Mental Capacity case studies help us apply knowledge in action. They can help us visualise scenarios and understand processes, as well as challenges, before considering the who, what, when, where and how.
In today’s blog, we start a series of case studies that explore particular aspects of the Mental Capacity Act within everyday practice. To help us with this, we will draw on familiar characters from the worlds of TV, film and literature that give an array of contexts and presentations.
This blog series was inspired by a fantastic presentation by The Technology Enabled Care Team at Dorset Council that really helped bring the Mental Capacity Act to life.
For the first in our new case study series, I would like to introduce our case study character, known to his friends as ‘Eeyore’:
- Born in 1924, ‘Eeyore’ has always lived outdoors, preferring to camp in the woodland, though for the purpose of this assessment we will adjust this slightly and say he has his own caravan and owns his own land, which he has resided in since childhood.
- His home regularly requires repair, and is quite dilapidated. He has the option to live with his friends but has declined on multiple occasions.
- Eeyore has a history of depression, being very low in mood, but has no other health conditions of note. While he often needs support he often worries about being a ‘burden’, but also is concerned of being ‘forgotten’ or alone.
- He often voices that he is lonely and feels isolated, but does have a close support network of friends who live locally. He is in contact with them regularly and will ask for help if needed, striving for independence wherever possible.
- Eeyore has recently had a period of ill health, and has been admitted to hospital for pneumonia following the winter period. The healthcare team are now exploring discharge options. These options are to either send him home with a step-down care package, or to place him in a rehabilitation and assessment bed.
- Although Eeyore’s short term memory has declined, there is no formal diagnosis of cognitive impairment.
- A ‘reasonable belief’ has been raised by staff, who are concerned that Eeyore may not fully understand the risks and benefits of the two discharge options. A mental capacity assessment has been requested to check he is able to make the decision about his discharge.
Key concepts and questions to ask
When preparing to assess capacity in a case such as this, the first thing is to establish all of the relevant facts alongside a clearly defined question to be addressed, and a set of options.
To start this process, the assessor will need to identify core concepts relating to the central question – in this case, Eeyore’s placement. In this example, the core concepts may include:
- Home environment, including access
- A typical week – the activities of daily living
- The individual’s network of family and friends
- Previous support needs (prior to hospitalisation)
- Any recent changes to the individual’s health
- Present needs and help required
- Options available
- Where do you live? How long have you lived there?
- What type of place is it? Is it a tent, caravan, house, supported living, or something else?
- Can you tell me more about your home? How do you access your home? What is the bathroom like? Where do you cook? Is your home spread across several floors?
- Do you have anything to support you within your home?
- How do you do your shopping each week?
- Do you pay your bills online or do you need to go to the Post Office?
- Do you have any friends or family? Can/do they help?
- How is your health?
- Have there been any changes to managing your health and wellbeing? (medication, mobility, fatigue, risk of falls, managing personal care or toileting, meals etc.)
- There are two options presently available: one is a care package at home [explain as needed]. What do you understand about this? How do you feel about this option?
- The other option is a ‘stepdown’ placement and assessment bed [explain as needed] What do you understand about this? How do you feel about this option?
Making a decision
Once the context has been established, the next step to consider how you (the assessor) can aid the client Eeyore in weighing up the decision. Questions to support this process may include:
- What will everyday living look like at home? Do you need any additional support or adaptations?
- While at hospital, you have had [X]. How will you manage when at home?
- This question will need breaking down into various care sections as needed, including prescription management, meals, mobility etc.
- What do you think of [X]?
- What are the benefits of going home? What are the risks?
- What are the benefits of going to the stepdown placement? What are the risks?
- What would be your decision on these two options?
Starting the assessment
Once all of the core concepts have been established and key questions identified, it is then on to the assessment itself. It is always a good idea to start with an introduction, explaining why you are there and what the Mental Capacity Act is.
Throughout the assessment, you can and should provide information as needed, keeping a note of any information given and then returning to check retention and understanding periodically. You should also provide resources and adaptations to aid engagement where appropriate. This may include communication aids, visuals to aid understanding, easy-read guides (etc).
It is also important to consider the environment that the assessment takes place in, plus other factors such as outside influences, sensory factors, the client’s health on the day, amount of sleep (etc). You should also ensure that hearing aids are present and working as needed.
During the assessment, if any answers are unclear or incomplete – or if new information is given – then the role of the assessor is to keep asking questions. The examples concepts and questions in this blog are just the starting point of an assessment. There will always be more questions to be asked, as each case is different. It may even be that you need to break the assessment down into smaller sessions over time, include breaks in the session, or make other adjustments as needed for the individual.
Further worked examples
To support you with your mental capacity assessments, we have a growing range of case studies and worked examples you can draw upon:
- What questions should I ask?
- Types of questions to ask
- Mental capacity assessments for complex decisions
- Preparing questions for a complex mental capacity assessment
- Decision paralysis
- What information is needed for a mental capacity assessment
- Example mental capacity assessments
For training or consultancy on how to prepare for a mental capacity test, what questions to ask, how to document, and more, please contact us.