The Act sets out five guiding principles to underpin

							Assessment of Capacity – Policy and Procedure for Staff

MENTAL CAPACITY ACT 2005 POLICY AND PROCEDURE FOR STAFF Assessment of Capacity
PROCEDURE NUMBER RATIFYING COMMITTEE DATE RATIFIED NEXT REVIEW DATE MC 01 Clinical Governance Committee 14 October 2008 October 2009

POLICY STATEMENT: This document seeks to give guidance when an assessment of capacity is to be made before carrying out any care or treatment. ACCOUNTABLE DIRECTOR: David Fearnley (Medical Director & Deputy Chief Executive) Barry Judge (Trust Legal Adviser) Jim Wiseman (MHA Legislation Practitioner)

POLICY AUTHOR:

(Policy reviewed and updated in Sep-08 by policy authors to take account of MHA 2007 amendments)

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KEY POLICY ISSUES Implementation & management of assessing capacity as per the Mental Capacity Act 2005 To support staff and service user’s in the assessment of capacity

This document is presented in a standard structure and format. It will be made available in appropriate languages and formats on request. 1

Assessment of Capacity – Policy and Procedure for Staff

Contents Page 1. 2. 3. 4. 5. 6. 7. Introduction Policy Corporate Procedure Development and Consultation Process Reference Documents Bibliography Appendix 1 Impact Assessment Screening Appendix 2 Implementation Plan 3 4 5 10 11 11 12 16

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Assessment of Capacity – Policy and Procedure for Staff

1.

Introduction

This document explains: • • • • • why the policy is necessary (rationale) to whom it applies and where and when it should be applied (scope) the underlying beliefs upon which this policy is based (principles) the standards to be achieved (policy) how the policy standards will be met through working practices (procedure)

Compliance Statement Where appropriate anyone using this policy and procedure must be familiar with, and comply with the following:This document is compliant with the Human Rights Act 1998, the Mental Capacity Act 2005 the Care Programme Approach and all other legal requirements. It should not be read or acted upon in isolation. Instead, where appropriate, it should be considered in conjunction with the following, all of which directly interact with the Mental Health Act 1983:• • • • • • • • The Mental Health Act 2007 The Mental Health Act 1983 (as amended by the Mental Health Act 2007) The Mental Capacity Act 2005 (including the Deprivation of Liberty Safeguards delegated to this Act under the Mental Health Act 2007) The respective Codes of Practice of the above Acts of Parliament The Human Rights Act 1998 (and the European Convention on Human Rights) The Violence, Crime and Victims Act, 2004 The Care Programme Approach All Mersey Care NHS Trust policies on the Mental Health Act 1983 as appropriate.

Whenever mental capacity is to be considered the following practice must be adopted:“In particular, they will need to be familiar with the principles of the MCA to understand what it means to lack capacity and to know when decisions can be taken in the best interest of people who lack capacity to take those decisions themselves, the steps to be taken before doing so, and the principles to be applied”. (MCA 2005 Code of Practice, Introduction, para X1VIII). Equality and Diversity Statement Mersey Care NHS Trust recognises that all sections of society may experience prejudice and discrimination. This can be true in service delivery and employment. The trust is committed to equality of opportunity and antidiscriminatory practice both in the provision of services and in our role as a major employer. The Trust believes that all people have the right to be treated with dignity and respect. 3

Assessment of Capacity – Policy and Procedure for Staff The Trust is working towards, and is committed to the elimination of unfair and unlawful discriminatory practices. All employees have responsibility for the effective implementation of this policy. They will be made fully aware of this policy and without exception must adhere to its requirements. Mersey Care NHS Trust also is aware of its legal duties under the Human Rights Act 1998. 1.1 Rationale

Trust staff have always had a key role in helping and supporting people with impaired mental functioning to understand what decisions need to be made and why, and what the consequences of those decisions are. We are sometimes the only people in a position to provide information to service users about the options available to them, or where they can get further help and/or advice. This guidance should increase staff awareness of the different options available to people to help them in this situation. We also need to be able to determine a person’s mental capacity in relation to the decisions they face both throughout the adult care process and more widely in their lives. This guidance helps staff to understand the factors that affect capacity. In the past, Trust staff have had to rely on common law guidance alone when arriving at these decisions. The Mental Capacity Act 2005 (MCA) gives statutory rights to service users regarding the way Trust Staff arrive at given decisions. The MCA also provides protection to Trust staff when performing acts in the care and treatment of patients. Consequently, the rationale for this policy is to ensure that Trust Staff work within the statutory framework. 1.2 Scope

This policy is for information and application by all Mersey Care NHS Trust staff in respect of all service users receiving care and treatment within the organisation. 1.3 Principles

Trust staff should be aware that the MCA details five guiding principles which underpin its fundamental concepts and govern its implementation. The five key principles are: • • • • Assume capacity unless it is proved otherwise Give all appropriate help before concluding someone cannot make their own decisions Accept the right to make what might be seen as eccentric or unwise decisions Always act in the best interests of people without capacity 4

Assessment of Capacity – Policy and Procedure for Staff • Decisions made should be the least restrictive of their basic rights and freedoms.

2.

Policy

The MCA provides a statutory framework to empower and protect vulnerable people who may not be able to make their own decisions. It makes it clear who can take decisions in which situations and how they should go about this. It enables people to plan ahead for a time when they may lose capacity. The MCA enshrines in statute, current best practice and common law principles concerning people who lack mental capacity and those who take decisions on their behalf. The aim of this policy is to help staff and carers appropriately assess capacity of a service user. This policy is to be read and applied in conjunction with the MCA 2005 Code of Practice. It is anticipated that the implementation and practice of the MCA will change relative to developments in case law. Therefore, this policy should be read in conjunction with any MCA Guidance Notes and Documentation which will be posted by the MCA Steering Group on the Mersey Care website and issued to Service Managers as the Group deems appropriate to keep all staff aware of amendments to practice. The Guidance Notes and relevant Documentation will be incorporated into the MCA Policy at regular intervals to take account of the high level of amendments and case law decisions which are anticipated following the MCA’s implementation. This Policy and Procedure can be made available in different formats and languages. Please contact the policy’s authors for further information.

3.
3.1

Corporate Procedure
What is mental capacity?

Mental capacity is the ability to make a decision. The decisions may be wide ranging and have varying consequences. The decision may be one which affects daily life e.g. what to wear or one which has legal consequences e.g. making a will. People will require varying degrees of help when making or communicating a decision – this does not necessary mean they lack the capacity to make a decision. The key is the person’s ability to carry out the processes involved in making the decision and not the outcome. 3.2 Defining a ‘lack of capacity’

A person lacks capacity in relation to a matter if at the material time s/he is unable to make a decision for him/herself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain. 5

Assessment of Capacity – Policy and Procedure for Staff This means that a person lacks capacity if : They have an impairment or disturbance that affects the way their mind or brain works, And The impairment or disturbance means they are unable to make a specific decision at the time it needs to be made. (see MCA 2005 COP, paragraph.4.3, page 42) It does not matter whether the impairment or disturbance is permanent or temporary. A lack of capacity cannot be established merely by reference to: • • a person's age or appearance, or a condition, or an aspect of their behaviour, which might lead others to make unjustified assumptions about their capacity. (for examples see MCA 2005 COP, paragraphs 4.8 and 4.9 page 43) 3.3 What is an ‘Inability to make a decision’?

A person is unable to make a decision for him/herself if s/he is unable to: • • • to understand the information relevant to the decision, to retain that information in their mind, to use or weigh that information as part of the process of making the decision, or • communicate their decision (whether by talking, using sign language or any other means). (for more detail and examples of these four points see MCA 2005 COP, paragraphs 4.16 – 4.25 pages 46 – 49) To help a person understand the information relevant to the nature and consequences of a decision (including making no decision at all) the explanation of the information must be given to him/her in a way that is appropriate to their circumstances (using simple language, visual aids or any other means). The fact that a person is able to retain the information relevant to a decision for a short period only does not prevent him/her from being regarded as able to make the decision. Capacity is confirmed where a person is able to understand and retain information long enough to make an informed decision. The information relevant to a decision includes information about the reasonably foreseeable consequences of deciding one way or another, or failing to make the decision. The situation may arise when it is necessary to get a professional opinion when assessing a person’s capacity to make complex or major decisions. For example a person’s General Practitioner may be contacted for an opinion or the skills of a speech therapist may be sought if there are communication difficulties. 6

Assessment of Capacity – Policy and Procedure for Staff Further guidance and examples of when professional help should be sought are given in the MCA 2005 COP at paragraphs 4.51 – 4.54, pages 59 – 61. 3.4 When should capacity be assessed?

Nobody can be forced to undergo an assessment of capacity. Threats or attempts to force a person to agree to an assessment are unacceptable. In these circumstances it may help to explain to someone refusing an assessment why it is needed and what the consequences for refusal are. If the person lacks capacity top agree or refuse, the assessment can normally go ahead, as long as the person does not object orto the assessment, and it si in their best interests. Where there is doubt about a service user’s capacity to make a decision a capacity assessment should be carried out using the Trust’s Capacity Assessment Form (CAF). It is important that the person who does an assessment can justify their conclusions so the completion of a CAF is an important protection for them. The CAF is based on the nationally recognised CAF and following guidance from Hill Dickinson Solicitors. A hard copy of the CAF may be found in Appendix 1 of the Trust’s MCA Policy and Procedure for Staff (MC 01), e-Pex and PACIS. If a Service User’s capacity is in doubt Trust staff must ensure that a service user receives a formal capacity assessment in the following circumstances: If there is a dispute between staff and/or carers regarding a service user’s capacity A change of residence Significant medical intervention A decision with clear legal impact A restriction of free movement (including recurrent instances of physical restraint) If a service user’s finances are to be managed by others If the service user behaves in a manner which may be harmful to themselves or others This list is non-exhaustive. Trust staff must use their judgment about when a capacity assessment is justified. When considering whether to carry out a formal assessment of capacity, staff must consider the gravity of the issue in question, the person’s behaviour and if somebody else has raised concerns . In some instances the mental capacity of someone suffering from a mental impairment fluctuates. Where this is the case, Trust staff must ensure that a new capacity assessment is carried out. It must be remembered that the assessment of capacity is an ongoing process and the possibility that a person has regained capacity must always be considered. Where there has been no apparent fluctuation or change in mental state, Trust staff must ensure that all formal capacity assessments are reviewed on an annual basis. 7

Assessment of Capacity – Policy and Procedure for Staff The MCA 2005 COP, Chapter 3 gives a full description of how to deal with the question of when capacity should be assessed and suggests steps to help people make their own decisions. 3.5 Who should assess capacity?

The MCA 2005 COP states that the person who assesses an individual’s capacity to make a decision will usually be the person who is directly concerned with the individual at the time the decision needs to be made. So, for instance, in relation to nursing interventions it is the nurse who must carry out a capacity assessment whilst in relation to medical interventions it is the doctor who must carry out the assessment. Professionals may advise the person carrying out an intervention on behalf of someone who lacks capacity, but they cannot assume responsibility for the capacity assessment itself. For acts of care or treatment (MCA 2005 COP Chapter 6) the assessor must have a ‘reasonable belief’ that the person lacks capacity to agree to the action or decision to be taken. To have reasonable belief the assessor must have taken ‘reasonable’ to establish that the person lacks capacity to make a decision or consent to an act at the time the decision or consent is needed. The assessor must also establish that the decision is in the person’s best interests (see Chapter 5 MCA 2005 COP). The MCA 2005 COP paragraphs 4.44 – 4.45 give a full explanation of what steps are considered ‘reasonable’. In order to ensure that there is not undue inconsistency in the care delivered to service users, the following examples of best practice should be applied when Trust staff carry out capacity assessments: Where there is any doubt about the presence of capacity a referral must be made to a relevant professional. Assessment of capacity related to a significant medical intervention, must be made by the doctor who is responsible for prescribing the intervention. Assessments of capacity in relation to a decision where there is a significant legal dimension should be made with the assistance of a solicitor. . An individual claiming a person lacks capacity should be able to provide proof. Any question whether a person lacks capacity must be decided on the balance of probabilities. This means being able to show that it is more likely than not that the person lacks the capacity to make the decision in question.(see MCA COP 2005, paragraph 4.10, page 44).

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Assessment of Capacity – Policy and Procedure for Staff 3.6 Carrying out a capacity assessment

Whoever carries out an assessment of mental capacity must take reasonable steps to assess whether or not a person has capacity, and must decide whether there are reasonable grounds for believing that a person does not have capacity following an assessment. The MCA Code of Practice recognises that assessments of capacity will vary in sophistication according to the circumstances. Trust staff are required to apply normal clinical and professional standards in determining capacity. Before an assessment of capacity can commence, the staff carrying out the assessment must first formulate the question to which the assessment of capacity is intended to provide the answer. Staff carrying out the assessment must gather appropriate evidence to formulate a judgement about whether the service user lacks capacity in relation to the issue in question. This evidence should be documented on the CAF. 3.7 Additional factors for consideration when carrying out an assessment for capacity

A number of factors may affect capacity and should be taken account of, for example: A person’s mental capacity can fluctuate or be temporarily impaired due to mood or depression. In these circumstances, it may be possible to put off a decision until such time as the person has regained capacity. It is appropriate to incorporate a review date into the care plan. A person’s mental capacity may also vary or be temporarily impaired due to an underlying physical disorder e.g. urinary tract infection. A person may have the capacity to make some decisions but not others. A person’s capacity against the specific decision that needs to be made must be weighed up. For example, a person who cannot understand the financial issues around entering long term care might still have the capacity to make a choice about whether they want to go into long term care at all and, if so, which home. A lack of information. We need to make sure that any information relevant to the decision is provided in a format that the person can understand. Pressure. Carers or other family members may sometimes exert undue pressure when the person being cared for is actually capable of making their own decisions or where expert help may help them do so.

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Assessment of Capacity – Policy and Procedure for Staff A lack of trust. A person may feel anxious about dealing with staff from any other interested agency, so it must be ensured that they have access to independent support, advice or advocacy in these circumstances. 3.8 Disputes as to a finding of a lack of capacity

Where there is a dispute about the results of a capacity assessment between different members of Trust staff, or between Trust staff and relatives/significant others/advocates, or between Trust staff and a service user, or between relatives/ significant others/advocates and service users, the assistance of a psychiatrist or independent professional not directly associated with the care of the service user, must be sought.

If there is no resolution to the dispute following the intervention of the psychiatrist or an independent professional equivalent the dispute may need to be referred to the Court of Protection. The Court of Protection can rule on whether a person has capacity to make the decision covered by the assessment (see Chapter 8 MCA 2005 COP). In these circumstances, the relevant manager must seek legal advice from the Trust’s Legal Management Team. Chapter 15 of the MCA 2005 COP gives further suggestions for dealing with disputes.

4.
4.1

Development & Consultation Process
Consultation

This policy and procedure has been developed in conjunction with • • • • Mersey Care NHS Trust’s MCA Steering Group The associated MCA Training sub-group The Regional and National Advisory Groups re the implementation of the New Amended Mental Health Act1983 Bill The Regional and National Advisory Groups re the implementation of the Mental Capacity Act 2005

Once the Steering Group is satisfied with the policy and procedure it will be distributed to appropriate personnel within Mersey Care NHS Trust for consultation. 4.2 Training and Development

Training will be incorporated within existing mental health law training structures available to all staff across the Trust. The Local Authority has the lead for funding related training to help implementation of the MCA for both health and social care staff.

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Assessment of Capacity – Policy and Procedure for Staff 4.3 Impact Assessment

This policy and procedure is designed to be consistent with the Trust’s policy on Equality and Diversity and does not discriminate in its application. To this end this policy will be made available in a variety of formats on request, including languages to meet ethnic minority requirements, people with learning disabilities (these may include picture versions, large print format, braille versions, etc). 4.4 Review

It is provisionally proposed that this policy and procedure be reviewed 12 months from the date of ratification. As part of the review process patient equality data will be recorded. This is to enable a better understanding of minority groups who are affected by this policy. This will be done in conjunction with other MHA policies.

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Reference Documents
Mental Capacity Act 2005 Mental Capacity Act Code of Practice (draft) The MCA and the MCA Code of Practice may be accessed from the Department of Constitutional Affairs Website www.dca.gov.uk/legalpolicy/mental-capacity Adult Protection care reviews and Independent Mental Capacity Advocates (IMCA): Guidance on interpreting the regulations extending the IMCA role. See DH website www.dh.gov.uk/PublicationsAnd Statistics and/or www.dh.gov.uk/imca

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• • •

Bibliography
Mental Capacity Implementation Programme (Department for Constitutional Affairs/Department of Health, 2006) Mental Capacity Act 2005 Self Assessment Tool Action Plan Template (CSIP, 2006) Mental Capacity Act Manual First Edition (Richard Jones, 2005)

ACTION PLAN TO ENSURE SAFEGUARDS AGAINST ‘ACCESS NEGATIVE COMPLIANCE’ 1. 2. 3. 4. This policy is currently written in English only. However, as stated in both 4.3 of the Policy and 5.14 of the Impact Assessment above, this policy will be made available in the required media formats on request. Again, as stated, requests for the above can be made to the Policy Author. On receipt of such a request, and consistent with Trust policy, the Policy Author will access Language Line and order the required media format.

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Assessment of Capacity – Policy and Procedure for Staff RESOURCE IMPLICATIONS Language Line quote the rates for translation of this policy as follows:Media Format (as per 5.1-5.13 of the Impact Assessment Toolkit) Somali Chinese (Simple & Traditional) Kurdish (Sorani) Arabic Russian French Turkish Farsi Portuguese Romanian Braille British Sign Language (DVD) Audio Tape Video Tape Cost per 1000 words £120 £140 £160 £140 £120 £100 £140 £160 £120 £120 £30 per page per DVD per tape per Video Approx cost per translation £899.52 £1049.44 £1199.36 £1049.44 £899.52 £749.60 £1049.44 £1199.36 £899.52 £899.52 £900 £900 approx £500 approx £900 approx

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Assessment of Capacity – Policy and Procedure for Staff

POLICY IMPLEMENTATION PLAN

MENTAL CAPACITY ACT FOR STAFF POLICY AND PROCEDURE

POLICY NO RATIFYING COMMITTEE DATE RATIFIED NEXT REVIEW DATE

MC01 Clinical Governance Committee 14 October 2008 October 2009

ACCOUNTABLE DIRECTOR:

David Fearnley (Medical Director & Deputy Chief Executive)

POLICY AUTHORS:

Barry Judge (Trust Legal Adviser) Jim Wiseman (MHA Legislation Practitioner)

An implementation plan should be completed for all policies. This will ensure that a systematic approach is taken to the introduction of policies in order to secure effective working practices.

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Assessment of Capacity – Policy and Procedure for Staff
Issues identified / Action to be Time-Scale taken The policy will be made available to November all staff via the Trust website. 2008 All modern matrons, CHMT Managers, Service Managers, Clinical Director, Medical Director and Ward Managers will be sent a copy of the policy for dissemination. All staff, carers and service users. N/A The Trust-wide risk committee has October reviewed the policy, which is a multi- 2008 professional group of staff. Yes. A process of consultation between service users, carers and Directorate Leads is in place and will be utilised. Service Users: Clarification of statutory rights Staff: Awareness that neglect or abuse of service users with mental incapacity is a criminal offence. To benefit from the protections offered by the MCA 2005 (s.5) there is a need for comprehensive, well documented, timely and on-going mental capacity assessments Advocates: Need to be aware of the IMCA role and its implications/limitations. To be aware of the MCA 2005 and MCA 2005 Code of Practice To be aware of the Trust’s overarching MCA Policy, its associated Policies and access to Capacity Assessment Forms.

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Co-ordination of implementation How will the implementation plan be co-ordinated and by whom?

• •

Engaging staff Who is affected by the policy? Are the most influential staff involved in the implementation?

Involving service users / carers • Is there a need to provide information to service users and carers regarding this policy? Communicating • What are the key messages to communicate to the different stakeholders?

Ongoing

Ongoing

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Training What are the training needs related to this policy?

Ongoing since 2005

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Resources Are other resources required to enable the implementation of the policy eg. increased staffing, new documentation? Securing and sustaining change Have the likely barriers to change and realistic ways to overcome them been identified? Evaluating What are the main changes in practice that should be seen from the policy?

N/A
Not at present.

Yes

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October 2008

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Increased safeguards for service N/A users lacking capacity. Necessity for improved documenting of the assessment of capacity.

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Assessment of Capacity – Policy and Procedure for Staff Stage 1

Equality impact assessment Screening Checklist Function, policy or procedure Title: Policy and Procedure For Staff Assessment of Capacity Name of people auditing / authoring policy: ( minimum of 3) George Sullivan(Equality and Human Rights Advisor) Joanne Wharton( Advocacy) Service User and Carer Representative Helen Harding (Advocate) Policy Content:
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Directorate: Trust Policy

For each of the following checks is this policy sensitive to people of different age, ethnicity, gender, disability, religion or belief, and sexual orientation? The checklists below will help you to see any strengths and / or highlight improvements required to ensure that the policy / procedure is compliant with equality legislation.

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1. Check for DIRECT discrimination against any minority group of SERVICE USERS: Action Resource Question: Does your policy contain any statements Response required implication which may exclude people from using the services who otherwise meet the criteria under the grounds of: 1.0 Age? 1.1 Gender (Male, Female and Transsexual/Transgender)? 1.2 Learning Difficulties / Disability or Cognitive Impairment? 1.3 Mental Health Need? 1.4 Sensory Impairment? 1.5 Physical Disability? 1.6 Race or Ethnicity? 1.7 Religious, Spiritual belief (including other belief)? 1.8 Sexual Orientation? Yes No Yes No Yes No

√ √ √ √ √ √ √ √ √

If yes is answered to any of the above items the policy may be considered discriminatory and requires review and further work to ensure compliance with legislation. 15

Assessment of Capacity – Policy and Procedure for Staff

2. Check for DIRECT discrimination against any minority group relating to EMPLOYEES: Action Question: Does your policy contain any statements Response required which may exclude employees from operating the under the grounds of: 2.0 Age? 2.1 Gender (Male, Female and Transsexual/Transgender)? 2.2 Learning Difficulties / Disability or Cognitive Impairment? 2.3 Mental Health Need? 2.4 Sensory Impairment? 2.5 Physical Disability? 2.6 Race or Ethnicity? 2.7 Religious, Spiritual belief (including other belief)? 2.8 Sexual Orientation? Yes No Yes No

Resource implication Yes No

√ √ √ √ √ √ √ √ √

If yes is answered to any of the above items the policy may be considered discriminatory and requires review and further work to ensure compliance with legislation. Number of YES answers for Direct Discrimination = 0 3. Check for INDIRECT discrimination against any minority group of SERVICE USERS: Action Resource Question: Does your policy contain any conditions Response required implication or requirements which are applied equally to everyone, but disadvantage particular persons’ because they cannot comply due to: 3.0 Age? 3.1 Gender (Male, Female and Transsexual/Transgender)? 3.2 Learning Difficulties / Disability or Cognitive Impairment? 3.3 Mental Health Need? 3.4 Sensory Impairment? 3.5 Physical Disability? 3.6 Race or Ethnicity? 3.7 Religious, Spiritual belief (including other belief)? 3.8 Sexual Orientation? Yes No Yes No Yes No

√ √ √ √ √ √ √ √ √

If yes is answered to any of the above items the policy may be considered discriminatory and requires review and further work to ensure compliance with legislation.

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Assessment of Capacity – Policy and Procedure for Staff 4. Check for INDIRECT discrimination against any minority group relating to EMPLOYEES: Action Resource Question: Does your policy contain any statements Response required implication which may exclude employees from operating the under the grounds of: 4.0 Age? 4.1 Gender (Male, Female and Transsexual/Transgender)? 4.2 Learning Difficulties / Disability or Cognitive Impairment? 4.3 Mental Health Need? 4.4 Sensory Impairment? 4.5 Physical Disability? 4.6 Race or Ethnicity? 4.7 Religious, Spiritual belief (including other belief)? 4.8 Sexual Orientation? Yes No Yes No Yes No

√ √ √ √ √ √ √ √ √

If yes is answered to any of the above items the policy may be considered discriminatory and requires review and further work to ensure compliance with legislation. Number of NO answers for Indirect Discrimination =0 5. Check for ACCESS discrimination Question: Are policies / procedures available in the following languages: Current top 5 languages requested within Mersey Care are: 5.0 English 5.1 Mandarin 5.2 Kurdish 5.3 Czech (Czechoslovakian) 5.4 German 5.5 Arabic 5.6 Other (as requested) Response Yes No Action required Yes No Resource implication Yes No

√ √ √ √ √ √ √ √ √ √ √ √ √

√ √ √ √ √ √ √

Question: Are policies / procedures available in the following mediums: 5.7 5.8 5.9 5.10 Easy Read Format British Sign Language Braille Audio Tape /Video Tape

Response Yes No

Action required Yes No

Resource implication Yes No

√ √ √ √

√ √ √ √

√ √ √ √
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5.11

5.12

Assessment of Capacity – Policy and Procedure for Staff √ √ Statement included acknowledging interpretation services and availability of other mediums as requested. Do you know the procedure within Mersey √ Care to obtain/request translated information?

√

Number of No answers for access =10

Equality and Diversity Compliance / Percentage Calculation Number of ‘Yes’ answers for DIRECT discrimination. Number of ‘Yes’ for INDIRECT discrimination. Total answers for POLICY CONTENTS discrimination. Percentage content negative compliance. (A)0 (B)0 (A+B)0% (A+B )÷ 36 = C C x 100 = %

Total =0% Total No for access compliance Percentage access negative compliance. 10 Number of Yes ÷ 12 Answer x 100 = %

Total =83% Outcome √ Compliant Non compliant-- Immediate actions taken Non compliant-- Full impact assessment required 18

Assessment of Capacity – Policy and Procedure for Staff Signatures of authors / auditors: George Sullivan, Joanne Wharton, Helen Harding

Date of signing 23 September -2008

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