care.

They studied the audit tool and chose one area to audit – B.13 Has the impact ofreligious/cultural/individual beliefs and values been taken into account? The ward grouprealised they did not fully appreciate how to assess this through their own lack ofknowledge of other’s cultures. They consulted with services users and families, communitygroups and religious leaders; this helped them in developing a set of questions for theassessment using appropriate language. One additional specific result was that the teamworked more closely with families much earlier in the planning process where capacityappeared to be impaired to allow the person to have time to think about possibleoutcomes of their hospital stay (B.11 Has the person had sufficient time to assimilateissues that have arisen? Have psychological aspects of adjustment to change been takeninto account in their responses?)

4. Development of the audit tool – methodology

The original audit tool was developed as part of training for applied psychologists as theMental Capacity Act came into force and was used to analyse assessments as part of anumber of workshops and amended in the light of feedback.

At the start of the project, the tool was circulated within the various specialist groups of theSociety, through e-mail groups, primarily in neuropsychology, learning disability and olderadults. Other professions were also invited to respond and there have been responses fromthe Royal College of Psychiatrists, College of Occupational Therapists, and the RoyalCollege of Speech and Language Therapists.

(In the initial development consent was included as part of the areas to be audited; afterconsultation it was decided that this would be excluded; the rationale is that consentaspects would need to be addressed.)

4.1 Establishing standardsThe first stage was to clarify and confirm the standards expected. As the approaches usedacross the range of decisions, groups of people and contexts is extremely wide, thestandards posed primarily as questions to prompt assessors to consider if these need to beaddressed and, if so, how.

The audit cycle requires clarification of standards but also the source of these standards.This was the second stage and it was decided that the sources could be from:

n The Mental Capacity Act;n Mental Capacity Act Code of Practice;n professional guidelines;n professional practice;n research; andn medico-legal perspectives.

As part of the iterative consultation process these were identified for each standard. It isrecognised that this work could be developed further and it is intended that as the audit toolis used and reviewed the evidence base for the standards will also be reviewed and extended.

4.2 Detailed commentary on each standardThe third stage is to provide a more detailed qualitative commentary section by section toenable the assessor to address the issue, particularly if there should be complexity or dilemmas.

These sections include:

n more detailed summaries of key works;n comments on some of the complexities in these areas;n examples of good practice; andn ideas for methodology to work through problematic issues.

These sections are included as hyperlinks; by necessity this is also a ‘work in progress’ andit is hoped that this will be critiqued and amended as experience indicates.


4.3 Matters to noteThree matters have come up as part of the consultation: the assessor’s skills andcompetency; standards for audit; and consent.

4.3.1 The assessor’s skills and competencyThe audit is of the assessment procedure and processes, not of the assessor directly but indirectlythe audit would provide evidence about the assessor’s skills and competency in this field.

It would be expected that anyone carrying out an assessment of mental capacity would

n have a good knowledge base and working understanding of mental capacity, theMental Capacity Act (2005) and of the requirements of the particular decisionmaking situation;

n have undertaken any mandatory training and that they have the specific knowledgeand skills required for each of the instruments they use;

n be aware of any limitations that may affect the reliability, validity and generalisabilityof the assessment when not using formal assessment tools, e.g. if conductinginterviews or using observational data; and

n receive supervision.

If as part of the audit of an assessment, concerns are raised about this area (for instance, if many items are scored as 1 or 0) this may indicate that the skills and competencies needto be reviewed.

4.3.2 Standards for auditThis audit tool is intended primarily for a more specialist assessment; however, these maytake place within a specialised unit, such as a neuro-rehabilitation centre, where capacityassessments might be a regular activity. However, settings might vary from mental health wardsfor older people with dementia, to acute general hospital wards and to community settings,such as residential and nursing homes. Therefore it is considered that decisions about thefrequency of the use of the tool and the manner of its use must be for local decision.

4.3.3 ConsentConsent was originally included as an item in the checklist but it was felt to be outside theremit of the audit, which is about the process and outcome of the actual assessment. Inaddition it was felt that it would be difficult to establish standards at this time. Where peopleare able to give full informed consent (such as a person consulting a solicitor to revise a will)and where the person lacks capacity to be able to consent (whereupon a best interest decisioncan be made on their behalf) this is more straightforward. However, there is a vast area inthe middle where it is not easy to define meaningfully full valid consent or to assess this.

5. Status of this publication

This document provides standards and examples of good practice in assessing mentalcapacity. It is not intended to be, nor can it provide, definitive instruction to thoseundertaking an assessment. Anyone undertaking an assessment should use clinicalsupervision and local support and expertise to help them to decide how best to proceed.



Standard Rationale Source

A BEFORE STARTING THE ASSESSMENT

A1 Are the circumstances andrationale for theassessment clear?

This sets the scene for theassessment and helps inthe interpretation offindings, allowing anylimitations to be identified(see E2)

Relevant professionalguidelines

A2 Is there any aspect of thecontext that may affect thereliability or validity of theassessment?

E.g. person deaf, drowsy orunco-operative; noisypublic environment,limited time to carry outassessment


A3 Initiating assessment –have there been checks:

A3.1 The ‘diagnostic test’

Does the person reach thethreshold for questioningcapacity? I.e. had it beendemonstrated that theperson has an impairmentof, or disturbance in thefunctioning of mind orbrain?

‘…because of animpairment of, or adisturbance in thefunctioning of the mind orbrain’

MCA Section 2(1)

CoP Chapter 4.11–4.12

A3.2 Is it clear why capacitywas questioned for thisspecific decision?

Need evidence for this CoP Chapter 4.34 – 4.36

A3.3 Do any of theexclusions apply either tothe person (age, MHA,valid and relevant AdvanceRefusals)?

Age – see CoP Chapter 12

MHA generally ‘trumps’the MCA but can becomplex

Advance Decisionsto refuse treatment

MCA Section 2(5) andCoP Chapter (12)

MCA Section 28 and CoPChapter 13Medico Legal

MCA Section 24–26 andCoP Chapter 9

6. Standards for an Assessment under the Mental Capacity Act (2005)

Key:

CoP Mental Capacity Act 2005 Code of Practice (2007)COT College of Occupational Therapists MCA Mental Capacity Act 2005RCS&LT Royal College of Speech and Language Therapists


A3.4. Do any of theexclusions apply to thedecision?

Intimate personalrelationships

Voting

Adoption or mattersaffecting the person’s child

Care or treatmentauthorised under theMental Health Act

There are a number ofdecisions that cannot betaken on behalf ofsomeone who lackscapacity, includingmarriage, sexual relationsand parenting.

MCA Section 27–29 and 62and CoP Chapter 1.8–1.11

A4 Is the question to beanswered stated clearlyand specifically?

Relevant professionalpractice

A5 Is there more than onequestion?


A6 Is it clear who the actualdecision maker is?

‘… ultimately, it is up tothe professionalresponsible for theperson’s treatment tomake sure that capacityhas been assessed’

CoP Chapter 4.40

A7 The assessment should bemade against clear criteriafor the expected level ofknowledge/decisionmaking required todemonstrate the requiredcapacity. Has this beenstipulated in advance?


B THE ASSESSMENT

B1 Is there evidence that theassessment was carried outat the right time?


B2 Was appropriate andrelevant informationincluded? This mightinclude the following:

Anyone assessingsomeone’s capacity willneed to decide which ofthese steps are relevant totheir situation

CoP Chapter 4 generallyand Chapter 4.49

BPS Interim GuidelineChapter

B2.1 Adequatebackground information/from people or records

CoP Chapters 4 and 16(Rules governing access toinformation)

B2.2 Interviews withrelevant parties

Have these been listed inthe report?

CoP Chapter 4.49 & 4.52



B3 Was there a checkon/assessment of theperson’s neurological,cognitive andcommunication ability?

E.g. if English not firstlanguage; receptive orexpressive problems; useof communicationsupports


COT/RCS&LT

B4 What evidence is there ofattempts to compensate forcognitive/communication/emotional disabilities oruse support tools?


COT/RCS&LT

B5 Were formal assessmentsused that were relevant tothe functional capacityquestion?

Common Law tests formaking a will, making agift, entering into acontract, litigate andmarry

CoP Chapter 4.32

BMA/Law Society

BPS Interim Guidelines


B.6 Were the formalassessments listed and/ordescribed?

B7 Was there identification ofany emotional/mentalillness aspects that mightaffect responses:includes n anxietyn depressionn psychosis

These could impact oneither or both:n the process of

assessment n the decision about

mental capacity


(RCP/BPS)

B.8 Does insight impact on theperson’s ability tounderstand theinformation relevant to thedecision and offoreseeable consequencesof the decision?


(RCP/BPS)

B.9 Was there any assessmentof whether the persondemonstrated that theycould retain theinformation relevant to thedecision?

Items such as notebooks,photographs, posters,videos and voice recorderscan help people recordand retain information

Code of Practice

4.20 RetainingInformation

The person must be able tohold the information in theirmind long enough to use itto make an effective decision.But section 3(3) states thatpeople who can only retaininformation for a short whilemust not automatically beassumed to lack the capacityto decide – it depends onwhat is necessary for thedecision in question.


B.10 Was there any assessmentof whether the persondemonstrated that theycould identify and weighrisks and benefits for thespecific issue?

Code of Practice

Chapter 4.21 (Using orweighing information aspart of the decision-making process) andChapter 4.22

Relevant professionalguidelines (RCP/BPS)

B.11 Has the person hadsufficient time to assimilateissues that have arisen?Have psychological aspectsof adjustment to changebeen taken into account intheir responses?

BPS Interim Guidance

B.12 Is there evidence that theperson could make thedecision if given moretime?


B.13 Has the impact ofreligious/cultural beliefsand values been taken intoaccount?

Code of PracticeChapter 5, 5.46

BPS Interim GuidanceChapter 2 page 23

B.14 Were there any checks forconsistency of responses?


B.15 Was there any evidence ofsuggestibility/socialinfluence in theirresponses?


B.16 If so, is there evidence ofhow this was addressedand/or taken intoaccount?


C ENHANCING CAPACITY

C1 What evidence is there asto how capacity could beenhanced?

Mental Capacity Act Part 1,1 The principles (3)

CoP Introduction,Chapter 2.6 – 2.7

C2 What was done to enhancecapacity?

Mental Capacity Act Part 1, 1, 6

Section 1(3)

C3 If this was not done whatwere the reasons?


CONCLUSION

Have the four questionsbeen explicitly answered?

Mental Capacity Act

D1 Whether the person couldunderstand theinformation?

A person is unable to makea decision for himself if heis unable – a) to understandthe information relevant tothe decision.

Mental Capacity Act Section 1 3(1) (a)

CoP Chapter 4

D2 Whether the person couldretain the information?

A person is unable to makea decision for himself if heis unable – b) to retainthat information.

Mental Capacity Act Section 1 3(1) (b)

CoP Chapter 4

D3 Whether the person couldweigh information inregard to foreseeableconsequences?

A person is unable to makea decision for himself if heis unable – c) to use orweigh that information aspart of the process ofmaking the decision.

Mental Capacity Act Section 1 3(1) (c)

CoP Chapter 4

D4 Whether the person couldcommunicate theirdecision?

A person is unable to makea decision for himself if heis unable – d) tocommunicate his decision(whether by talking, usingsign language or any othermeans)

Mental Capacity Act Section 1 3(1) (d)

CoP Chapter 4

E THE OUTCOMEWritten report or decision/answer – written report ortemplate or case record

E1 Was information about theassessment process andcontent clearly stated?

n Date of reportn Name and title of

assessorn Name of unitn Name and title of

decision maker


E2 Were issues of reliabilityand validity that mighthave affected theassessment acknowledgedas part of the opinion/judgement?


E3 Did the assessment includesufficient explanation ofcapacity findings?


E4 Was the decision makingprocess well structured?


E5 Was factual evidenceclearly distinguished fromopinion?



E6 Has the assessment dulyconsidered and balanceddifferent factors, ethicalprinciples and value judgements,(such as autonomy versusprotection)?

Relevantprofessionalguidelinesand Codes ofEthics

E7 Was the opinion/judgement ofthe assessor clearly expressed?

Relevantprofessionalguidelines

F RECOMMENDATIONS

F1 If the person is judged to lackcapacity are thererecommendations for actions toempower and protect the person?

E.g. IMCA, Deprivation of Liberty RelevantprofessionalCodes ofConduct andEthicalGuidelines

F2 If the person is judged to havecapacity are thererecommendations for actions toprovide support to empower andprotect the person?

E.g. Safeguarding/Advocacy RelevantprofessionalCodes ofConduct andEthicalGuidelines

F3 Is there a recommendation as towhether the assessment should berepeated?

Relevantprofessionalpractice


7. References

British Medical Association/The Law Society (2004). Assessment of mental capacity: Guidancefor doctors and lawyers (2nd edn.). London: BMA Books.

Barber, P., Brown, R & Martin, D. (2009). The Mental Capacity Act 2005: A guide for practice(post-qualifying social work practice) (2nd edn). Exeter: Learning Matters Ltd.

Brown, R. & Barber, P. (2008). The social worker’s guide to the Mental Capacity Act 2005. Exeter:Learning Matters.

Chapman, S. (2008). The Mental Capacity Act in practice: Guidance for end of life care. London:National Council for Palliative Care.

Dimond, B. (2008). Legal aspects of mental capacity. Oxford: Blackwell.

Mental Capacity Act 2005. London: Stationary Office.

Mental Capacity Act 2005 Code of Practice (2007). London Stationary Office. Alsoavailable from www.dca.gov.uk/legal-policy/mental-capacity/mca-cp.pdf

Jones, R. (2009). Mental Capacity Act manual (3rd edn.). Cornwall: Sweet and Maxwell.

National Institute of Clinical Excellence (2002). Principles of best practice in clinical audit.London: NICE.

Suto, I., Clare, I. & Holland, A. (2007). Financial decision making: Guidance for supportingfinancial decision making by people with learning disabilities. Kidderminster: BILDPublications.

BPS/PPB publications (electronic versions, available from www.bps.org.uk)Assessment of capacity in adults: Interim guidance for psychologists (2006)

Short reference guide (2007)

Best interest guidance (2008)

Research guidance (2008)

Audit Tool for Mental Capacity Assessmeents 17

Audit of Mental Capacity Assessments – summary sheet

Date of completion of audit:

Dec 09/Jan 10

Name of person completing the audit:

JG/RN

Type of Audit Peer/ MDT

Name/job title of person(s) who undertook the assessment:

JG (Consultant Clinical Psychologist) RN (Speech and Language Therapist)

Name of unit/service:

Community Learning Disability Team (X Trust)

Brief description of the person being assessed, the decision and the context (please ensure confidentiality of personal information is maintained): 37 year old man with learning disability. He also has a visual impairment and mental health problems. His carers retired and a new care team took over. A request was made for client to go and live with parents. It is a decision about where to live. Usually this would be a decision for social services but there were some complicating health and advocacy issues. We felt that this needed to be a MDT decision. An assessment by psychologist and speech and language therapist was done to inform this decision making process. Assessment by SALT and Psychologist looked at the pre-requisite skills required in order to make this decision. This assessment highlighted that the service user did not have the level of understanding, abstract thinking or expressive communication to understand and process the information with regard to moving house. Consequently information regarding a choice of places to live was never presented to the service user. A number of different assessments were completed by other professionals that informed the process but were not specifically about the decision e.g. sensory assessment regarding eyesight, medical letters from psychiatrist.

Total score:

No of items scored

Total score

Fully met (2) 30 60

Partly met (1) 6 6

Not met (0) 2 0

Not applicable 6 (score 2) 12

TOTAL 44 78/86

Appendix 1: Example of an audit

18 Social Care Institute for Excellence

Overall comments from person completing the audit: Some of the items are difficult to score as they seem to be more about qualitative information We realised that we had not explicitly addressed some of the conflicts and ethical issues (E6) that could arise. As this was a fairly clear cut decision it may not have mattered and we think/hope that for a more complex situation we would have been aware of this and addressed it within the assessment. For some of the areas scored 1 (A6 and B2.1 and 2.2) we recognised that this was largely due to the fact that the knowledge was contained within the and service and therefore not made explicit within the report. However we realised that this was a gap that in future we would make sure was clearly stated, even in summary form.

M MDT


Audit of Mental Capacity Assessments – questionnaire Please rate each standard as follows: If a standard is:

• Fully met please score 2 • Partly met please score 1 • Not met please score 0, or n/a if not applicable

A Before starting the assessment

Score Comment

A1 Are the circumstances and rationale

for the assessment clear? 2

A2 Is there any aspect of the context that may affect the reliability or validity of the assessment?

2 Eyesight might have been an issue but previous sensory assessment was taken into consideration

A3 Initiating assessment – have there

been checks:-


Does the person reach the threshold for questioning capacity? I.e. Had it been demonstrated that the person has an impairment of, or disturbance in the functioning of mind or brain?

2

A3.2 Is it clear why capacity was questioned for this specific decision?

1 This is implied in the assessment rather than explicitly stated.

A3.3 .Do any of the exclusions apply either to the person (age, MHA, valid and relevant Advance Refusals)?

2

A3.4. Do any of the exclusions apply to the decision? Intimate personal relationships Voting Adoption or matters affecting the person’s child Care or treatment authorised under the Mental Health Act

2

A4 Is the question to be answered stated clearly and specifically?

2

A5 Is there more than one question?

1 To stay in current location. To move to another area to live with parents.


A6 Is it clear who the actual decision maker is?

1 Though we felt there was a role for MDT, the social worker has major role to play in final decision as it was regarding a social issue.

A7 The assessment should be made against clear criteria for the expected level of knowledge/decision making required to demonstrate the required capacity. Has this been stipulated in advance?

2 The decision was broken down to different ‘tasks’ the client would need to complete to be considered to have capacity.

B The assessment

Score Comment

B1 Is there evidence that the assessment was carried out at the right time?

2 It was carried out prior to the move

B2. Was appropriate and relevant information included? This might include the following:

B2.1 Adequate background information/from people or records

This was not provided in the assessment but was available to those making the decision as they had known client for many years. Liaison with family and use of family photographs to support capacity

assessment

B2.2 Information from/Interviews with relevant parties Have these been listed in the report?

1 People’s opinion was given in MDT format and by other assessments completed. Not listed in report

B3 Was there a check on/assessment of the person’s neurological, cognitive and communication ability?

2 SALT assessment completed Due to level of LD formal assessment of cognitive ability not possible

B4 What evidence is there of attempts to compensate for cognitive/communication/emotional disabilities or use support tools?

2 We used talking mats to try and help client make the choice Use of photographs and symbols

B5 Were formal assessments used that were relevant to the functional capacity question?

/

B6 Were the formal assessments listed and/or described?

B7 Was there identification of any emotional factors/mental illness that might affect responses: including • anxiety • depression • psychosis

2 He had been seen for a mental health problem and was stable at the time of testing

B8 Does insight impact on the person’s ability to understand the information relevant to the decision and of foreseeable consequences of the decision?

n/a

1

N A Not aware of formal assessments available

N/A


B9 Was there any assessment of whether the person demonstrated that they could retain the information relevant to the decision?

2

B10 Was there any assessment of whether the person demonstrated that they could identify and weigh risks and benefits for the specific issue?

2

B11 Has the person had sufficient time to assimilate issues that have arisen? Have psychological aspects of adjustment to change been taken into account in their responses?

2 Assessment took 3 sessions over a period of a month

B12 Is there evidence that the person could make the decision if given more time?

2

B13 Has the impact of religious/cultural/individual beliefs and values been taken into account?

1 MDT discussions about the role of the family when service user had been in residential care for so long. ??Churchgoer – new carers Christian too??

B14 Were there any checks for consistency of responses?

2

B15 Was there any evidence of suggestibility/social influence in their responses in the interview?

2

B16 If so, is there evidence of how this was addressed and/or taken into account?

N/A Questions weren’t presented as he evidently lacked capacity to comprehend information

C Enhancing capacity Score Comment

C1 What evidence is there as to how capacity could be enhanced?

2 We spent a lot of time thinking about how to maximise capacity. Using the talking mats was a way of doing this.

C2 What was done to enhance capacity?

2 Involving familiar care staff from day service, use of Makaton, use of talking mats, seen regularly to build rapport, use of pictorial information – all done to improve service users ability to engage with information and assessors.

C3 If this was not done what were the reasons?

N/A

Conclusion Score Comment

Have the four questions been explicitly answered?

D1 Whether the person could understand the information?

2

D2 Whether the person could retain the information?

2

D3 Whether the person could weigh information in regard to foreseeable consequences?

2

D4 Whether the person could communicate their decision?


E The Outcome Score Comment

E1 Was information about the assessment process and content clearly stated?

2

E2 Were issues of reliability and validity that might have affected the assessment acknowledged as part of the opinion/judgement?

2 Acknowledgement that difficult to ascertain his understanding of circumstances due to limited expressive communication.

E3 Did the assessment include sufficient explanation of capacity findings?

2

E4 Was the decision making process well structured?

2

E5 Was factual evidence clearly distinguished from opinion?

2

E6 Has the assessment duly considered and balanced different factors, ethical principles and value judgements, (such as autonomy versus protection)?

0 Not explicitly addressed

E7 Was the opinion/judgement of the assessor clearly expressed?

2

F Recommendations Score Comment

F1 If the person is judged to lack capacity are there recommendations for actions to empower and protect the person?

0

F2 If the person is judged to have capacity are there recommendations for actions to provide support to empower and protect the person?

N/A e.g. Safeguarding/Advocacy

F3 Is there a recommendation as to whether the assessment should be repeated?

N/A


Audit of Mental Capacity Assessments – summary sheet

Date of completion of audit:

Name of person completing the audit:

Type of audit

Name/job title of person(s) who undertook the assessment:

Name of unit/service:

Brief description of the person being assessed, the decision and the context (please ensure confidentiality of personal information is maintained):

Total score:

No of items scored

Total score

Fully met (2)

Partly met (1)

Not met (0)

Not applicable

Overall comments from person completing the audit:

(score 2)

Appendix 2: Audit Tool Questionnaire


Audit of Mental Capacity Assessments Introduction This is an audit tool to evaluate the quality of mental capacity assessments. Although it may be used by anyone who had carried out an assessment, the tool’s primary audience are those carrying out formal assessments of capacity, for example:

• Speech and Language Therapists • Occupational Therapists • Applied Psychologists • Nurses • Psychiatrists • Social Workers

The tool is designed for auditing a formal written assessment, but could be used in analysing documentation within care records. Examples of how it could be used are:

• by the individual as a self evaluative measure • within a peer group/team/service • when feeding back orally within a supervision session • within a supervisory or managerial relationship

General guidance for use of the tool This tool is intended to be used to audit a completed assessment of capacity. It should not be used as a checklist or aide memoire. It does not lay down a set procedure either in terms of sequencing or the content of an assessment, but identifies standards of good practice across a range of issues that may apply. The full document or other resources may need to be accessed to provide more information and practical guidance. It is not assumed that all areas will need to be checked in any assessment – there may be areas which are not relevant for the particular situation. There may also be a point in an assessment, e.g. if the person is not able to retain information, where following sections would then be redundant. The tool includes a summary sheet to allow for qualitative as well as quantitative feedback.


Audit of Mental Capacity Assessments – questionnaire Please rate each standard as follows: If a standard is:

• Fully met please score 2 • Partly met please score 1 • Not met please score 0, or n/a if not applicable

A Before starting the assessment

Score Comment

A1 Are the circumstances and rationale for the assessment clear?

A2 Is there any aspect of the context that may affect the reliability or validity of the assessment?

A3 Initiating assessment – have there

been checks:-


Does the person reach the threshold for questioning capacity? I.e. Had it been demonstrated that the person has an impairment of, or disturbance in the functioning of mind or brain?

A3.2 Is it clear why capacity was questioned for this specific decision?

A3.3 .Do any of the exclusions apply either to the person (age, MHA, valid and relevant Advance Refusals)?

A3.4. Do any of the exclusions apply to the decision? Intimate personal relationships Voting Adoption or matters affecting the person’s child Care or treatment authorised under the Mental Health Act

A4 Is the question to be answered stated clearly and specifically?

A5 Is there more than one question?

A6 Is it clear who the actual decision maker is?


A7 The assessment should be made against clear criteria for the expected level of knowledge/decision making required to demonstrate the required capacity. Has this been stipulated in advance?

B The assessment

Score Comment

B1 Is there evidence that the assessment was carried out at the right time?

B2. Was appropriate and relevant information included? This might include the following:

B2.1 Adequate background information/from people or records

B2.2 Information from/Interviews with relevant parties Have these been listed in the report?

B3 Was there a check on/assessment of the person’s neurological, cognitive and communication ability?

B4 What evidence is there of attempts to compensate for cognitive/communication/emotional disabilities or use support tools?

B5 Were formal assessments used that were relevant to the functional capacity question?

B6 Were the formal assessments listed and/or described?

B7 Was there identification of any emotional factors/mental illness that might affect responses: including • anxiety • depression • psychosis

B8 Does insight impact on the person’s ability to understand the information relevant to the decision and of foreseeable consequences of the decision?

B9 Was there any assessment of whether the person demonstrated that they could retain the information relevant to the decision?


B10 Was there any assessment of whether the person demonstrated that they could identify and weigh risks and benefits for the specific issue?

B11 Has the person had sufficient time to assimilate issues that have arisen? Have psychological aspects of adjustment to change been taken into account in their responses?

B12 Is there evidence that the person could make the decision if given more time?

B13 Has the impact of religious/cultural/individual beliefs and values been taken into account?

B14 Were there any checks for consistency of responses?

B15 Was there any evidence of suggestibility/social influence in their responses in the interview?

B16 If so, is there evidence of how this was addressed and/or taken into account?

C Enhancing capacity Score Comment

C1 What evidence is there as to how capacity could be enhanced?

C2 What was done to enhance capacity?

C3 If this was not done what were the reasons?

Conclusion Score Comment

Have the four questions been explicitly answered? Was it shown-

D1 Whether the person could understand the information?

D2 Whether the person could retain the information?

D3 Whether the person could weigh information in regard to foreseeable consequences?

D4 Whether the person could communicate their decision?


E The Outcome Score Comment

E1 Was information about the assessment process and content clearly stated?

E2 Were issues of reliability and validity that might have affected the assessment acknowledged as part of the opinion/judgement?

E3 Did the assessment include sufficient explanation of capacity findings?

E4 Was the decision making process well structured?

E5 Was factual evidence clearly distinguished from opinion?

E6 Has the assessment duly considered and balanced different factors, ethical principles and value judgements, (such as autonomy versus protection)?

E8 Was the opinion/judgement of the assessor clearly expressed?

F Recommendations Score Comment

F1 If the person is judged to lack capacity are their recommendations for actions to empower and protect the person?

F2 If the person is judged to have capacity are there recommendations for actions to provide support to empower and protect the person? e.g. Safeguarding/Advocacy

F3 Is there a recommendation as to whether the assessment should be repeated?

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