Mental Capacity Assessment Documentation Audit

This project audits whether mental capacity assessments are documented clearly and proportionately, in line with the Mental Capacity Act and local policy. It reviews the specific decision and its timing, the reason for assessment, practicable steps to support decision-making, communication and advocacy support, the diagnostic and functional elements, the evidence for the conclusion, and — where capacity is lacking — best-interests documentation, consultation, legal authority, least restrictive options, safeguarding and DoLS/LPS interfaces, review planning and transfer of information.

• Doctors, nurses, AHPs, pharmacists, ACPs and PAs documenting capacity assessments
• Liaison psychiatry, frailty, learning disability and safeguarding teams
• Care-home, hospice, community and GP practice clinical teams
• QI leads, governance and patient safety teams
• Supervisors and educators supporting ARCP and appraisal evidence

• Measure whether assessments are decision-specific and time-specific
• Assess documentation of supported decision-making and communication needs
• Review the diagnostic and functional elements and the evidence for the conclusion
• Test best-interests documentation, consultation, advocacy and least restrictive options
• Generate governance-ready and ARCP-ready evidence and a re-audit cycle

• Anonymous case identifier
• Inclusion / eligibility decision
• Anonymised context (age band, sex/gender recorded, care setting, capacity assessment context)
• Clinical area / location and optional specialty / service
• Twenty-two mental capacity documentation criteria (met / not met / not applicable)
• Free-text learning points and any project custom fields

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

This ready-built project is developed using the guidance, standards and authoritative sources listed below, so you can see what is being measured and why. Lazomis QI does not publish or own this guidance, and inclusion here does not imply endorsement or approval by any of these organisations.

• UK legislation / Ministry of Justice

  Mental Capacity Act 2005 and Code of Practice(opens the original source in a new tab)

  Statutory principles, the two-stage test, practicable steps to support decision-making, best-interests decision-making, least restrictive options and consultation duties.

• NICE

  NG108: Decision-making and mental capacity(opens the original source in a new tab)

  Supported decision-making, advance care planning, assessment practice, best-interests decision-making and documentation expectations.

• NICE

  NG197: Shared decision making(opens the original source in a new tab)

  Applies where shared and supported decision-making are within the local project scope.

• Care Quality Commission

  Regulation 11: Need for consent(opens the original source in a new tab)

  Regulatory expectations for consent, capacity and lawful decision-making where a person cannot consent.

• DHSC / GOV.UK

  Mental Capacity Act: making decisions(opens the original source in a new tab)

  Government guidance for health and social care staff on applying the Act in day-to-day care and treatment decisions.

• Local policy

  Local Mental Capacity Act, best-interests, consent, safeguarding and DoLS/LPS policies

  Local Mental Capacity Act policy, capacity assessment form or EPR template, best-interests guidance, consent policy, safeguarding adults policy, IMCA/advocacy referral pathway, DoLS/LPS policy, restraint and restrictive practice policy, DNACPR/ReSPECT and escalation policy, discharge and residence decision pathways and EPR documentation guidance define what is required locally. Confirm local policy before setting targets. Legal conclusions, deprivation of liberty decisions and best-interests outcomes are not set here.

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.
• This tool supports documentation review only. It does not provide legal advice, patient-specific capacity advice, best-interests decisions or safeguarding decisions.
• Legal conclusions, deprivation of liberty decisions, best-interests outcomes, advocacy routes and escalation pathways are locally configured and are not presented here as national standards.
• Use anonymous case identifiers only — never patient-identifiable information, and never identifiable detail about family members, attorneys, deputies or staff.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Clinical GovernanceLeveraging Incident Themes for Quality Improvement and Patient SafetyThis guide helps NHS teams identify and analyse recurring incident themes, transforming reported safety events into practical quality improvement opportunities to enhance patient safety and system reliability.
• Clinical GovernanceIntegrating Quality Improvement into Clinical Governance FrameworksThis article explores the vital relationship between Quality Improvement (QI) and Clinical Governance within the NHS, demonstrating how they are two sides of the same coin when aiming for continuous, systematic improvement in patient care.
• Patient SafetyIntegrating Patient Safety and Quality Improvement: A Practical Guide for UK CliniciansThis guide explains the foundational principles of patient safety and quality improvement (QI) within the UK healthcare context, offering practical strategies for clinicians to enhance safety and improve care delivery.
• Patient SafetyHow to Select a Patient Safety Quality Improvement ProjectThis guide helps NHS teams identify and select patient safety quality improvement (QI) projects that are impactful, achievable, and aligned with organisational and national priorities. Learn how to move from identifying concerns to choosing a focused and measurable project.