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

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