The Mental Capacity Act 2005 (MCA) provides the legal framework for supporting people who may lack capacity to make certain decisions. In care homes, capacity assessments are routine—but they're often done incorrectly or inadequately documented. Getting this right protects residents' rights and protects your care home legally.
The Five Principles of the MCA
Before any capacity assessment, remind yourself of the five statutory principles:
Presumption of Capacity
Every adult is presumed to have capacity unless proven otherwise. Never assume someone lacks capacity because of their age, diagnosis, or appearance.
Support to Make Decisions
All practicable steps must be taken to help someone make their own decision before concluding they lack capacity.
Right to Make Unwise Decisions
A person is not to be treated as lacking capacity just because they make a decision others consider unwise.
Best Interests
Any decision made on behalf of someone lacking capacity must be in their best interests.
Least Restrictive Option
Any intervention must be the least restrictive of the person's rights and freedoms.
When to Assess Capacity
Capacity assessments should be conducted when:
- There is reason to believe someone may lack capacity for a specific decision
- A decision needs to be made and the person's ability to make it is in question
- The person's capacity may have changed since a previous assessment
- A significant care decision is required
Key Point
Capacity is decision-specific and time-specific. Someone may have capacity to decide what to eat but not to manage their finances. Capacity for the same decision may vary depending on the time of day or health status.
Common Decisions Requiring Assessment
Daily Care
- •Personal care choices
- •What to eat and drink
- •What to wear
- •Daily activities
- •Visitors
Health Decisions
- •Medical treatment
- •Medication consent
- •Hospital admission
- •Vaccinations
- •Dental treatment
Care Planning
- •Where to live
- •Care arrangements
- •Moving rooms
- •Use of bedrails
- •Sensor mats
Safety Measures
- •Locked doors
- •Supervised outings
- •Medication covert administration
- •CCTV use
- •Restraint
The Two-Stage Capacity Test
The MCA sets out a two-stage test for assessing capacity:
Stage 1: Diagnostic Test
Is there an impairment of, or disturbance in, the functioning of the person's mind or brain?
This could be due to:
- Dementia
- Learning disability
- Mental illness
- Brain injury
- Delirium or acute confusion
- Effects of drugs or alcohol
- Unconsciousness
Stage 2: Functional Test
Does this impairment mean the person cannot make the specific decision at this time? A person lacks capacity if they cannot:
Understand
Can they understand the information relevant to the decision, including consequences of deciding one way or another?
Retain
Can they retain the information long enough to make the decision? (Even if only briefly, this is sufficient.)
Use or Weigh
Can they use or weigh the information as part of making the decision?
Communicate
Can they communicate their decision by any means (talking, signing, blinking, etc.)?
Important
The person only needs to fail ONE of the four elements of the functional test to lack capacity. But remember: you must first have taken all practicable steps to help them.
Documenting the Assessment
Your documentation must include:
Basic Information
- Date and time of assessment
- Who conducted the assessment
- The specific decision being assessed
- Why the assessment was needed
Support Provided
- What steps were taken to help the person understand
- Communication methods used
- Timing considerations (best time of day, after medication, etc.)
- Who else was present (family, advocate)
Assessment Findings
- Stage 1: What is the impairment/disturbance?
- Understand: What information was given? Did they understand it?
- Retain: Could they hold the information in mind?
- Use/Weigh: Could they weigh up the options?
- Communicate: Could they express a decision?
Direct Quotes
Include the person's own words where possible. This provides strong evidence of your assessment.
Conclusion
- Does the person have capacity for this decision? Yes/No
- Reasoning for this conclusion
- Review date if capacity may change
Best Interests Decisions
If someone lacks capacity, any decision made for them must be in their best interests. The MCA provides a checklist:
Will capacity be regained?
Can the decision wait until they have capacity?
Participation
Involve the person as much as possible in the decision.
Past and present wishes
What would they have wanted? Any advance statements?
Beliefs and values
What religious, cultural, or moral values are relevant?
Other relevant factors
What would the person consider if they had capacity?
Consult others
Seek views from family, carers, attorneys, deputies.
Documenting Best Interests Decisions
Your best interests documentation should record:
- The decision being made
- Who was involved in the decision-making process
- The person's past and present wishes considered
- Views of family/carers consulted
- All options considered
- Why the chosen option is in best interests
- Why it is the least restrictive option
- Who made the final decision
- Date of decision and review date
Who Can Assess Capacity?
The "decision-maker" is the person who needs to assess capacity:
Care Staff
Day-to-day care decisions: personal care, meals, activities
Care Home Manager
Care planning decisions, room moves, safety measures
Healthcare Professionals
Medical treatment, medication changes, hospital admission
Social Workers
Care arrangements, safeguarding, DoLS
Lasting Power of Attorney
If someone has appointed an attorney under a Health and Welfare LPA:
- The LPA must be registered with the Office of the Public Guardian
- It only activates when the person lacks capacity
- Check what decisions the LPA covers
- The attorney must still act in best interests
- Document consultation with the attorney
Deprivation of Liberty Safeguards (DoLS)
If your care arrangement amounts to a deprivation of liberty for someone who lacks capacity to consent, you need DoLS authorisation. Consider DoLS if:
- The person is under continuous supervision
- They are not free to leave
- They lack capacity to consent to these arrangements
Legal Requirement
Depriving someone of their liberty without proper authorisation is unlawful. Most care home residents who lack capacity will require a DoLS assessment. Apply to your local authority supervisory body.
CQC Expectations
CQC specifically examines capacity assessments. They expect:
- Staff understanding of MCA principles
- Capacity assessments completed for relevant decisions
- Assessments that are decision-specific, not blanket
- Evidence of support provided before concluding lack of capacity
- Best interests processes properly followed
- Appropriate DoLS applications made
- Regular training for all staff
Common Mistakes to Avoid
Mistake: Blanket assessments
Correction: Each decision needs its own assessment
Mistake: Assuming dementia = no capacity
Correction: Many people with dementia have capacity for some decisions
Mistake: Not documenting support provided
Correction: Record what you did to help them understand
Mistake: Letting family decide
Correction: Family views inform best interests but don't determine capacity
Mistake: One-off assessment for ongoing decisions
Correction: Reassess when circumstances change or capacity may fluctuate
Conclusion
Mental capacity assessment is a fundamental skill for care home staff. Done well, it protects residents' autonomy by ensuring their own decisions are respected when they have capacity, and their best interests are served when they don't.
The key is thorough documentation—not just the conclusion, but the process: what support was given, what was understood, and how the decision was reached. This protects the resident, protects your staff, and demonstrates to regulators that you understand and apply the law correctly.
Structured MCA Documentation
Revitaco guides staff through capacity assessments with structured forms that ensure nothing is missed and documentation is complete.
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