Consent to Care and Support Policy and Procedure

1. Governance

1.1. This is the Consent to Care and Support Policy and Procedure for The Good Place Home Care Services Limited.

1.2. The Good Place Home Care Services Limited will be referred to in this document as "The Good Place Home Care Services Limited","The Good Place","We","Us", or "Our".

1.3. Our registered address is: 186 Wetmore Road, Burton-on-Trent, Staffordshire, DE14 1QZ.

1.4. We can be contacted by:-

• a. Telephone: 01283 296 337
• b. Email: [protected:ahello][protected:athegoodplace.care]
• c. Post: The Good Place, 186 Wetmore Road, Burton-on-Trent, Staffordshire, DE14 1QZ

1.5. Words importing one gender include all genders, and words in the singular include the plural and vice versa, unless the context requires otherwise.

1.6. Document control sheet:-

2. Purpose

2.1. To ensure we uphold service users' rights to make informed decisions.

2.2. To detail our commitment to person-centred care and consent.

2.3. To assess mental capacity and ensure that individuals receive the necessary support to make informed decisions.

2.4. To detail making best interests decisions when a person is unable to make choices for themselves.

2.5. To recognise and manage situations where deprivation of liberty may occur in a domiciliary care setting.

2.6. To ensure that we fulfil our legal and regulatory responsibilities.

2.7. To support us to meet, and be able to evidence compliance with, the following CQC Single Assessment Framework quality statements:-

3. Scope

3.1. This policy applies to all employees and representatives of The Good Place who are involved in the provision of domiciliary care services. It ensures that every staff member understands their role in obtaining, documenting, and respecting service users’ consent before providing care or treatment.

3.2. This policy also applies to all service users receiving domiciliary care from The Good Place, with particular focus on those with conditions affecting their cognitive function, such as dementia, learning disabilities, or brain injuries.

4. Policy Statement

4.1. At The Good Place, we are dedicated to ensuring that all service users receive care and treatment that respects their rights, autonomy, and individual preferences. This policy sets out our commitment to obtaining valid consent before providing care or treatment, ensuring that decisions are made in the best interests of the individual and in line with legal and regulatory requirements.

4.2. We are committed to upholding the rights and dignity of all service users, ensuring that individuals receive care and support in a manner that respects their autonomy and decision-making abilities. This policy outlines our approach to assessing mental capacity and managing situations where restrictions may need to be applied in the best interests of service users, in line with the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) framework.

4.3. We recognise that our care services must comply with the fundamental principles of the MCA, ensuring that individuals are supported to make their own decisions wherever possible, while also protecting those who lack capacity from harm. Our approach is aligned with CQC Regulation 11 – Need for Consent, which requires that all care and treatment be delivered with the informed consent of the individual or in their best interests if they lack capacity​.

4.4. Upholding Service Users' Rights to Make Informed Decisions

4.4.1. Every individual has the fundamental right to make informed decisions about their own care and treatment. This policy ensures that:-

• a. Service users are provided with clear, accessible, and relevant information about their care options, including benefits, risks, and alternatives.
• b. Decisions are made voluntarily, without coercion or undue influence.
• c. Consent is specific and time-limited, meaning it applies only to the agreed-upon care or treatment at that time.
• d. Individuals have the right to refuse or withdraw consent at any time, even if this may result in harm to themselves.
• e. Where necessary, appropriate communication aids (e.g., easy-read materials, interpreters, advocates) are used to ensure the service user fully understands their choices.

4.5. Compliance with Legal and Regulatory Requirements

4.5.1. This policy ensures that the organisation complies with all relevant legislation and best practice guidelines, including:-

• a. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 9 (Person-centred care), Regulation 11 (Need for Consent), Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding service users from abuse and improper treatment) and Regulation 17 (Good governance), which together underpin safe, lawful and person-centred consent and capacity practice.
• b. Mental Capacity Act 2005 and Code of Practice: If a service user lacks the mental capacity to consent, decisions must be made in their best interests following the statutory framework.
• c. Human Rights Act 1998 (Article 8: Right to Private and Family Life): Individuals have the right to make decisions about their care without unnecessary interference.
• d. Care Act 2014: Emphasises person-centred care and decision-making.
• e. Equality Act 2010: Ensures individuals are not discriminated against in the consent process due to disability, language barriers, or other factors.
• f. UK General Data Protection Regulation (UK GDPR) and Data Protection Act 2018: We ensure that personal and health data is processed lawfully, fairly and transparently. While consent may be one lawful basis, health and social care information will usually be processed under the “provision of health or social care” and “vital interests” bases, rather than relying solely on consent.
• g. Deprivation of Liberty Safeguards (DoLS) under the Mental Capacity Act 2005: These apply to hospitals and care homes. In community settings, including people’s own homes with domiciliary care, any deprivation of liberty must be authorised by the Court of Protection.

4.6. Commitment to Person-Centred Care

4.6.1. At the core of our approach is person-centred care, meaning that each service user is treated as an individual with unique needs, preferences, and values. This policy supports this commitment by ensuring that:-

• a. Service users are actively involved in decisions about their care.
• b. Care plans are developed in collaboration with the individual, their family, and legal representatives (where applicable).
• c. Staff are trained to respect individual choices and provide appropriate support to help service users make informed decisions.
• d. Consent is regularly reviewed and updated to reflect any changes in the service user’s preferences or circumstances.

4.6.2. Person-centred care and consent (Regulation 9)

4.6.2.1. Consent is central to person-centred care at The Good Place. We work with each service user to agree care that reflects their individual needs, preferences, routines, protected characteristics and desired outcomes. We will ensure:-

• a. Care plans are co-produced with the service user (and those lawfully acting on their behalf where applicable);
• b. Consent is sought for the agreed care plan and for each visit/task as required;
• c. The service user’s choices (including refusals and “unwise decisions” where they have capacity) are respected and recorded; and
• d. Consent is reviewed during care plan reviews and whenever needs, risks, capacity or preferences change.

4.6.2.2. Where concerns arise that a service user’s consent or refusal may be influenced by coercion, abuse, neglect or exploitation, staff will treat this as a safeguarding concern and will follow our Safeguarding Adults Policy and Procedure.

5. Legal & Regulatory Framework

5.1. This policy aligns with:-

• a. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 11 (Need for Consent).
• b. Mental Capacity Act 2005 and its Code of Practice.
• c. The Human Rights Act 1998, including Article 8 (Right to respect for private and family life) and Article 5 (Right to liberty and security), which underpin consent, capacity and deprivation of liberty.
• d. Equality Act 2010.
• e. Care Act 2014 (ensuring person-centred care and decision-making).
• f. UK General Data Protection Regulation (UK GDPR) and Data Protection Act 2018 (for consent relating to personal information).
• g. Deprivation of Liberty Safeguards (DoLS) under the Mental Capacity Act 2005 for individuals deprived of their liberty in their best interests.

5.2. At the time of this policy, the Liberty Protection Safeguards (LPS) have not been implemented. The Good Place will monitor national guidance and update this policy, staff training and practice promptly when any new statutory framework for authorising deprivation of liberty comes into force.

5.3. The Good Place is fully committed to meeting the requirements of the Accessible Information Standard (AIS), as set out by NHS England. This means we will ensure that people with a disability, impairment, or sensory loss receive information and communication support that they can understand and use effectively. This may include large print, easy-read versions, audio formats, or the use of interpreters and communication aids. See our Accessible Information Standard (AIS) Policy and Procedure for further details.

5.4. We also comply with the Equality Act 2010 and are fully committed to promoting diversity, and human rights in all aspects of our service provision and employment practices. We are dedicated to ensuring that all individuals, including staff, service users, and stakeholders, are treated fairly, with dignity and respect, and without discrimination. We will also make reasonable adjustments so that no individual is treated less favourably when using our service. This includes supporting people with protected characteristics such as age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. See our Equality, Diversity and Human Rights Policy and Procedure for further details.

6. Roles & Responsibilities

6.1. Care Workers and Support Staff

6.1.1. Care workers are responsible for:-

• a. Obtaining consent before delivering personal care, support, or treatment.
• b. Providing service users with information about their care in an accessible and understandable way.
• c. Recognising when a service user lacks capacity and following the Mental Capacity Act 2005 framework.
• d. Respecting a service user’s right to refuse care and reporting refusals appropriately.
• e. Documenting consent properly in care records, ensuring it is up to date and reviewed when necessary.

6.2. Managers and Senior Staff

6.2.1. The registered manager and senior management have an essential role in ensuring that staff understand and comply with consent policies. Their responsibilities include:-

• a. Training and supervising staff on consent procedures, ensuring compliance with legal frameworks.
• b. Monitoring and auditing consent records to ensure proper documentation and compliance.
• c. Ensuring best interest decisions are made appropriately when a service user lacks capacity.
• d. Providing guidance to care workers when consent is refused or withdrawn.
• e. Engaging with families, advocates, and legal representatives in cases where the service user lacks capacity.

6.3. Roles for Capacity Assessment

6.3.1. Front-line assessment:-

• a. Care staff check understanding and agreement at the point of care and identify any concerns about capacity. Where there is doubt, trained staff complete decision-specific Mental Capacity Act (MCA) assessments using the two-stage test, recording the rationale and outcome in the care record.

6.3.2. Oversight and complex decisions:-

• a. The Registered Manager (or a trained Senior/ Deputy) reviews formal assessments, quality-checks documentation, and leads or coordinates best-interests decision-making when the person lacks capacity, involving relevant professionals as needed.

6.3.3. Escalation:-

• a. Where there is dispute, fluctuating capacity, high-risk or restrictive options, or potential DoLS/ Liberty Protection Safeguards implications, the case is escalated to the Registered Manager for multi-disciplinary input (e.g., GP, social worker) and, where applicable, an IMCA.

6.3.4. Legal representatives:-

• a. Where there is a valid LPA (Health & Welfare) or Court-Appointed Deputy, staff must consult them and record their decision(s) and authority.

6.3.5. Review:-

• a. Capacity is decision- and time-specific; reassess if circumstances change.

6.3.6. Consent, safeguarding and Regulation 13:-

• a. Where there are signs of coercion, undue influence or restrictive practices, staff must escalate to the Registered Manager without delay. Any necessary restrictions will follow Mental Capacity Act best-interests decision-making, be the least restrictive option, time-limited and reviewed. Concerns are managed under our Safeguarding Adults Policy and Procedure and CQC Regulation 13.

6.3.7. The Registered Manager is responsible for ensuring capacity assessments are completed by trained and competent staff and are recorded appropriately, with escalation to relevant professionals where required.

6.4. Administrative and Office Staff

6.4.1. While administrative staff may not provide direct care, they may handle consent-related documentation and communications. Their role includes:-

• a. Maintaining accurate records of consent forms and legal documents (e.g., Lasting Power of Attorney, advance decisions).
• b. Ensuring data protection compliance when handling service users’ personal and medical information.
• c. Coordinating with care teams to ensure consent documentation is up to date.

6.5. Other Professionals and External Partners

6.5.1. This policy also applies to any external professionals working with The Good Place, including:-

• a. Healthcare professionals (e.g., GPs, nurses, occupational therapists) involved in care planning and consent discussions.
• b. Independent Mental Capacity Advocates (IMCAs) who may be required when a service user lacks capacity and has no family to support them.
• c. Legal representatives (e.g., Lasting Power of Attorney, Court-Appointed Deputies) who must be consulted when making decisions for service users who lack capacity.
• d. External professionals are expected to work in line with the Mental Capacity Act 2005 and share relevant assessment and decision-making information (with the person’s consent or a lawful basis) so that records are accurate and consistent.
• e. While external professionals (such as NHS staff or local authority social workers) retain responsibility for their own clinical or statutory decisions, The Good Place is responsible for ensuring that relevant information and decisions about consent and capacity are clearly reflected in our own care records and care plans.

7. Data Protection & Confidentiality

7.1. At The Good Place, we recognise that protecting an individual's confidentiality and ensuring compliance with data protection laws are fundamental to ethical and legal care practices, especially when handling personal and sensitive health data.

7.2. See our Confidentiality and Data Protection (UK GDPR) Policy and Procedure for full details on how personal and health data must be obtained, stored, shared, and processed in accordance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018.

7.3. When Data Can Be Shared Without Consent

7.3.1. In some situations, data protection laws allow information to be shared without consent if it is necessary for:-

• a. Safeguarding: If there is a serious risk of harm to a service user or others, staff have a duty to share information with appropriate agencies (e.g., local authority safeguarding teams).
  • aa. Local Authority: Staffordshire County Council
    • i. Email: [protected:aSSASPB.admin][protected:astaffordshire.gov.uk]
    • ii. Online: Staffordshire & Stoke-on-Trent Adults Safeguarding Partnership Board
    • iii. Telephone (working hours): 0345 604 2719
    • iv. Telephone (out of hours): 0345 604 2886
• b. Medical emergencies: If a service user is unconscious or unable to provide consent, relevant medical information may be shared with healthcare professionals to provide urgent care.
• c. Legal obligations: Where information must be shared to comply with a court order, statutory duty or other legal obligation (for example, duties under the Mental Capacity Act 2005, Deprivation of Liberty Safeguards, or safeguarding legislation).

7.3.2. In all cases where consent is overridden, the decision must be justified, recorded, and reported to senior management. Only the minimum necessary information will be shared with relevant agencies, and information-sharing will be proportionate to the identified risk or legal requirement.

8. Definitions

8.1. For the purposes of this policy:-

• a. 'Consent' means a service user’s voluntary and informed agreement to a proposed action, following the provision of adequate information about the nature, purpose, benefits, risks and alternatives.
• b. 'Capacity (mental capacity)' means the ability to make a specific decision at the time it needs to be made, as defined by the Mental Capacity Act 2005.
• c. 'Mental Capacity Assessment' is the structured process, using the MCA two-stage test, to determine whether a service user can make a particular decision for themselves.
• d. 'Best Interests Decision' is a decision made on behalf of a service user who lacks capacity for that specific decision, following the Mental Capacity Act 2005 best interests checklist and least restrictive principle.
• e. 'Deprivation of Liberty' occurs, for the purposes of Article 5 of the European Convention on Human Rights, when a service user who lacks capacity to consent to the arrangements for their care and treatment is under continuous supervision and control and is not free to leave, and those arrangements are attributable to the state (the “acid test”).
• f. 'Deprivation of Liberty Safeguards (DoLS)' are the legal safeguards that apply to people who lack capacity and are deprived of their liberty in hospitals and care homes, under the Mental Capacity Act 2005.
• g. 'Court of Protection' authorisation refers to the legal process for authorising a deprivation of liberty in community settings, including people’s own homes with domiciliary care.
• h. 'Liberty Protection Safeguards (LPS)' are the forthcoming legal framework intended to replace DoLS. At the time of this policy, LPS has not yet been implemented; practice will be updated when it comes into force.
• i. 'Lasting Power of Attorney (LPA)' is a legal document that enables an adult to appoint one or more people to make decisions on their behalf if they lose capacity in the future. An LPA for Health and Welfare may include authority for decisions about care and treatment.
• j. 'Court-Appointed Deputy' is a service user appointed by the Court of Protection to make decisions for someone who lacks capacity, usually in relation to property and financial affairs and, in some cases, health and welfare.
• k. 'Implied consent' is consent that is not given explicitly in words but is inferred from the service user’s actions and the circumstances (for example, extending an arm for assistance when offered).
• l. 'Covert medication' means administering medicines in a disguised form, usually in food or drink, without the knowledge or consent of the service user receiving them.
• m. 'Advocate' is someone who provides independent support to help a service user express their views and participate in decisions, including Independent Mental Capacity Advocates (IMCAs) where required by law.
• n. 'Best interests meeting' means a structured discussion, involving the service user (as far as possible), relevant family, friends, advocates and professionals, to consider information and agree a best-interests decision where the service user lacks capacity for that decision.

9. Principles of Consent

9.1. At The Good Place, we recognise that obtaining valid and meaningful consent is fundamental to providing safe, ethical, and person-centred care. The principles below guide our approach to obtaining and managing consent.

9.2. We apply the five statutory principles of the Mental Capacity Act 2005 when obtaining and managing consent:-

• a. A service user must be assumed to have capacity unless it is established that they lack capacity.
• b. A service user is not to be treated as unable to make a decision unless all practicable steps to help them do so have been taken without success.
• c. A service user is not to be treated as unable to make a decision merely because they make an unwise decision.
• d. Any act done, or decision made, on behalf of a service user who lacks capacity must be done, or made, in their best interests.
• e. Before the act is done, or the decision is made, regard must be had to whether the purpose can be as effectively achieved in a way that is less restrictive of the service user’s rights and freedom of action.

9.3. Consent Must Be Voluntary

9.3.1. Service users must give consent freely, without coercion, undue pressure, or manipulation from staff, family members, or others.

9.3.2. Staff must create a supportive environment where individuals feel comfortable making their own decisions.

9.3.3. If there are concerns about undue influence (e.g., family members pressuring a service user), staff must take steps to ensure the service user’s autonomy is respected.

9.4. Consent Must Be Informed

9.4.1. Service users must receive sufficient, relevant, and accessible information to make an informed decision about their care.

9.4.2. Information should include:-

• a. The nature and purpose of the care or treatment.
• b. The potential benefits and risks of the care or treatment.
• c. Any alternative options available.
• d. The right to refuse or withdraw consent at any time.

9.4.3. Staff must ensure that information is provided in a way the service user can understand, using:-

• a. Easy-read documents, pictorial guides, and large print materials.
• b. Interpreters, sign language, or communication aids where needed.
• c. Advocates or family members (if appropriate and with consent).

9.5. Consent Must Be Specific and Time-Limited

9.5.1. Consent applies only to the specific care, treatment, or intervention agreed upon at that time.

9.5.2. If new treatments or changes in care arise, fresh consent must be obtained.

9.5.3. Consent must be regularly reviewed and updated, especially if:

• a. The service user’s health condition changes.
• b. They are offered new treatment options.
• c. Their circumstances or preferences evolve.

9.6. Capacity Must Be Assessed When Necessary

9.6.1. If there is any doubt about a service user’s ability to consent, staff must follow the Mental Capacity Act 2005 (MCA) two-stage test.

9.6.2. Stage 1

9.6.2.1. Does the service user have an impairment or disturbance in the functioning of their mind or brain (e.g., dementia, learning disability, mental illness)?

9.6.3. Stage 2

9.6.3.1. Does this impairment prevent them from:-

• a. Understanding the relevant information?
• b. Retaining the information long enough to make a decision?
• c. Weighing up the options and consequences?
• d. Communicating their decision (verbally, in writing, or through gestures)?

9.6.3.2. If the service user lacks capacity, a best interests decision must be made following the MCA guidelines.

9.7. Consent Is Ongoing and Can Be Withdrawn at Any Time

9.7.1. A service user has the right to change their mind and withdraw consent at any time.

9.7.2. If consent is withdrawn:-

• a. Staff must respect the decision and stop the care or treatment.
• b. The withdrawal of consent must be clearly documented in the service user’s care records.
• c. Staff must discuss any potential risks or consequences of withdrawal and offer alternative solutions.
• d. If the withdrawal of consent poses a safeguarding risk, staff must follow safeguarding protocols and involve relevant professionals (e.g., GP, social worker).

9.8. Emergencies where consent cannot be obtained

9.8.1. In a medical emergency where a service user is unable to give or refuse consent (for example, due to unconsciousness or acute illness), staff may act in the person’s best interests to preserve life or prevent serious deterioration, in line with the Mental Capacity Act 2005. This may include calling 999, following emergency care plans, and sharing relevant information with emergency services. Staff must document what happened, why consent could not be obtained at the time, and the actions taken.

9.9. Applying consent in day-to-day domiciliary care

9.9.1. In people’s own homes, consent must be checked and respected at each visit and for each care task. Staff must:- 

• a. Introduce themselves, explain what they are there to do, and check that the person is happy for the planned care to go ahead before starting;
• b. Offer choices about how and when tasks are carried out, and adapt the visit where the person requests reasonable changes that are safe;
• c. Pause or stop care if the person appears distressed, says “no” or withdraws cooperation, and explore whether they still consent;
• d. Consider whether apparent refusal may be due to communication difficulties, pain, distress, or fluctuating mental capacity, and seek advice from a senior or the Registered Manager where there is uncertainty; and
• e. Record any significant refusals, changes in wishes, or new concerns about capacity or potential coercion in the care records and escalate in line with this policy.

10. Understanding the Mental Capacity Act 2005

10.1. The Mental Capacity Act 2005 (MCA) provides a legal framework for supporting individuals to make their own decisions wherever possible and sets out how decisions should be made for those who lack capacity. It applies to individuals aged 16 and over in England and Wales and ensures that people who may have difficulties with decision-making are protected, empowered, and treated with dignity and respect.

10.2. At The Good Place, we ensure that all staff are trained in the MCA and apply its principles in day-to-day care. Our approach is designed to maximise independence while ensuring that service users who lack capacity receive appropriate support and protection.

10.3. The Five Key Principles of the Mental Capacity Act

10.3.1. The MCA is built upon five key principles, which underpin all decision-making regarding mental capacity. These principles are legally binding and must be followed by all staff when working with service users.

10.3.2. A Presumption of Capacity

10.3.2.1. This principle means that every adult is assumed to have capacity unless there is clear evidence to suggest otherwise. A person should not be treated as lacking capacity just because they have a disability, mental health condition, or cognitive impairment such as dementia or a learning disability.

10.3.2.2. At The Good Place, we train our staff to avoid making assumptions about a person's ability to make decisions based on their diagnosis, age, appearance, or behaviour. Instead, staff must ensure that each individual's capacity is assessed on a case-by-case basis and in relation to specific decisions rather than making a blanket judgement about their overall ability.

10.3.2.3. If concerns arise about an individual's capacity, our team follows a structured assessment process to determine whether the person is able to make a particular decision at that moment.

10.3.3. The Right to Make Unwise Decisions

10.3.3.1. Every person has the right to make decisions that others may consider risky, unwise, or unusual. The MCA ensures that individuals are not deemed to lack capacity simply because their decisions do not align with conventional wisdom or what others think is best for them.

10.3.3.2. For example, a service user may choose to spend their money on non-essential items rather than saving for future expenses. While staff may have concerns about their financial choices, this does not mean the individual lacks capacity.

10.3.3.3. At The Good Place, we respect individual choice and autonomy, ensuring that personal preferences, values, and lifestyles are acknowledged and supported. Our staff are trained to distinguish between unwise decisions (which a person has the right to make) and decisions made without full understanding (which may indicate a lack of capacity).

10.3.4. The Duty to Support Decision-Making

10.3.4.1. Before concluding that someone lacks capacity, every possible effort must be made to help them understand the information and communicate their decision. This includes providing additional support, using different communication methods, and giving people extra time to process information.

10.3.4.2. At The Good Place, we use various strategies to support decision-making, including:-

• a. Breaking down information into simpler terms to make it easier to understand.
• b. Using visual aids, gestures, or alternative communication tools for individuals with speech or language difficulties.
• c. Ensuring a calm and distraction-free environment when discussing important decisions.
• d. Providing repeated explanations over time to allow the person to process information at their own pace.
• e. Involving trusted family members, advocates, or interpreters where appropriate to facilitate understanding.

10.3.4.3. By offering tailored support, we ensure that individuals have the best possible opportunity to make their own informed choices.

10.3.5. Best Interests Decision-Making

10.3.5.1. If a person is found to lack capacity for a specific decision, then any decision made on their behalf must be in their best interests. This means considering what the person would have wanted, involving family members, advocates, and professionals, and choosing the least restrictive option available.

10.3.5.2. When making best interests decisions, our staff consider:-

• a. The individual’s past and present wishes, beliefs, and values.
• b. Input from family members, carers, or Independent Mental Capacity Advocates (IMCAs).
• c. The benefits and risks of different options, ensuring that the decision minimises harm while respecting the person's preferences.
• d. Whether the individual may regain capacity in the future and whether the decision can be delayed until they can make it themselves.

10.3.5.3. At The Good Place, we ensure that all best interests decisions are documented clearly, including the reasoning behind them, the people involved in the decision-making process, and the steps taken to ensure the decision was lawful and ethical.

10.3.6. The Least Restrictive Option

10.3.6.1. When a decision must be made on behalf of someone who lacks capacity, it must interfere as little as possible with their rights and freedoms. The MCA requires that less restrictive alternatives be considered before imposing significant restrictions.

10.3.6.2. For example, if a service user with dementia has a tendency to leave their home unsafely, a locked door may seem like an immediate solution. However, a less restrictive alternative could be exploring the use of an alarm system or providing additional support from a carer at specific times.

10.3.6.3. At The Good Place, we are committed to ensuring that any interventions are necessary, proportionate, and the least restrictive possible while keeping service users safe.

10.4. How We Implement the Mental Capacity Act in Our Services

10.4.1. To ensure full compliance with the MCA, we have established clear procedures for assessing capacity, supporting decision-making, and safeguarding individuals' rights.

• a. Regular Training and Awareness: All staff receive in-depth training on the MCA and its application in domiciliary care.
• b. Capacity Assessments as Standard Practice: Before making decisions on behalf of a service user, staff are trained to conduct thorough and legally compliant capacity assessments.
• c. Involvement of Family and Advocates: We work closely with family members, legal representatives, and independent advocates to ensure decisions align with the individual’s best interests.
• d. Comprehensive Record-Keeping: All decisions related to mental capacity assessments and best interests decisions are carefully documented to ensure transparency and legal compliance.
• e. Ongoing Review of Decisions: Capacity assessments are not one-time judgements; we continuously review an individual’s ability to make decisions and adjust their care plan accordingly.

11. Decision-Making Procedures for Service Users

11.1. At The Good Place, we are committed to supporting service users in making informed decisions about their care and treatment. Decision-making must always prioritise the individual's rights, preferences, and legal safeguards. We will ensure that decisions are made appropriately, particularly when a service user has difficulties in understanding, retaining, or communicating their choices.

11.2. We support decision-making with accessible information, see our Accessible Information Standard (AIS) Policy and Procedure for full details.

12. Assessing Mental Capacity

12.1. Assessing a person’s mental capacity is a fundamental responsibility in ensuring that individuals receive safe, ethical, and legally compliant care. Capacity assessments allow us to determine whether a service user is able to make specific decisions about their own care and treatment, and to ensure that any decisions made on their behalf are done so in their best interests.

12.2. Under the Mental Capacity Act 2005 (MCA), an individual’s ability to make decisions should always be assumed unless proven otherwise. This means that a lack of capacity must never be assumed based on a person’s age, condition, disability, or appearance. Instead, a structured, legally compliant assessment must be carried out when there is reason to believe that the person may not fully understand the implications of a decision.

12.3. At The Good Place, we ensure that all staff involved in care provision receive specialist training in mental capacity assessments so that they can apply the correct process when required.

12.4. When a Capacity Assessment is Required

12.4.1. A mental capacity assessment should only be conducted when there is a reasonable belief that a person may not be able to make a particular decision at a given time. This could be due to conditions such as:-

• a. Dementia or cognitive impairment affecting memory and reasoning.
• b. Brain injuries or neurological conditions affecting understanding and decision-making.
• c. Severe learning disabilities that impact the ability to process information.
• d. Mental health conditions, such as schizophrenia or severe depression, affecting rational thought.
• e. The effects of medication, alcohol, or drugs, which may impair judgment temporarily.

12.4.2. Capacity must always be assessed in relation to a specific decision at a specific time. A person may have the capacity to make some decisions (e.g., what they want to eat or wear) but not others (e.g., whether to consent to medical treatment).

12.4.3. Decisions requiring capacity assessments might include:-

• a. Whether the individual can safely manage their finances.
• b. Whether they can consent to a care plan or medical treatment.
• c. Whether they can understand risks associated with their choices.
• d. Whether they can decide where they want to live.

12.5. The Two-Stage Capacity Assessment

12.5.1. When an assessment is required, our staff follow the two-stage test outlined in the Mental Capacity Act 2005 to determine if the person lacks capacity.

12.5.2. Stage 1: Determining an Impairment or Disturbance

12.5.2.1. The first stage assesses whether the individual has an impairment or disturbance in the functioning of their mind or brain that could affect their ability to make decisions.

12.5.2.2. This may include:-

• a. A diagnosed medical condition, such as Alzheimer’s, brain injury, or stroke.
• b. A temporary impairment, such as delirium, extreme stress, or the side effects of medication.
• c. A progressive condition, where mental capacity may fluctuate (e.g., multiple sclerosis, Huntington’s disease).

12.5.2.3. If no such impairment or disturbance is identified, the person is considered to have full capacity, and no further assessment is required.

12.5.3. Stage 2: Evaluating Decision-Making Ability

12.5.3.1. If an impairment is identified, the next step is to assess whether this impairment is preventing the person from making a specific decision at that time.

12.5.3.2. The MCA states that a person lacks capacity if they are unable to do one or more of the following:-

• a. Understand the relevant information – The person must be able to grasp the facts about the decision, including risks and consequences. If they struggle to process the information despite reasonable explanations, they may lack capacity.
• b. Retain the information long enough to make a decision – The person must be able to hold the relevant information in their mind for long enough to consider their options. If memory problems prevent them from doing so, capacity may be impaired.
• c. Weigh up the information and reach a decision – The person must be able to analyse the risks and benefits of different options and come to a rational conclusion. If they struggle with logical reasoning due to their condition, they may lack capacity.
• d. Communicate their decision – The person must be able to express their choice in some way, whether verbally, in writing, through gestures, or assistive technology. If they can communicate their decision clearly, they should be considered to have capacity.

12.5.3.3. If an individual is unable to meet one or more of these criteria, they are considered unable to make the decision and will be deemed to lack capacity for that specific matter.

12.6. How Our Organisation Ensures a Fair and Legal Process

12.6.1. At The Good Place, we take a person-centred approach to capacity assessments, ensuring that individuals are given every possible opportunity to make their own decisions before concluding that they lack capacity.

12.6.2. To achieve this, we:-

• a. Use accessible communication methods – If a person struggles to understand verbal explanations, we use pictures, written summaries, visual aids, interpreters, or simplified language to help them process information.
• b. Give additional time and support – Some individuals need more time or repetition to understand information. We ensure that capacity assessments are conducted at a time and place where the person is most comfortable.
• c. Consult with relevant parties – Family members, carers, and Independent Mental Capacity Advocates (IMCAs) may provide insight into the person’s ability to make decisions and their past preferences.
• d. Reassess capacity over time – Capacity can fluctuate, particularly in conditions such as dementia. If a person lacks capacity at one time, we regularly review the situation to determine if they regain decision-making ability.
• e. Keep clear documentation – Every capacity assessment is recorded in detail, including:-
  • aa. The decision being assessed.
  • ab. The assessment method used.
  • ac. The findings and outcome.
  • ad. Any supporting evidence or input from advocates.

12.6.3. By following these practices, we ensure that assessments are fair, legally compliant, and respect the individual’s rights and dignity.

12.7. Who Conducts Capacity Assessments

12.7.1. Mental capacity is decision-specific and time-specific, so it may need to be assessed at different times and for different decisions. At The Good Place, the staff member or professional who is proposing the specific care or treatment will ensure that capacity has been considered and, where needed, assessed.

12.7.2. Capacity will be assessed by:-

• a. the Registered Manager (Dean Hill) or a delegated senior member of staff who is trained and competent in the Mental Capacity Act 2005; and
• b. where the decision is complex or high risk (for example, significant changes to care arrangements, accommodation decisions, serious medical treatment decisions, or where there is disagreement), the Registered Manager will involve the relevant health and/or social care professional(s) (for example, GP, nurse, social worker) to support and inform the assessment and decision-making process.

12.7.3. Day-to-day capacity checks:-

• a. Care staff may need to check understanding and agreement at the point of care (for example, consent to personal care tasks during a visit). Where a concern about capacity is identified, staff must escalate to the Registered Manager so that a formal capacity assessment can be completed where required.

12.7.4. Recording:-

• a. All capacity assessments and outcomes will be recorded in the service user’s care records, including: the specific decision, the support provided to help the service user decide, the outcome, and any best-interests decision (where the service user  lacks capacity).

12.8. The Role of the Court of Protection

12.8.1. If there is a dispute over a person’s capacity, or if a complex decision needs to be made that is not covered under standard MCA best interests procedures, the Court of Protection may be required to intervene.

12.8.2. The Court of Protection can:-

• a. Decide whether a person has capacity for a specific decision.
• b. Appoint a Deputy to make ongoing decisions for a person who lacks capacity.
• c. Authorise a deprivation of liberty in settings not covered by the Deprivation of Liberty Safeguards (for example, in people’s own homes or supported living arrangements) and determine disputes about whether a deprivation of liberty is occurring.

12.8.3. If a service user at The Good Place requires legal intervention, we work closely with legal professionals and social services to ensure their best interests are upheld.

12.9. Involvement of Legal Representatives (LPA or Court-Appointed Deputy)

12.9.1. If a service user has a legal representative responsible for health and welfare decisions, staff must:-

• a. Verify the legal status of the representative by checking Lasting Power of Attorney (LPA) for Health and Welfare or a Court-Appointed Deputyship.
• b. Consult the LPA or Deputy before making decisions about care and treatment.
• c. Ensure the representative’s decisions align with the best interests of the service user and are within their legal authority.
• d. Document all interactions with the LPA or Deputy, including the decisions made and the rationale.

12.9.2. Important Notes:-

• a. If there is a dispute between the care provider and the legal representative, legal advice or involvement of the Court of Protection may be necessary.
• b. A Property and Financial Affairs LPA does not have authority over health and welfare decisions unless explicitly granted.

13. Best Interests Decision-Making

13.1. When a person is found to lack the capacity to make a particular decision, the Mental Capacity Act 2005 (MCA) requires that any decision made on their behalf must be in their best interests. This ensures that the person’s rights, wishes, and well-being are central to the decision-making process.

13.2. At The Good Place, we follow a structured, person-centred approach to best interests decision-making, ensuring that every decision respects the individual's dignity, autonomy, and unique preferences while prioritising their health, safety, and well-being.

13.3. Considering All Relevant Factors

13.3.1. When making a best interests decision, it is essential to take into account all aspects of the individual’s life to ensure that the decision reflects what they would have chosen if they had capacity.

13.3.2. This includes:-

• a. Past and present wishes and feelings – If the individual expressed clear preferences before losing capacity, these must be considered. This may be documented in advance statements, Lasting Powers of Attorney (LPA), or past conversations with family or carers.
• b. Cultural, religious, and moral beliefs – The decision should align with the individual’s values and identity. For example, a service user from a specific religious background may have dietary restrictions or medical treatment preferences that must be respected.
• c. Emotional well-being and personal relationships – Consideration must be given to how the decision will affect the person’s relationships and mental well-being. For instance, a decision about moving a service user into a care home should take into account their attachments to their home environment, family, and social connections.
• d. The benefits and risks of different options – Each possible choice must be carefully weighed, ensuring that potential harm is minimised while promoting independence and quality of life.

13.3.3. At The Good Place, we document all considerations thoroughly to demonstrate that decisions have been made in line with legal requirements and ethical principles.

13.4. Involving the Individual in Decision-Making

13.4.1. Although a person may lack capacity for a specific decision, this does not mean they should be excluded from the decision-making process. We ensure that individuals are involved as much as possible, giving them the opportunity to:-

• a. Express their preferences using accessible communication methods, such as visual aids, sign language, or assistive technology.
• b. Participate in discussions about their care, even if they cannot make the final decision themselves.
• c. Experience different options where possible – For example, if a service user is struggling to decide whether to accept a care package, we may arrange a trial period to allow them to experience the arrangement before a final decision is made.

13.4.2. Our staff are trained to provide information in a way that is understandable to the individual, ensuring that they have every opportunity to contribute to decisions affecting their life.

13.5. Consultation with Family Members, Advocates, and Legal Representatives

13.5.1. Best interests decision-making must involve the right people, ensuring that different perspectives are considered. Where appropriate, we consult:-

• a. Family members and close friends who have insight into the individual’s wishes and preferences.
• b. Health and social care professionals, such as GPs, social workers, or occupational therapists, to provide expert opinions on medical or care-related decisions.
• c. A legally appointed Lasting Power of Attorney (LPA) if the person has designated someone to make decisions on their behalf.
• d. Independent Mental Capacity Advocates (IMCAs) when there is no family or trusted representative available.

13.5.2. While family input is valuable, the final decision must always be based on the best interests of the individual, not the preferences of relatives. If disagreements arise, we follow a structured mediation process, and if necessary, involve the Court of Protection for legal resolution.

13.6. Exploring the Least Restrictive Option

13.6.1. The Mental Capacity Act 2005 requires that any decision made in a person’s best interests must use the least restrictive option available. This means that any actions taken must interfere as little as possible with the individual’s rights and freedoms.

13.6.2. For example:-

• a. If a service user with dementia is at risk of wandering, rather than locking doors (which may deprive them of liberty), we may consider using sensor alarms, supervised outings, or structured routines to ensure safety while maintaining freedom.
• b. If a person refuses personal care but lacks capacity to understand the risks, we explore alternative methods, such as building trust through familiar carers, adjusting the timing of care, or using gentle persuasion, rather than enforcing care against their wishes.

13.6.3. At The Good Place, we prioritise dignity, choice, and autonomy, ensuring that any restrictions are justified, proportionate, and time-limited.

13.7. When is an Independent Mental Capacity Advocate (IMCA) Required?

13.7.1. In cases where a significant decision needs to be made and there are no family members or legally appointed representatives available, the law requires that an Independent Mental Capacity Advocate (IMCA) be involved.

13.7.2. Significant decisions that require an IMCA include:-

• a. Long-term changes to living arrangements, such as moving into a care home.
• b. Major medical decisions, such as surgery or refusal of life-sustaining treatment.
• c. Serious financial matters where a best interests decision is required.

13.7.3. IMCAs provide an independent and impartial viewpoint, ensuring that decisions are made lawfully and in the best interests of the individual. At The Good Place, we liaise with local IMCA services when needed to ensure compliance with legal obligations.

13.8. Documentation and Accountability

13.8.1. All best interests decisions must be clearly documented to provide evidence that they were made in accordance with the Mental Capacity Act 2005. This includes:

• a. A summary of the capacity assessment that led to the best interests decision.
• b. A record of the people involved in the decision-making process.
• c. A clear explanation of the considerations taken into account, including the person’s past and present wishes.
• d. The final decision made and why it was deemed the least restrictive and most appropriate option.

13.8.2. At The Good Place, we maintain detailed records of all best interests decisions, ensuring that they can be reviewed and challenged if necessary. All documentation is securely stored in line with GDPR and data protection regulations.

13.9. Disputes and Legal Intervention

13.9.1. Sometimes, disagreements arise between family members, professionals, or advocates about what is truly in a person’s best interests. If a dispute cannot be resolved through discussion and mediation, the case may be referred to the Court of Protection, which has the legal authority to:-

• a. Make a final ruling on the individual’s best interests.
• b. Appoint a Deputy to make ongoing decisions if necessary.
• c. Resolve disputes between family members and professionals.

13.9.2. At The Good Place, we work proactively to resolve disputes amicably, ensuring that service users receive the care and support that is in their best interests while avoiding unnecessary legal action.

13.9.3.

13.10. Right to Refuse Care and Associated Procedures

13.10.1. Service users with capacity have the absolute right to refuse care or treatment, even if their decision may result in harm. Staff must:-

• a. Respect the decision and not attempt to coerce or pressure the individual.
• b. Document the refusal clearly in the care records, including any reasons given by the service user.
• c. Explore alternative solutions that may be more acceptable to the individual.
• d. Ensure the service user understands the consequences of refusing care (e.g., increased health risks).
• e. Report concerns to the appropriate professionals (e.g., GP, social worker) if refusal of care poses a serious risk, and follow our Safeguarding Adults Policy and Procedure if there are concerns about abuse, neglect, coercion or self-neglect.

13.10.2. Exception:-

• a. If a service user lacks capacity and refusing care would cause significant harm, a best interests decision must be made, and our Safeguarding Adults Policy and Procedure may apply.

13.10.3. Summary of the Decision-Making Process

14. Deprivation of Liberty Safeguards (DoLS) in Domiciliary Care

14.1. The Deprivation of Liberty Safeguards (DoLS) is a legal framework under the Mental Capacity Act 2005 (MCA) designed to protect individuals who lack mental capacity and are at risk of being deprived of their liberty for their own safety or care. The framework ensures that any restrictions placed on an individual’s freedoms are necessary, proportionate, and legally authorised.

14.2. Deprivation of liberty refers to situations where a person is under continuous supervision and control and not free to leave their care setting. DoLS currently applies only to individuals in hospitals and care homes, where providers must seek authorisation from the local authority. Individuals receiving domiciliary care may also be deprived of their liberty if their care arrangements are restrictive; in these community settings, any deprivation of liberty must be authorised by the Court of Protection.

14.3. At The Good Place, we are committed to ensuring that any restrictions placed on service users are lawfully justified, properly recorded, and the least restrictive possible, in accordance with legal requirements and CQC Regulation 13 – Safeguarding Service Users from Abuse and Improper Treatment​.

14.4. When DoLS Applies in a Domiciliary Care Setting

14.4.1. A deprivation of liberty may occur in domiciliary care when a person receiving care at home lacks the capacity to consent to their care arrangements, and those arrangements significantly restrict their freedom. In such cases, the statutory DoLS scheme does not apply directly; instead, authorisation must be sought from the Court of Protection. Some examples include:-

• a. The individual is constantly supervised and cannot leave their home freely, even with support.
• b. Physical restraints, locked doors, or electronic monitoring are used to prevent the person from leaving.
• c. The person is prevented from seeing certain people or engaging in activities due to safety concerns.
• d. The person is subject to significant medication control that affects their ability to make choices.
• e. There is no realistic alternative to their current living situation because other options have been deemed unsafe.

14.4.2. If a service user’s care plan includes any of these restrictive elements, we must consider whether a deprivation of liberty is occurring and, if so, take steps to ensure it is legally authorised.

14.5. The Legal Process for Authorising a Deprivation of Liberty in Domiciliary Care

14.5.1. Unlike care homes and hospitals, where DoLS authorisation is granted by the local authority, domiciliary care settings require an application to the Court of Protection to authorise any deprivation of liberty.

14.5.2. At The Good Place, we follow a structured process to ensure full compliance with the law.

14.5.3. Assessing Whether a Deprivation of Liberty is Occurring:-

• a. We conduct a care plan review to determine whether the service user’s freedoms are restricted in a way that meets the legal definition of a deprivation of liberty.
• b. We ensure that less restrictive alternatives have been explored and that the restrictions are truly necessary for the individual’s safety and well-being.

14.5.4. Consulting with the Individual and Their Representatives:-

• a. We involve the service user as much as possible in discussions about their care.
• b. We consult family members, legal representatives, and advocates to gather their views.
• c. If there is no one suitable to represent the individual, we involve an Independent Mental Capacity Advocate (IMCA).

14.5.5. Submitting an Application to the Court of Protection:-

• a. If we determine that a deprivation of liberty cannot be avoided, we work with the local authority or legal professionals to submit an application to the Court of Protection.
• b. The application includes a detailed care plan, medical assessments, and supporting evidence to justify the deprivation of liberty.

14.5.6. Reviewing and Monitoring the Authorisation:-

• a. Once authorised, we regularly review the care arrangements to ensure they remain necessary.
• b. If circumstances change (e.g., the person regains capacity or their care needs change), we seek to remove or modify restrictions as soon as possible.

14.5.7. By following this process, we ensure that any deprivation of liberty is lawful, justified, and kept under regular review.

14.6. Ensuring Least Restrictive Practices

14.6.1. The MCA requires that any restrictions on liberty be as minimal as possible, meaning that care plans should prioritise the least restrictive interventions while still ensuring safety.

14.6.2. At The Good Place, we:-

• a. Explore alternative solutions before applying for a DoLS authorisation, such as assistive technology, structured routines, or additional support staff.
• b. Regularly review care plans to reduce restrictions wherever possible.
• c. Ensure that staff are trained in positive risk-taking, allowing individuals to have as much control over their lives as possible while keeping them safe.

14.6.3. For example, instead of locking doors to prevent a service user from leaving their home, we might:-

• a. Use sensor alarms to alert carers when they leave.
• b. Implement a structured support plan to encourage safe outings.
• c. Work with family members to provide a familiar, supervised environment that supports independence.

14.6.4. These approaches help ensure that we only use deprivation of liberty as a last resort.

14.7. The Role of the Court of Protection and Lasting Powers of Attorney (LPA)

14.7.1. If there is disagreement about a person’s care arrangements or if serious decisions need to be made, the Court of Protection can make rulings on:-

• a. Whether a deprivation of liberty is justified.
• b. Appointing a Deputy to make ongoing care decisions.
• c. Reviewing cases where there is dispute between family members and professionals.

14.7.2. If a service user has a Lasting Power of Attorney (LPA) for Health and Welfare, the appointed representative has legal authority to make certain care decisions on their behalf. However, they cannot authorise a deprivation of liberty—this must always go through the Court of Protection.

14.7.3. At The Good Place, we work closely with families, legal representatives, and local authorities to resolve issues proactively, ensuring that legal intervention is only sought when absolutely necessary.

14.8. Note on Liberty Protection Safeguards (LPS)

14.8.1. At the time of this policy, Deprivation of Liberty Safeguards (DoLS) apply in hospitals and care homes, and community deprivation of liberty is authorised via the Court of Protection where the legal test is met. The Good Place will keep MCA/ DoLS requirements under review and will update practice, training and documentation in line with any future legal changes, including the Liberty Protection Safeguards, when implemented.

14.9. Immediate actions when a potential DoLS is identified

• a. Inform the Registered Manager without delay.
• b. Complete/refresh the Mental Capacity Assessment and record the specific decision(s).
• c. Hold a best-interests meeting, involving the service user (as far as possible), family/representatives, and relevant professionals; consider the IMCA where required.
• d. Document the least-restrictive analysis and risk rationale.
• e. Escalate to the appropriate body to obtain the lawful authorisation (DoLS or Court of Protection) and track progress to outcome.

14.10. Objections and restrictions

14.10.1. Where the service user objects to arrangements or there are significant restrictions, staff must escalate immediately to the Registered Manager to consider legal authorisation.

14.11. Notifications and records

14.11.1. Where required by the CQC Notification Regulations and guidance, the Registered Manager will notify CQC without delay of applications for, and outcomes of, authorisations of deprivation of liberty for people using this service (including DoLS authorisations in hospitals or care homes where we are involved in the person’s care, and Court of Protection authorisations for community settings). All assessments, best-interests decisions, applications, outcomes, and review dates must be clearly recorded in the care record and in the central deprivation of liberty register held by The Good Place.

14.12. Advocacy and support to understand choices

14.12.1. Some people may want support to understand information, communicate their views, or take part in decisions about their care. The Good Place will:-

• a. encourage the service user to involve someone they trust (where the service user consents);
• b. provide information in accessible formats and allow extra time for decision-making;
• c. signpost or refer to independent advocacy where appropriate, including where there are substantial difficulties in being involved and no suitable representative; and
• d. arrange an Independent Mental Capacity Advocate (IMCA) where required under the Mental Capacity Act (for example, serious medical treatment or accommodation decisions for a service user who lacks capacity and has no appropriate family/friend to consult).

14.12.2. Where relevant, we will work with the commissioning/ local authority to support advocacy access:

• a. Local Authority: Staffordshire County Council
  • aa. Email: [protected:aSSASPB.admin][protected:astaffordshire.gov.uk]
  • ab. Online: Staffordshire & Stoke-on-Trent Adults Safeguarding Partnership Board
  • ac. Telephone (working hours): 0345 604 2719
  • ad. Telephone (out of hours): 0345 604 2886

15. Obtaining and Documenting Consent

15.1. Consent must be appropriately obtained, clearly recorded, and regularly reviewed to ensure it remains valid and reflects the service user’s current wishes and needs.

15.2. Explanation of Care, Risks, and Alternatives

15.2.1. Before obtaining consent, staff must ensure that the service user has received a full explanation of their care, support, or treatment, including:-

15.2.2. Nature of the Care or Treatment:-

• a. A clear description of the care or treatment being proposed (e.g., personal care, medication administration, mobility assistance).
• b. What the care involves, how it will be provided, and who will be delivering it.

15.2.3. Potential Benefits and Risks:-

• a. Explanation of how the care or treatment will support the service user’s health, well-being, or independence.
• b. Any potential risks, side effects, or discomforts associated with the care.
• c. How risks can be minimised through safe care practices.

15.2.4. Available Alternatives:-

• a. Other care or treatment options that may be available, allowing the service user to make an informed decision.
• b. The option to refuse care and any potential consequences of refusal (without coercion).
• c. If the individual refuses, alternative solutions should be discussed where possible.

15.2.5. Staff must ensure that:-

• a. The information is provided in a clear, jargon-free, and accessible format.
• b. The service user has the opportunity to ask questions and receive further clarification.
• c. Consent is obtained voluntarily, without pressure or undue influence.

15.2.6. Covert medication and restrictive practices

15.2.6.1. The Good Place will not support covert administration of medication (for example, disguising medicine in food or drink) unless there is a lawful best-interests decision under the Mental Capacity Act, the option is necessary and proportionate, and it is initiated and/or clearly endorsed by the prescribing clinician (for example, GP) with appropriate clinical oversight (for example prescriber/ pharmacist advice) and a clear, time-limited care plan. Any restrictive practices must be the least restrictive option, fully documented, regularly reviewed and managed in line with safeguarding requirements (Regulation 13).

15.3. Types of Consent: Verbal, Written, and Implied

15.3.1. Consent can be expressed in different ways, and the method of obtaining it depends on the type of care being provided.

15.3.2. Verbal Consent:-

• a. Given orally by the service user (e.g., "Yes, I am happy for you to assist me with my medication").
• b. Acceptable for routine, low-risk care tasks, such as assistance with dressing or meal preparation.
• c. Must be documented in the service user’s records to confirm that consent was obtained.

15.3.3. Written Consent:-

• a. Obtained through a signed consent form, care plan agreement or other written record.
• b. Normally required for significant or higher-risk care interventions, and where commissioners, prescribers or professional guidance specify written authorisation, such as: 
  • aa. Administration of prescribed medicines where The Good Place is responsible for administering (rather than only prompting or reminding);
  • ab. Personal care involving intimate or dignity-sensitive tasks, where this is not already clearly agreed and signed within the care plan;
  • ac. Use of equipment that may pose risks (for example, hoists, profiling beds or complex moving and handling equipment); and
  • ad. Sharing personal or sensitive health information with other organisations for purposes beyond direct care delivery (for example, case studies or training materials), unless another lawful basis applies and the information is effectively anonymised.
• c. Provides clear documentation that consent was given and what the service user agreed to.

15.3.4. Implied Consent:-

• a. When a service user’s actions indicate agreement, even if they do not verbally express it.
• b. Examples include:-
  • aa. Extending a hand for support when being assisted to stand.
  • ab. Opening their mouth when offered medication.
• c. Staff must be confident that implied consent is intentional and document their observations appropriately.

15.3.5. Important Considerations:-

• a. If a service user is unable to communicate clearly, verbal and implied consent should not be relied upon – a capacity assessment and best interests decision may be required.
• b. If there is doubt about consent, staff must stop and seek clarification.

15.4. Regular Review of Consent

15.4.1. Consent is not a one-time event; it must be regularly reviewed and updated to reflect changes in the service user’s health, preferences, or capacity.

15.4.2. When to Review Consent:-

• a. Changes in health condition – If a service user develops new health issues or deteriorates, their ability to consent may change.
• b. New treatments or interventions – If a new form of care is introduced, fresh consent must be obtained.
• c. Fluctuating capacity – If a service user has a condition like dementia or a mental health disorder, their capacity to consent may vary over time.
• d. Withdrawal of consent – If a service user decides to withdraw their consent, this must be documented, and alternative solutions discussed.
• e. Annual or routine care plan reviews – As part of ongoing care planning, consent should be reviewed to ensure it still reflects the service user’s wishes.

15.4.3. Documentation of Consent Reviews:-

• a. Any changes or updates to consent should be clearly recorded in the service user’s care records.
• b. If a service user withdraws consent, staff must:-
  • aa. Respect their decision and discontinue the care or treatment.
  • ab. Discuss alternatives and document the conversation.
  • ac. Escalate concerns to a manager or healthcare professional if refusal of care presents a risk to the service user’s safety.

15.4.4. Service users (and, where appropriate, their families, advocates or legal representatives) will be actively involved in care plan and consent reviews. Staff must check whether the person’s wishes, goals and preferred outcomes have changed and update care plans and consent records to reflect this.

15.5. Best Practices for Documenting Consent

15.5.1. All staff must follow best practice guidelines when documenting consent to ensure compliance and accountability.

• a. Clearly state what the service user has consented to.
• b. Record the date and time when consent was given.
• c. Specify the type of consent (verbal, written, or implied).
• d. Note any discussions about risks, benefits, and alternatives.
• e. Document any withdrawal of consent, including the reason (if provided) and any actions taken.
• f. If the service user lacks capacity, record the results of the Mental Capacity Assessment and the Best Interests decision-making process.
• g. Records should be completed as close in time as possible to the discussion or decision, and must be clear, factual and objective.

15.5.2. By following these procedures, The Good Place ensures that service users’ rights are protected, care is delivered ethically, and legal compliance is maintained.

15.6. Documentation for Potential or Authorised Deprivation of Liberty

15.6.1. For any case where a DoLS is suspected, applied for, or authorised, the care record must include:-

• a. The capacity assessment for the relevant decision(s) and date.
• b. The best-interests decision record, attendees, and rationale.
• c. The least-restrictive options considered and why they were not suitable.
• d. Details of the application (DoLS or Court of Protection), the status, and any urgent authorisation used by the Managing Authority (if applicable).
• e. The authorisation outcome, start/expiry dates, conditions, and review date(s).
• f. Any CQC notifications made and the date/time of submission.
• g. Ongoing monitoring notes evidencing that restrictions remain necessary and proportionate, and that the service user is supported to exercise rights of representation/ appeal.