Consent to Care

Consent is the difference between care and something done to a person. In day-to-day support it is mostly informal and continuous: "Shall we get you washed now, or after your tea?" — the person's yes, their outstretched arm, their nod. That everyday quality can make it feel trivial. It isn't. Touching someone without consent, moving them, medicating them, even entering their room, engages their most basic rights.

Real consent has three ingredients: the person knows what they are agreeing to (informed), they are free to say no (voluntary), and they are able to make this decision (capacity). Take away any ingredient and what remains is compliance, not consent. A person who stops resisting because resisting never works has not consented to anything.

Refusals are where practice gets tested. A person with capacity is entitled to refuse care that professionals think they need — creams, hoisting, food, hospital. The task is not to override or to walk away, but to respect the refusal, understand it, reduce its risks, keep offering, and record honestly.

• Regulation 11 (2014 Regulations): care and treatment only with the consent of the relevant person, or otherwise lawfully under the MCA 2005.
• Common law: touching a person without consent can be unlawful, however well-meant.
• MCA 2005: capacity is presumed; where it is lacking for the decision, section 5 allows care in best interests; section 6 limits restraint.
• Health and welfare LPAs and court deputies can make certain decisions for a person without capacity — check the document's scope; property-and-affairs LPAs give no say over care.
• Advance decisions to refuse treatment (MCA ss.24–26) bind future treatment refusals if valid and applicable.
• Informed consent standard: since Montgomery (2015), people must be told about material risks and reasonable alternatives in terms that matter to them.

CQC looks for consent as lived practice: staff asking and explaining naturally, consent recorded for key elements of the plan, capacity assessed where doubt exists, and legal authority checked rather than assumed — inspectors regularly find "next of kin consented" on files where no LPA exists, which is a Regulation 11 breach, not a courtesy. They also look at how refusals are handled: respected and recorded, revisited kindly, and escalated (capacity review, GP, family, safeguarding) when the risk grows.

• Ask every time. Yesterday's yes was for yesterday. Consent to "personal care" in a plan never replaces asking this morning.
• Explain in the person's terms what you're proposing, why, and any real alternatives — then genuinely accept the answer.
• Learn each person's yes and no: words, gestures, expressions, body tension. Record them in the communication section of the plan so new staff know too.
• Treat resistance during care as withdrawal of consent: pause, reassure, re-offer later. "We pushed on because it needed doing" is a phrase that should worry everyone.
• Verify authority: ask to see LPAs or deputyship orders and file copies; note exactly what they cover.
• Record refusals factually with the person's reasons, what you did to reduce risk, and who you informed. Patterns of refusal deserve review, not resignation.
• Never trade consent for something the person wants — "you can have your cigarette after your shower" is coercion in a lanyard.

Example 1. A man with capacity and diabetic foot ulcers refuses district nurse dressings for the third day. His care workers don't nag or bypass him. They ask what's behind it — the dressings hurt and the visits clash with his favourite radio programme. The coordinator arranges analgesia before dressing changes and a later slot. He consents. Most "non-compliance" is a problem with the offer, not the person.

Example 2. A daughter instructs a care home to give her mother, who lacks capacity for care decisions, no sugar "because she'd hate being overweight". Staff check: the daughter holds a property and affairs LPA only. Her view is heard as part of best interests — but the record shows her mother's lifelong love of cake, and the plan keeps pudding on the menu. The decision is made under the MCA, in the mother's interests, not under an instruction nobody had authority to give.