How well is the Mental Capacity Act being used in care homes?

Our survey of care home managers revealed common barriers to MCA implementation, and creative ways to tackle them, writes Saskia Goldman

Photo: Gary Brigden

By Saskia Goldman, policy officer at Care England

The Mental Capacity Act is not as embedded in practice as it should be across health and social care. Care homes, despite pockets of good practice, are no exception.

The Law Commission’s review of mental capacity and deprivation of liberty legislation, and the formation of the National Mental Capacity Forum, seeking to further embed the act in practice, drew to Care England’s attention that our sector didn’t really know how well-implemented the act was, or how care home managers were supporting their staff to implement it in their day-to-day work.

We wanted to discover the ‘how’ and the ‘how much’ of Mental Capacity Act (MCA) implementation in care homes.

We designed a survey to answer these questions: using our membership networks and social media, we surveyed 84 care home managers across over 50 local authority areas. We are grateful to all the care home managers that took the time to respond.

Around 50% of our respondents’ main service user group were adults with dementia, 35% adults with a learning disability, and 15% adults with a mental health problem.

We asked managers a series of questions around the five principles of the MCA. We wanted to know how they led and supported their staff teams to understand and enact these principles.

Mentorship and coaching

The results were interesting. Managers that responded most confidently used a range of approaches to embed the MCA in their staff’s work: mentorship, coaching, leading by example and active, floor-based management seemed correlate with managers knowing the MCA inside out, and having confidence in their home’s adherence to it. Here are some of the tips to emerge from this group:

  • Start a coaching scheme between senior and less experienced staff, focusing on issues of capacity and decision-making.
  • Put ‘capacity and decision-making’ as an item on every agenda of staff meetings, and ask questions like: “is this person’s care plan as liberty-based as it safely can be?”; “are we sure we’re not restricting people’s freedom out of habit?”
  • Because capacity is time and decision-specific, ensure that capacity is discussed during staff hand-overs.
  • Try role play with your staff team, exploring how it feels to be deprived of your liberty, or denied the right to make what other people might consider ‘an unwise decision’.
  • When walking around the home, explore staff practice and start a dialogue about whether a less restrictive option could be used, and highlight less obvious forms of restriction that might not have been considered.
  • Involve staff in Best Interests Decisions and capacity assessments as far as is possible, using their unique knowledge of service users, and engaging them with the processes of the MCA.
  • Put as much freedom as possible into care plans and ‘MCA-check’ them together with staff, to see if capacity, or changing capacity, has been taken into account, or if anything could be done less restrictively.
  • Create a wall display about the five principles of the MCA, asking staff to contribute examples of good practice under each.

Barriers to implementation

However, the survey also identified a series of common problems too. Over-reliance on formal, classroom MCA training appeared to be a major barrier to implementing the legislation in practice. While training is a vital starting point for creating a care team who understand the MCA, mental capacity awareness should not be confined to training days, but embedded in every day decisions.

Another barrier to MCA implementation was information and knowledge not filtering down. This was an issue in homes where managers considered that the MCA, capacity assessments, best interests decisions and the Deprivation of Liberty Safeguards were the concern of managers only, and not the whole staff team.

Overall the survey highlighted several learning points for services:

  • Care home managers can be too reliant on classroom training to support their staff to understand and implement the MCA.
  • Managers who take a range of approaches are implementing the MCA in ‘good practice’ terms, increasing their chances of successful MCA implementation.
  • Managers can be hesitant to admit where they can improve MCA implementation, and must be supported to work towards a ‘learning culture’.
  • The MCA can be built into everyday processes and exchanges, like team meetings, supervisions, observations and daily decision-making with service users.
  • Care teams must be encouraged to see MCA implementation as presenting an opportunity, not a burden. This is an attitudinal change, but also relies on more support.
  • There is a lack of local MCA good practice schemes but also an appetite for more of them.

Managers also expressed a desire for more local support to improve MCA implementation in care homes.

The challenge will be to overcome the barriers identified, and the cultures or habits that might underpin them. We were impressed by the pockets of creative thinking that we discovered, but like all the best innovations in our sector, we will have to work hard to spread and embed these ideas into common practice.

For information about the survey, or to receive a copy of the report on MCA implementation in care homes, email Saskia at sgoldman@careengland.org.uk

3 Responses to How well is the Mental Capacity Act being used in care homes?

  1. Jimbob May 11, 2016 at 11:31 pm #

    I personally think more could be done to educate not just providers but local authorities on how the practical application of the MCA looks in a care home setting. As a social worker I have heard many frustrated managers talk about following contact monitoring visits out overzealous workers reviewing that care homes are expected to have LA formal mental capacity assessments and such paperwork for if someone is given corn flakes instead of porridge one day. The element of proportionality (not song that the guiding principles shouldn’t be any less at the forefront however) of recording is lost making the process unnecessarily bureaucratic with the irony being the same local authorities especially in older people settings barely enough staff to cope with basic needs such as regular support with going to ever toilet!

    I firmly believe that there is good practice in many Cate homes though there is still work to be done. I think though there needs to be much more emphasis on how the theory translates to practice and evidencing practice in an appropriate and manageable way for care homes as even when I have tried to look up such to share with managers there is next to nothing available. Yes many get practical steps, fluctuating capacity and do forth but how is it care homes are supposed to demonstrate such practice? Codes of practice seem clear (day to day decisions require less tornadoes evidence than decisions with greater consequences) but seems LAs are not!

  2. CK May 12, 2016 at 10:17 am #

    The over-reliance on formal MCA training has led to an overabundance of training and guidance around MCA. An unhelpful focus in proceduralism has led to many on the frontline (whether in care settings, LAs, hospitals, wherever) experiencing ‘MCA-fatigue’, which is anathema to the Act’s underpinning ethos and principles. The ‘hows’ of MCA do not amount to rocket science. The Code of Practice isn’t perfect (how could it be in the context of highly individualised circumstances?) but it’s clear and useful and has been supplemented by some excellent examples of practice guidance (e.g. from 39 Essex Chambers). The focus should instead be on conversations about the ‘whys’ of MCA: Why is it important to support people to make their own decisions? Why is a capacity assessment set out in this way (i.e. diagnostic + cumulative functional test)? Why do we even have an MCA? etc. . . Such conversations lead to deeper understanding of the ‘hows’, greater motivation to bring about the MCA’s vision and, in turn, to better, more proportionate, practice.

    • Ruth Cartwright May 14, 2016 at 11:41 am #

      CK is right. Local authorities (and most other organisations) always do this with legislation and regulation – work out what is the minimum they need to do and then proceduralise it all (with attendant paperwork and ‘feeding of the beast’). This completely loses the spirit of the legislation in the case of the MCA and rules out any use of professional discretion.