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1
Mental Capacity Assessment
Please refer to the associated guidance document (page 4-8) and/or chapters 2, 3 and 4 of the Mental Capacity
Act (MCA) Code of Practice before undertaking an assessment
Name of adult: Mrs R
Date of Birth:
Person’s first language:
French but speaks good English
NHS number:
Name of Assessors: Laura Dunn and Tom Curtis
Job title / role: Student physiotherapist and physiotherapist
Date(s) and time(s) of assessment: 25/11/16 15:00 02/12/16 14:45
Section 1: The decision in question
Describe the decision that the person is making:
A decision as to the most appropriate discharge destination from hospital because Chorlton Place,
her previous place of residence, report they are unable to cope with her needs.
Section 2: People consulted
Mrs R’s daughter.
Section 3: Supportgiven to make the decision /maximise capacity
The MCA Code of Practice states that the level of support depends on personal circumstances, the type of decision to be
made and the time available to make the decision.
The following sections (including the two-stage test) should only be undertaken once all practicable support to help the
person make the decision has failed – in that there is still doubt about the person’s ability to make the decision. (Code of
Practice 4.13).
Discussion took place in a quiet and distraction free environment. Information was clear and simple ensuring Mrs R could
hear. Mrs R was able to repeat some words when speaking to her showing she could hear.
Section 4: The diagnostic testof capacity (stage one)
Does the person have
an impairment of, or
disturbance in the
functioning of their
mind or brain?
E.g. delirium,confusion,
dementia,stroke,autism.
Yes No
If no, the person can be deemed to have capacity and you should proceed to the conclusion
section.
If yes, describe the nature of the impairment, e.g. a brief summary of the diagnosis, the source
of any information and how the diagnosis might impact on decision making:
Mrs R has a diagnosis of vascular dementia. Diagnosed approximately 4 years
ago- reported by daughters 08/12/16.
Mrs R presents as confused.

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2
Additional information
relating to the
impairment
The impairment is:
Permanent Temporary Fluctuating
Please provide details:
If the impairment is fluctuating or temporary would it be appropriate to delay the assessment?
Yes No
If yes, go to the conclusion section.
Section 5: Additionalfactors beyondthe skills of the person
Are there any other factors beyond the cognitive and communication skills of the individual
that you believe are affecting the person’s ability to make a free and balanced decision?
This may include internal factors like low mood or external influences such as coercion or threats from others. The
influence of any factors identified must also be considered as part of your decision-making in the next section (6)
None identified at time of assessment
In some instances you mightalso need to trigger safeguarding procedures ifthere is a concern that a person is at risk.
Section 6: The functionaltest of capacity (stage two) see guidance page 7
Do you consider the
person able to
understand the
information relevant to
the decision?
This includes the person’s
understanding ofhow the
decision arose and the
options available to them
Yes No
Evidence: E.g. the questions you asked and the responses given
(see associated guidance for more detail)
25/11/16
Explained to Mrs R that, prior to admission to hospital,she was living in Chorlton Place care home and
consideration has been given to her moving to a different home.Mrs R was unable to recall this
information and when asked whatwe had spoken aboutreplied "its hard".
02/12/16
Mrs R was asked where she was living prior to admission to hospital.Mrs R was unable to answer and
looked at daughter for the answer.
I explained to Mrs R that she was living in a nursing home called Chorlton place butthey are unable to
accommodate her needs so need to look for somewhere else. Iasked her to summarise this information
but she was unable to.
Mrs R was asked where she wantto go after discharge from hospital.Mrs R mentioned she wants her
own place.
Mrs R was asked do you think you could manage living in your own place. Mrs R reported she would try to
manage.
Whilstspeaking to Mrs R she was able to repeatwords as I was talking to her but when asked to
summarise information she was unable to.
I explained again to Mrs R that she was living in a nursing home prior to admission butthey are unable to
accommodate her needs so we need to find somewhere else for her to live. I asked her if she could
summarise this information butshe was unable to and proceeded to talk aboutgetting her own place.
Do you consider the
person able to retain the
information relevant to
the decision?
The question ofhow long a
person need retain
information will vary as they
need only remember salient
information long enough to
make an effective decision.
Yes No
I explained a second time to Mrs R that prior to admission she was living in a care home called Chorlton
Place but they are unable to accommodate needs so need to look for somewhere else to live. I asked he r
to summarise this information Mrs R reported we were talking abouttrying to get a place of her own.
Mrs R is unable to retain information even for shortperiods oftime.
Do you consider the
person able to use or
weigh up the
information as part of the
Yes No

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3
decision making
process?
See previous sections- understand and retain.
Do you consider the
person able to
communicate their
decision?
Yes No
Yes, Mrs R can verbalise her decision
If you have answered yes to all of the questions in section 6 then the person is considered to
have capacity about this specific decision at this time.
If you have answered no to any of the questions in section 6 then the person does not have
the capacity to make this specific decision at this time.
The influence of any factors identified in section 5 (additional factors) should also be
considered as part of your conclusion.
Section 7: Conclusion(please tick ONE)
I consider that the person has the capacity to make the decision.
* You should be able to show that, on the balance of probabilities,thatthe person has capacity.
The decision that the person has made is recorded below:
I consider that the person does not have the capacity to make the decision.
* You should be able to show that, on the balance of probabilities,thatthe person lacks capacity.
A best interest’s decision must now be made and the appropriate documentation completed.
I consider that it is appropriate to delay this assessment until such time that the
person is better able to demonstrate their capacity.
Explain your reason(s) below:
For on-going decisions it will usually be important to review the person’s capacity given that capacity
is rarely static and can improve or decline.
Where this applies, please indicate when the assessment should be reviewed below:
This assessment is valid for the decision indicated at the time of completion.
Signature of assessor: Laura Dunn
Tom Curtis (HCPC Number PH60532 )
Based at: Ward 2, Trafford General Hospital. Date: 02/12/16
Contact phone number: 0161 746 2183 Email address:

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