Mental Capacity Act 2005

The Mental Capacity Act answers one of the hardest questions in care: what do we do when someone may not be able to make a decision for themselves? Its answer is humane and demanding — start by assuming they can, help them as much as possible, and only step in when a proper test says you must, doing the least restrictive thing that works.

The Act protects people from two opposite failures. The first is neglect dressed up as respect: "it's her choice" used to walk away from someone who genuinely cannot weigh a decision. The second is control dressed up as kindness: taking decisions away from someone because their choices worry us. The two-stage test is how you steer between them, decision by decision.

It matters every day, in small decisions as much as big ones: what to wear, whether to have a shower now, whether to see the GP, how money is spent, where to live. Most capacity assessments in care are not formal events with forms — they are moments where a worker checks understanding, supports the decision, and records what happened.

The five statutory principles (section 1):

• A person must be assumed to have capacity unless it is established they lack it.
• All practicable steps to help them decide must be taken first.
• An unwise decision does not by itself mean a lack of capacity.
• Acts and decisions for a person lacking capacity must be in their best interests.
• Choose the option least restrictive of rights and freedom that still achieves the purpose.

The two-stage test (sections 2–3): first, is there an impairment or disturbance of the mind or brain (permanent or temporary)? Second, because of it, can the person not understand, retain, use or weigh the relevant information, or communicate their decision by any means?

Best interests (section 4): involve the person, consider their past and present wishes, feelings, beliefs and values, consult family, carers, attorneys and deputies, and don't make assumptions from age, appearance or condition.

Also in the Act: section 5 protection for care given in a person's best interests; section 6 limits on restraint (necessary and proportionate); Lasting Powers of Attorney; Court of Protection deputies; advance decisions to refuse treatment; IMCAs for people with no one to consult facing serious decisions; and the section 44 offence of ill-treatment or wilful neglect. The MCA Code of Practice (2007) remains the statutory guidance; staff have a duty to have regard to it.

Liberty: where care arrangements may deprive a person of liberty, an authorisation is needed — see the DoLS and LPS topic, including the important June 2026 Supreme Court ruling on what counts as a deprivation of liberty.

Consent is a fundamental standard (Regulation 11), and CQC expects the MCA to be visibly alive in the service: staff who can explain the principles in their own words, capacity assessments that are decision-specific rather than blanket statements, best-interests decisions with the right people involved and recorded reasoning, and the least restrictive thinking evidenced — especially around locked doors, sensors, bed rails and covert medication.

Classic findings CQC criticises: "lacks capacity" written in a care plan with no decision named; relatives signing consent forms with no legal authority to do so; blanket restrictions applied to everyone regardless of individual assessment. Each is fixable with better habits and better records.

• Name the decision. Every assessment starts "capacity to decide X on [date]" — never "capacity" in general.
• Stack the deck in the person's favour: best time of day, familiar setting, short sentences, pictures, a trusted person present, glasses on and hearing aids working.
• Record the four abilities separately — understand, retain, use and weigh, communicate — with what you actually observed.
• Check the paperwork reality: is there a health and welfare LPA? A property and affairs LPA? A deputy? An advance decision? These change who decides.
• For best-interests decisions, write down who was consulted, what the person's own wishes were, options considered, and why the chosen one is least restrictive.
• Reassess when things change — capacity fluctuates with infection, delirium, medication and time of day. If the decision can wait until the person can make it, wait.
• Try this site's MCA two-stage walkthrough to practise the sequence.

Example 1. A man with a learning disability wants to spend most of his weekly money on football stickers, again. His support worker's first instinct is to stop him. Instead she checks: he understands what money is left, knows it means no cinema this week, accepts that, and is delighted with his choice. That is an unwise-looking decision made with capacity — his to make. She records the conversation and lets him enjoy the stickers.

Example 2. A woman with advanced dementia refuses personal care every morning, and is becoming sore. Staff assess her capacity to decide about personal care: with the best support they can offer she cannot retain or weigh the information, linked to her dementia. A best-interests meeting involves her daughter (who holds a health and welfare LPA) and considers her lifelong preference for baths over showers and for female carers. The plan changes to a female carer offering a bath after breakfast, when she is calmest — refusals drop sharply. Least restrictive, personal, recorded.