Service User Name (required) LL Number This MCA assessment must adhere to the Act’s 5 key principles: Every adult has the right to make his or her own decisions and must be assumed to have the capacity to make them unless it is proved otherwise. A person must be given all practicable help before anyone treats them as not being able to make their own decisions. Just because an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision. Anything done or any decision made on behalf of a person who lacks capacity must be done in their best interests. Anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms. Assessment of Capacity Does the Service user have an impairment of, or a disturbance in the functioning of, their mind or brain? (are able to understand, retain, weigh or communicate in the decision at the time it needs to be made? ) YesNoN/A Please provide details: Is the person likely to regain capacity? If yes, what are the circumstances that are needed to support the person to regain capacity and when is capacity in relation to this decision likely to return? YesNoN/A Please provide details: Do they understand the information given to them? YesNoN/A Please provide details: Can they retain the information long enough to make an effective decision? YesNoN/A Please provide details: Do they understand the information relevant to the decision? YesNoN/A Please provide details: Can they communicate a decision (by any means whether by talking, using sign language or any other means?)? YesNoN/A Please provide details: Can they weigh up and discuss and cons of the decision or the action? YesNoN/A Please provide details: Does the individual have capacity in respect to the specific issue? YesNoN/A Please provide details: Before making this judgement you should ensure that every effort has been made to encourage and support the person to make the decision themselves. It is important to then ask the following questions: 1. Does the person have all the relevant information to make a decision? 2. If they are making a decision which means choosing between alternatives, do they have information on the different options? 3. Would the person have a better understanding if the information was explained or presented in a different way? 4. Are there times of the day when the person’s understanding is better? 5. Are there locations where they may feel more at ease? 6. Can the decision be put off until the circumstances are different and the person concerned may be able to make a decision? 7. Can anyone else help the person to make a choice or express a view? (e.g. family members or carer, an advocate or someone to help with communication) You should record in the space above that you have considered these issues and the actions you have taken. If your judgement is that the person lacks capacity and you are the decision-maker then you need to make a “best interests” decision. You must consider the best interests checklist before deciding what is in the service user’s best interests. You must complete the Best Interests Decision form. Record the outcome of your assessment in the service user’s healthcare records (along with a copy of this form) and sign and date your entry. I consider the service user has/does not have* capacity to make this decision. Please select YesNoN/A D&J Care Services undertakes that it will treat any personal information (that is data from which you can be identified, such as your name, address, e-mail address etc) that you provide to us, or that we obtain from you, in accordance with the requirements of the Data Protection Act of 1998 Service User Signature Signature Date Supervisor Signature Signature Date Supervisor Notes Involved the individual as far as is practically possible? YesNoN/A Consulted all relevant records? YesNoN/A Consulted all appropriate friends/family? YesNoN/A Consulted with the person’s generic advocate? YesNoN/A Consulted with other staff? YesNoN/A Considered evidence of the person’s past wishes and feelings (including advance decisions/directives)? YesNoN/A Take into account the IMCA’s report (if applicable)? YesNoN/A Consulted with any legal representatives? YesNoN/A What is the individual’s presenting condition: What is the exact decision to be made, or action to be taken: Service User Signature Signature Date D&J Care Services undertakes that it will treat any personal information (that is data from which you can be identified, such as your name, address, e-mail address etc) that you provide to us, or that we obtain from you, in accordance with the requirements of the Data Protection Act 1998 Supervisor Signature Signature Date