Part 10 How to record decisions
It is a legal requirement that evidence of assessments and best interest decisions is recorded. This can be in a care plan, a daily record or on the Mental Capacity Act (MCA) capacity assessment form. There is no legal requirement to use any particular form or paperwork to record decisions
A decision-maker must always use the two step method of decision-specific assessment of capacity. (Part 6: How to assess capacity)
The person arranging care needs to know if someone has capacity to make the decision about this care, and to make this clear in any documentation. Every care plan concerning a person who may lack capacity must include details of how their capacity has been assessed, whether they lack capacity and, if they do, what the best interests decision is.
Recording a decision on an MCA capacity assessment form
You can record a capacity assessment and a best interests decision on an MCA Capacity Assessment form, which is available on all local electronic recording systems. You can print off a paper copy if you don’t use an electronic recording system.
This form gives clear evidence of how a decision has been reached, and should be used to record any decision that is complex, controversial or life-changing. If someone is assessed as having capacity it is important that this is clearly recorded; Particularly if the person may make an unwise decision, or if they are at risk of losing capacity in the future.
Staff can also use the form as a prompt if they feel unsure of the two step process.
It isn’t necessary to complete a form for every decision and would often be inappropriate.
Recording a decision in a care plan
There must be evidence in a care plan that someone’s capacity to make a particular decision has been assessed and what the best interests decision is.
This be recorded in a care plan as:
Mrs X lacks capacity to decide if she should receive help with her personal care at this time. This is determined under MCA because her memory problems mean she isn’t able to understand that she can’t manage these tasks herself and can’t weigh up the risks she faces if she doesn’t have this help. There is a high risk to Mrs X’s wellbeing if she doesn’t receive this help. I have consulted Mrs X’s daughter and concluded that it’s in her best interests to receive help with her personal care. Care assistants should encourage and support Mrs X to accept help.
This statement lays out the specific decision, details the diagnostic test and two of the four questions in the functional test, details the best interests decision and gives instructions to the carers to proceed.