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

• 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 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.
• Clinical GovernanceEffective Clinical Governance Meetings: Driving Improvement, Not Just ReportingThis guide helps NHS teams redefine their clinical governance meetings, moving beyond mere reporting to foster proactive discussion, shared learning, and tangible improvement actions for patient safety and quality of care.
• Quality ImprovementPlanning Effective PDSA Cycles for Quality ImprovementThis guide provides a practical, step-by-step approach to planning effective Plan-Do-Study-Act (PDSA) cycles for quality improvement initiatives within the NHS, focusing on robust design and learning. It covers essential considerations from defining your aim to anticipating challenges, helping teams systematically test changes.
• Quality ImprovementHow Many PDSA Cycles Does a Quality Improvement Project Need?This guide explains the iterative nature of PDSA cycles and offers practical advice for determining the appropriate number of cycles needed for effective quality improvement in NHS settings.