Mental Capacity Assessment MENTAL CAPACITY ASSESSMENT (QMS-F043) Contact Document Ref: QMS-F043 (Mental Capacity Assessment) Version: 1.0 Confidentiality Level: HIGH (Restricted Access) CQC Alignment: Effective (Consent to Care) ISO 9001:2015 Requirement: Section 7.5 & 8.2 Service User Full NameService User ID NumberOperating Local Authority- Select -HaringeyIslingtonWaltham ForestBarnetOtherCare Funding & Financial Arrangements- Select -Local Authority Managed (Direct Commissioning)NHS Funded (Continuing Healthcare - CHC)Direct Payments (Personal Budgets)Self-Funded (Full Cost)OtherSECTION 1 - The DecisionWhat is the specific decision that needs to be made?- Select -Consent to the provision of domiciliary care services and agree to the proposed Care Plan.Consent to the administration and management of medication by Mutima Care staff.Consent to the sharing of health and social care records with third-party professionals.Consent to staff handling finances for specific tasks (e.g., local shopping).Consent to the use of specific assistive technology or monitoring equipment (e.g., bed sensors).Other (Please Specify)Specify the exact decision to be made.SECTION 2 - Stage 1 (The Diagnostic Test)Does the person have an impairment of, or a disturbance in the functioning of, their mind or brain? (e.g., Dementia, learning disability, brain injury, intoxication, severe delirium).- Select -YesNoPlease detail the nature of the impairment or disturbance.SECTION 3 - Stage 2 (The Functional Test)Can the person UNDERSTAND the information relevant to this specific decision?- Select -YesNoCan the person RETAIN that information long enough to make the decision?- Select -YesNoCan the person USE or WEIGH UP that information as part of the process of making the decision?- Select -YesNoCan the person COMMUNICATE their decision? (By talking, using sign language, blinking, or any other means).- Select -YesNoEvidence for Functional Test AnswersSECTION 4 - The OutcomeMCA Outcome Declaration- Select -The person HAS capacity to make this specific decision.The person LACKS capacity to make this specific decision.Who holds the legal authority to make this decision on the client's behalf?- Select -Registered Lasting Power of Attorney (Health & Welfare)Registered Lasting Power of Attorney (Property & Financial Affairs)Court Appointed Deputy (Health & Welfare)Court Appointed Deputy (Property & Financial Affairs)Valid Advance Decision to Refuse Treatment (ADRT) in placeNo legally appointed person (A Collaborative Best Interests Decision is required)Document Verification- Select -I confirm I have physically sighted or digitally verified the official OPG (Office of the Public Guardian) stamped document, and it explicitly covers the authority to make this specific decision.Assessor NameDate of AssessmentLock Assessment & Proceed
