We have, over the last 18 months or so, carried out a lot of capacity assessments in our team. Actually, truth be known, we were and have been carrying out capacity assessments for far longer but as far as codified assessments go, the paperwork has been in place since the introduction of the Mental Capacity Act (2005).
We receive a lot of referrals from the local social services offices and sometimes from GPs (although more usually from local social services via the GP!) asking for us to assess someone’s capacity. Of course, the law states now that unless we are looking at a particular applications to the Court of Protection (COP3 for reference) , it is the decision-maker – be that doctor or social worker – who makes the assessment, it doesn’t stop us being asked.
I mention this as I carried out a capacity assessment last week. We have a document which we use in the Trust to record these assessments and they are pretty good at holding your hand through the process – asking about what actions you have taken to ensure that the best conditions are met for the assessment in terms of time of day, place and attendees. We are asked about the ability of the person being assessed to retain and recap information and are prompted through the forms – the need to specify the exact decision which is being assessed as well as noting who has been informed.
It really does take you through the guidelines established in the Mental Capacity Act’s Code of Practice and Section One of the Act itself and although some may be tempted to scrawl yes/no responses in the rather large open spaces of the form which invite free text, it is a more coherent form that includes more details.
The assessment yesterday involves a woman with dementia who had been finding it difficult to manage at home and was admitted to hospital following a fall. Her family are suggesting residential care. I was asked to assess her capacity to make that decision in hospital. It is not something that is particular unique. Except perhaps for the fact that her family are extremely keen for her to move into care. Even then it is a situation that has presented itself many times over the years.
Coming as it did on the eve of the introduction of the ‘Deprivation of Liberty Safeguards’ being implemented , I had in mind that were she to move – there is a possibility that this would fall within the bounds of that law next week. She wants to go home. She is in hospital currently and although not quite ready for discharge, she will be soonish.
I’ll tell someone before I start a capacity assessment although often that draws pretty blank gazes, it is placed within some familiar terms of reference when possible.
I might explain the reasons I am asking the questions – that it is in order to make a decision relating to them. I asked about home, what the understanding of home is (often in simplified terms), what help she thinks she might need and switch the questions around a little or ask the same questions in different ways to ensure that I am not leading the way for her to answer.
She repeated to me over and over that she wanted to be at home. I expected no different. Sometimes the easier decision to take is to make a move. There were enough grounds to determine a lack of capacity. She spoke about wanting to be near her parents, of visiting them (she is in her mid-80s) – they were reasons for wanting to stay at home. She said that she could manage without any help and that she misses her pets.
Familiar surroundings are incredibly important and I hate making placements directly from hospital for the reason that, even when necessary, there has been no ‘goodbye’ to a home where someone might have lived for many decades. It is another loss, another process of mourning and to admit someone straight into care can be making a difficult situation worse.
When she was presented with the choice of moving to a different flat, she remained ambivalent – as long as it isn’t a ‘home’.
It is also important to consider past wishes if expressed and she had repeatedly explained that she never wanted to go into ‘a home’. She disliked community day centres and the communal environment they garner and encourage.
Then there is thought to the less restrictive outcome. She doesn’t want carers but would she refuse the help if proffered. It is less restrictive to ‘force’ care in the home than to remove to a different setting. However, if all her family and social networks are so opposed to her being at home, how does that link to her overall well-being?
Her family to whom I had already spoken, explained in detail why she needed 24 hour care – their worries, concerns and her need to be supervised.
It isn’t a question of her family’s needs superceding her own but rather how we maintain the networks without alienating a supportive family.
One of the positives about having an IMCA involved is that they can take away some of the individual pressure on the ‘decision-maker’ but in this situation, she is clearly not ‘unbefriended’ and has a family around her.
As for the capacity assessment, I was clear that she would not have capacity to make this particular decision relating to her long-term care. Her understanding of home, of safety, of her own needs were far from realistic.
The final decision about moving? My gut instinct tells me to respect her wish not to move into residential care per se but to move back to her home environment does carry substantial risks. My manager tells me to write a more thorough risk assessment.
The outcome though may well be pointing to, at least, a move to what we call ‘extra-care sheltered housing’. Sheltered housing ‘with a bit more care’ which provides the 24 hour support and would allow her to keep her cat with her as well as have the necessary privacy as well as the available support.
I’m not saying we get things right, it’s impossible, but it is about looking at available options and trying to tread a path between risk-taking and personal responsibility – especially when lack of capacity has been clearly established.