Code:
Name of auditor: Designation: Date audit completed:
MENTAL CAPACITY ACT HOSPITAL DISCHARGE AUDIT
Audit to test compliance of discharge planning policies and procedures with the Mental Capacity Act 2005
Instructions for auditor: Place a tick in whichever section most closely describes your findings, based on the criteria below each
indicator. Explanation only required if “Not Applicable” box is ticked.
Unique Indicators Reference N/A Not Needs Fully
Number (please give Achieved Improvement Achieved
reason/s)
1. Discharge planning policies and/or procedures Discharge from
incorporate guidance for staff managing the hospital: pathway,
discharge of people who may lack capacity, process and
including guidelines for people with conditions practice (DH
such as dementia, learning disability and mental 2003).
health problems. MCA Best Practice
Tool (DH 2006).
Not achieved: Discharge planning policies/procedures do not include guidance for managing the discharge of people who may lack capacity.
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to incorporate guidance for managing the discharge of
people who may lack capacity.
Fully achieved: Discharge planning policies/procedures include guidance for managing the discharge of people who may lack capacity or make clear
reference to guidance in other relevant policies (e.g. Mental Capacity Act Implementation Policy)
1
Unique Indicators Reference N/A Not Needs Fully
Number (please give Achieved Improvement Achieved
reason/s)
2. Discharge planning policies and/or procedures MCA Best Practice
make reference to the 5 statutory principles of Tool (DH 2006).
the Mental Capacity Act 2005. MCA 2005,
Section 1.
MCA Code of
Practice,
Chapter 2.
Not achieved: Discharge planning policies/procedures do not make reference to the 5 statutory principles of the Mental Capacity Act 2005
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to include reference to the 5 statutory principles of the
Mental Capacity Act 2005
Fully achieved: Discharge planning policies/procedures include the 5 statutory principles of the Mental Capacity Act 2005 or make reference to where these
can be found in other relevant policies (e.g. Mental Capacity Act Implementation Policy)
3. Discharge planning policies and/or procedures MCA 2005,
include guidance about supporting people to Section 3(2)
MCA Code of
make their own decisions and promoting their Practice,
participation in the discharge planning process Chapter 3.
(e.g. referring to specialists such as mental health Discharge from
services, Speech and Language Therapy, hospital: pathway,
considering the need for translation services, process and
advocacy etc.) practice (DH
2003).
Not achieved: Discharge planning policies/procedures do not include guidance about supporting people to make their own decisions and promoting their
participation in the discharge planning process.
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to incorporate guidance about supporting people to make
their own decisions and promoting their participation in the discharge planning process.
Fully achieved: Discharge planning policies/procedures include guidance about supporting people to make their own decisions and promoting their
participation in the discharge planning process, or make clear reference to guidance about this in other relevant policies (e.g. Mental Capacity Act
Implementation Policy).
2
Unique Indicators Reference N/A Not Needs Fully
Number (please give Achieved Improvement Achieved
reason/s)
4. Discharge planning policies and/or procedures MCA 2005,
include guidance about assessing mental capacity Sections 2 and 3.
MCA Code of
in accordance with the Mental Capacity Act 2005 Practice,
Chapter 4.
Not achieved: Discharge planning policies/procedures do not include guidance about assessment of mental capacity.
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to incorporate guidance about assessment of mental
capacity.
Fully achieved: Discharge planning policies/procedures include guidance about assessment of capacity or make clear reference to guidance about this in
other relevant policies (e.g. Mental Capacity Act Implementation Policy).
5. Discharge planning policies and/or procedures MCA 2005, Sections
include guidance about other decision-making 9-26.
MCA Code of
authorities for people who may lack capacity, Practice, Chapters 7,
including Lasting Powers of Attorney, Court 8 and 9.
Appointed Deputies, Advance Decisions to Refuse
Treatment and Court of Protection Declarations.
Not achieved: Discharge planning policies/procedures do not include guidance about other decision-making authorities.
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to incorporate guidance about other decision-making
authorities.
Fully achieved: Discharge planning policies/procedures include guidance about other decision-making authorities or make clear reference to guidance about
this in other relevant policies (e.g. Mental Capacity Act Implementation Policy).
3
Unique Indicators Reference N/A Not Needs Fully
Number (please give Achieved Improvement Achieved
reason/s)
6. Discharge planning policies and/or procedures MCA 2005,
include guidance about the criteria and Sections 35-41.
MCA Code of
procedure for making referrals to Independent Practice,
Mental Capacity Advocates (IMCA). Chapter 10.
IMCA Regulations
2006 SI: 1832 and
2883.
Not achieved: Discharge planning policies/procedures do not include guidance about making referrals to IMCA.
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to incorporate guidance about making referrals to IMCA.
Fully achieved: Discharge planning policies/procedures include guidance about making referrals to IMCA or make clear reference to guidance about this in
other relevant policies (e.g. Mental Capacity Act Implementation Policy).
7. Discharge planning policies and/or procedures MCA 2005, Section
include guidance about the process to be followed 4.
MCA Code of
for determining “best interests” for people Practice,
assessed as being unable to make decisions about Chapter 5.
their own discharge.
Not achieved: Discharge planning policies/procedures do not include guidance about determination of best interests according to Mental Capacity Act 2005.
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to incorporate guidance about determination of best
interests according to Mental Capacity Act 2005.
Fully achieved: Discharge planning policies/procedures include guidance about determination of best interests according to Mental Capacity Act 2005 or
make clear reference to guidance about this in other relevant policies (e.g. Mental Capacity Act Implementation Policy).
4
Unique Indicators Reference N/A Not Needs Fully
Number (please give Achieved Improvement Achieved
reason/s)
8. Discharge planning policies and/or procedures MCA Code of
include guidance about the sharing of Practice, Chapter 16.
Data Protection Act
information with third parties where people lack 1998.
capacity to give informed consent to this. No Secrets (DH
2000).
Human Rights Act
1998.
Not achieved: Discharge planning policies/procedures do not include reference to information sharing protocols (which include reference to sharing
information when the person may lack capacity to give informed consent).
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to incorporate guidance about information sharing
protocols (which include reference to sharing information when the person may lack capacity to give informed consent).
Fully achieved: Discharge planning policies/procedures include guidance about information sharing protocols (which include reference to sharing information
when the person may lack capacity to give informed consent) or make clear reference to guidance about this in other relevant policies.
9. Discharge planning policies and/or procedures MCA Code of
include guidance about the management of Practice,
Chapter 15.
disputes and conflicts about plans for a person’s
discharge.
Not achieved: Discharge planning policies/procedures do not include reference to the management of disagreements and disputes about plans for a person’s
discharge.
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to incorporate guidance about the management of
disagreements and disputes about plans for a person’s discharge.
Fully achieved: Discharge planning policies/procedures include guidance about the management of disagreements and disputes about plans for a person’s
discharge or make clear reference to guidance about this in other relevant policies.
5
Unique Indicators Reference N/A Not Needs Fully
Number (please give Achieved Improvement Achieved
reason/s)
10. Discharge planning policies and/or procedures MCA 2005,
include guidance about protecting people who Section 44.
MCA Code of
lack capacity from abuse Practice,
Chapter 14.
No Secrets (DH
2000).
Not achieved: Discharge planning policies/ procedures do not include reference to protecting people who lack capacity from abuse.
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to include guidance on protecting people who lack
capacity from abuse.
Fully achieved: Discharge planning policies/procedures include guidance on protecting people who lack capacity from abuse or make clear reference to
guidance about this in other relevant policies.
11. Discharge planning policies and/or procedures MCA 2005, Schedule
include guidance about the process to be followed A1 and 1A (Mental
Health Act 2007,
if a Deprivation of Liberty Safeguards c.12).
authorisation may be needed on discharge. DOLS Code of
Practice, Chapters 1-
3.
Not achieved: Discharge planning policies/procedures do not include reference to the process to be followed if a Deprivation of Liberty Safeguards
authorisation may be needed on discharge.
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to incorporate guidance about the process to be followed
if a Deprivation of Liberty Safeguards authorisation may be needed on discharge protocols (which include reference to sharing information when the person
may lack capacity to give informed consent).
Fully achieved: Discharge planning policies/procedures include guidance about the process to be followed if a Deprivation of Liberty Safeguards authorisation
may be needed on discharge or make clear reference to guidance about this in other relevant policies.
6
Unique Indicators Reference N/A Not Needs Fully
Number (please give Achieved Improvement Achieved
reason/s)
12. Discharge planning policies and/or procedures MCA 2005,
include guidance about the process to be followed Sections 6 and 15-
18.
if deprivation of liberty is likely to occur on MCA Code of
discharge in a setting not covered by the Practice,
Deprivation of Liberty Safeguards (e.g. in a Chapter 8.
supported tenancy).
Not achieved: Discharge planning policies/ procedures do not include reference to the process to be followed if deprivation of liberty is likely to occur on
discharge in a setting not covered by the Deprivation of Liberty Safeguards.
Needs improvement: The organisation is currently reviewing discharge planning policies/procedures to include guidance on the process to be followed if
deprivation of liberty is likely to occur on discharge in a setting not covered by the Deprivation of Liberty Safeguards.
Fully achieved: Discharge planning policies/procedures include guidance on the process to be followed if deprivation of liberty is likely to occur on discharge in
a setting not covered by the Deprivation of Liberty Safeguards.
Instructions for returning completed audit:
References
Data Protection Act 1998. (c. 29), London: TSO
Department for Constitutional Affairs, 2007. Mental Capacity Act 2005: Code of Practice. London: TSO
Department of Health, 2000. No Secrets: guidance on developing and implementing multi-agency policies and procedures to protect
vulnerable adults from abuse. London: Department of Health
Department of Health, 2003. Discharge from hospital: pathway, process and practice. London: Department of Health
7
Department of Health, 2006. Mental Capacity Act Best Practice Tool. London: Department of Health
Human Rights Act 1998. (c. 42), London: TSO
Mental Capacity Act 2005 (c.9), London: TSO
Mental Capacity Act 2005 (Independent Mental Capacity Advocates) (General) Regulations 2006. SI 2006/1832
Mental Capacity Act 2005 (Independent Mental Capacity Advocates) (General) Regulations 2006. SI 2006/2883
Mental Health Act 2007 (c.12), London: TSO
Ministry of Justice, 2008. Deprivation of Liberty Safeguards: Code of Practice to supplement the main Mental Capacity Act Code of
Practice. London: TSO
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