Care starts with consent.

That is an easy principle to understand and one that Managers and Providers are fully on board with. It runs centrally through our work, every day.

Capacity is not a new concept, given that the Mental Capacity Act has been around for a good while. (Let’s leave the LPS out of the equation for now.)

Best Interests and basing actions and decisions on the concept of Best Interests is quite an easy concept.

What happens then, when Health and Social Care colleagues mix this up, blend it together and misquote the whole thing.

There is nothing that our Team at the Care Guys like more than when someone with no clue starts quoting buzz words from this set of phrases. We love it. It amuses no end and then we start correcting it and fighting back. Eggs and faces.

A Case Study

I like this particular example of Nursing Nonsense and it is a good demonstration of a Professional Team and their absolute lack of understanding.

Picture a frail older lady living in a residential care home. She has a nice bedroom, with an en-suite and it is lovely and personalized. This lady I shall call Flo which is obviously not her real name.

Flo has insulin-controlled type 2 diabetes and has no impairment of the functioning of her mind or brain. She has capacity around her care and accommodation. She has capacity in all areas of her life. She understands her diabetes and the management of it.

Flo shakes somewhat when eating. She is a little nervous and is particularly conscious of spilling food on herself. She is also particular about the temperature, texture and consistency of her meals. She knows what she likes and doesn’t like.

Flo has 2 visits per day from the District Nurses to administer her insulin.

Flo does not like to be observed eating and is a private person. She is not a choking risk and can eat independently. She takes meals in her room.

Flo is losing a little bit of weight. Nothing drastic but over a period of a couple of weeks is losing. She also requests sandwiches or cheese on toast instead of meals. She is often visited at mealtimes by well-meaning family members, who sit and watch her eat. We can term this as support, but in reality, it is not helpful.

Family members are also therefore around when the DN’s pop in. There is then some collaboration and allegation made that the care home, over a 13 day period, are only feeding this lady sandwiches. This care home must be rubbish.

The lead DN for the home then gallops along on her high horse, organises a nursing checklist and determines that Flo is now a nursing resident and has to move.

“The home are not acting in her best interests and cannot meet her needs”. This comes with a direct instruction for us to sit and feed Flo every mealtime as this would be in her Best Interests in the collective wisdom of the nurses and family.  

Stop right there. Flo has capacity. This is not borderline, nor fluctuating and she doesn’t have good days and bad days. She has capacity. End of story.

Our response was to check our facts. We sit with Flo and talk through the concerns around food and diet and the impact on diabetes management. Flo is adamant that she is a private person, chooses to eat what she wants to eat, is given it and is happy. She understands the health management and says that she is nervous about being observed and does not want that to happen. She is mortified at the thought of being fed by a carer. She is aware that this assistance is on offer and that she only has to ask.

As a Manager, you could agree with the family and the nurses and update your care plan to reflect the clinical instruction which echoes family wishes also. You could agree that Flo needs nursing care, of sufficient duration and frequency to mean that a Nursing setting is required.  

Or, you could confirm that Flo has capacity around the decision of what to eat and the management of her blood sugar levels, record this together with her wishes and tell the clinicians to reconsider. You cannot make a BI decision on behalf of someone who has the capacity to make the decision themselves. You cannot ignore a person’s wishes and consent because you think you know better or simply because you have a PIN.

Buzz words and their usage does not mean good care. In this case it meant potentially ignoring Flo’s wishes entirely.

Remember that the Mental Capacity Act clearly states that people with capacity can make poor choices. We also assume capacity.

In a similar vein, I was once present when a Community Matron stood in the middle of a lounge in my residential dementia home and made a sweeping hand gesture whilst shouting “Do this lot have capacity?”.

Really. That really did happen.

My response was to ask her what decision she was asking in relation to and which resident. A capacity assessment is decision specific. Not generic to the person or the service.

These are basic examples, and the MCA is a complex bit of legislation and practice that Registered Managers and Providers often struggle to implement. We often see Managers being bullied into actions that are inappropriate, sometimes by family and sometimes by social workers.

I recently went “head to head” with a social worker around a capacity assessment for care and accommodation. I won.

DOLS are another aspect of the MCA that people really struggle with. Does someone need to be trying to escape or actively refusing the placement in order to require a DOLS application?

What happens when DOLS are not processed by the Local Authority in a timely manner?

Why are we seeing Sec 21A challenges all over the place?

Support

If you need support around MCA, capacity, consent and DOLS then please contact us. This is just one area where the Care Guys can support you via a low fixed monthly cost.