MENTAL CAPACITY ASSESSMENT

The Mental Capacity Act’s first principle is that the individual must be assumed to have capacity to make a decision or act for themselves unless it is established that they lack capacity in relation
to those matters.
Name:

Date of Birth:

Location at the time of the Assessment:

Decision Requiring Assessment of Mental Capacity
(A separate mental capacity assessment is required for all decisions that may need to be made)

Stage 1 - Determining Impairment or Disturbance of the Mind or Brain (See Code of Practice Chapter 4)
Every adult should be assumed to have the capacity to make a decision unless it is proved that they lack capacity. An assumption about someone’s capacity cannot be made merely on the basis of an
individual’s age or appearance, condition or aspect of his or her behaviour
1. Does the individual have an impairment of the mind or brain, or is there some X Yes (if yes, provide details
sort of disturbance affecting the way their mind or brain works?
(It doesn’t matter whether the impairment or disturbance is temporary or permanent - o No
provide evidence)

If you have answered Yes, proceed to Stage 2

If you have answered No, there is no such impairment or disturbance and thus the individual DOES NOT LACK CAPACITY within the meaning of the Mental Capacity Act 2005.
Sign below and file the assessment, there is no need to proceed any further.
Signature of Assessor: Date of Assessment:

Stage 2 – Assessment
Having determined impairment or disturbance (stage 1) you now need to complete the assessment and form your opinion as to whether the impairment or disturbance is sufficient that the individual
lacks capacity to make this particular decision at this moment in time.

SUPPLEMENTARY FILE – MENTAL CAPACITY ASSESSMENT

 Four Stage Test Respons Provide evidence in respect of the individual’s ability, in relation to each of the four elements of the
Answer the following questions, can the Individual: e test: (give detailed rationale)
Yes
1. Understand the information relevant to the decision?
No
Yes
2. Retain that information?
No
3. Use or weigh that information as part of the process of making Yes
decisions? No
4. Communicate their decision? Yes
(whether verbally or any other means) No
If the individual cannot do one or more of these four elements, they are unable to make the decision
Outcome of Mental Capacity Assessment

On the balance of probabilities, there is a reasonable belief that: Prompts:

o The individual has capacity to make this particular decision at this time  Best Interest Decision required - if the Individual does not have capacity

The individual does not have capacity to make this particular decision at this time
Signature of Assessor: Date:

Name & Designation:

The mental capacity assessment will need to be reviewed if there is a change in the individual’s condition which may result in a different outcome. If this is the case a new capacity
assessment should be completed. An individual capacity assessment will be required for all specific decisions.

SUPPLEMENTARY FILE – MENTAL CAPACITY ASSESSMENT