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Case study: How to document a Mental Capacity Assessment

Man sat on a picnic bench, smoking while playing a guitar

The way professionals document mental capacity tests can vary greatly across the health and care sectors. In some cases, professionals are not yet using the updated assessment format of Functional and then Diagnostic. More worrying still is that in some cases it’s not just the documentation format that varies, but the quality of the content that is recorded.

In this blog, we examine two example assessments, using the case of Dylan to show the impact documentation can have on the outcomes of an assessment.

Introducing Dylan

For this case study, I would like you to introduce you to our character, known to his friends as ‘Dylan’.

  • Born in 1965, Dylan grew up and continues to live in the UK, in a small village known as the ‘Enchanted Gardens’.
  • He resides with friends in a shared accommodation, receiving help and support for chronic fatigue and fibromyalgia.
  • Dylan is a very creative individual, and enjoys making sculptures as well as playing the guitar. These talents have enabled him to form a career as a musician and part time artist.
  • He is described by his friends as a very laid back character, and is observed to regularly experience fatigue, sleeping often.
  • Due to pain and fatigue, Dylan has not been eating and drinking well. As a result, Dylan has recently suffered several urinary tract infections (UTIs), which have caused delirium and have required hospital admissions.
  • On discharge from hospital, Dylan’s support workers have raised concerns around Dylan’s smoking – that he is at risk of harm as he is often found asleep with a lit cigarette in his hand. Therefore, a mental capacity assessment has been requested in order to explore his decision-making around smoking.

Assessing capacity for the decision to smoke

In previous blogs, we have explored common errors in mental capacity tests, as well as examples of good practice in terms of documentation. To explore this topic further, I have prepared two example assessments to highlight some of the issues that can arise.

Example 1 – poor documentation

This example is based on a real assessment I have seen documented recently…

  • Understanding: No.
  • Retention: Sometimes.
  • Weighing up: Yes.
  • Communication: Yes.

This is a very poor assessment. It gives no context or frame of reference as to how Dylan engaged with the assessor.

If this assessment were to be reviewed (due to a health change, challenged or otherwise) there is no evidence of baseline behaviour. Although technically speaking, the documentation shows whether the assessor believes Dylan can or cannot demonstrate the core competencies around the decision to smoke, this particular examples does not meet the minimum standard of documentation.

Of course, I say ‘minimum standard’, however, at the time of writing there is no formal standard available, and little guidance on the practical steps needed to record an assessment to a good standard.

However, I would suggest that as a rule of thumb, anyone documenting a mental capacity assessment should reflect on their report and ask themselves the following:

  • ‘If I were to read this assessment in a year’s time, would I be able to say that this is a good representation of X?’
  • ‘If I were to be challenged on this assessment, and needed to speak to my superiors, family members or professionals, could I justify the outcome?’

In this case study example, the answer to both these questions is a resounding ‘no’. Clearly, more information is required. As we have said time and time again in our blogs on this subject: if it is not written down, it has not happened.

I would therefore strongly encourage anyone reading this to ensure a full and detailed record of facts in any documentation – to safeguard both the client and yourself.

Example 2 – better documentation

Based on my comments above, here is an example of a better mental capacity assessment. While it is by no means perfect, it is far more useful as a means of assessing Dylan’s situation, and gives a baseline of behaviour for future assessments if they are required.

  • Understanding: Dylan was able to understand smoking, voicing calmly and with consideration that he has ‘always smoked’. Dylan was smoking during the assessment, explaining the mechanics of where he purchases cigarettes, when he smokes, and how he disposes of his used cigarettes.
  • Retention: Dylan could freely recall basic concepts around smoking. He was able to remember that one of his support workers ‘was rather concerned’, when he had fallen asleep on the old wooden roundabout while taking a break.
  • Weighing up: Dylan took time to consider examples of when and where he has smoked in the past, being aware that he regularly falls asleep when smoking while sitting down. Dylan voiced that ‘it is probably best to smoke after I wake’ and that he will be ‘careful’, understanding others were worried for him.
  • Communication: Dylan was able to communicate his decision, given time to process and respond. 

Compared to the first example, this second case gives a far clearer picture of Dylan, and even includes some direct quotes from his responses. This helps the assessor (and anyone else reading the assessment) to understand his direct thoughts, feelings and views on the decision being addressed. Thus, giving a clear point of reference should another assessment be needed in the future. While the assessment itself is still in a fairly basic format, it gives a far more detailed picture of Dylan’s context and hones in on the key points relevant to the decision being addressed.

But of course, there are still many elements to this assessment that could be improved further still. Readers will notice that at no point does the assessor note exactly what concepts they discussed in relation to smoking – whether all risks and benefits were explored, or what options were considered for the management of the ‘problem’. Nor is it clear the level of support that was given to Dylan to support his capacity in line with the second principle of the Mental Capacity Act.

Therefore, while this assessment is certainly better than Example #1, there is still much room for improvement.

Further improvements

To take Example #2 to the next level, the assessor would need to provide a breakdown of the interview before providing an analysis of the assessment under each of the headings listed above. After which, a diagnostic and causative nexus should be completed with the concluding statement to the assessment.

For further details, please see our other blogs on this subject. You can also contact us for training and support.

Next steps

Of course, the work does not stop here! If the client is assessed to have capacity, then the next steps follow everyday processes of autonomy and consent – possibly requiring a jointly worked care plan and risk assessment. The decision may also need to be reviewed if any changes occur in the future.

Meanwhile, if the client is assessed to lack capacity, then a best interest decision must be made, with due consultation, ensuring the individual’s rights are respected and upheld.  

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