Mental Capacity, Consent and Best Interests Governance in Dementia Services
In dementia services, governance of mental capacity and consent is fundamental to protecting people’s rights while managing risk. Cognitive impairment means that capacity can fluctuate, decisions are complex, and restrictive practices can easily become normalised without strong oversight.
This article sits within Dementia – Quality, Safety & Governance and links closely with Dementia – Service Models & Care Pathways, as capacity governance must reflect how and where dementia support is delivered.
Why MCA governance is critical in dementia services
Mental Capacity Act (MCA) governance ensures that:
- Decisions are lawful and person-centred.
- Restrictions are justified and proportionate.
- Best interests processes are robust.
- People are supported to make decisions wherever possible.
Without governance, capacity assessments can become inconsistent and best interests decisions poorly evidenced.
Regulator / CQC expectation: lawful decision-making
Regulator / Inspector expectation (CQC): CQC expects providers to demonstrate clear MCA governance, including:
- Decision-specific capacity assessments.
- Properly documented best interests decisions.
- Evidence of least restrictive practice.
- Regular review of restrictions.
Commissioner expectation: rights-based assurance
Commissioner expectation: commissioners expect providers to evidence that people’s rights are upheld, particularly where dementia affects capacity, and that restrictions are monitored and reduced wherever possible.
Operational Example 1: Governance of fluctuating capacity
Context: A domiciliary care provider supported people with early to mid-stage dementia whose capacity varied day to day.
Support approach: MCA governance processes were adapted to reflect fluctuation.
Day-to-day delivery detail:
- Decision-specific assessments completed regularly.
- Staff trained to recognise changes in capacity.
- Care plans updated dynamically.
How effectiveness is evidenced: Improved decision-making consistency and positive inspection feedback.
Operational Example 2: Best interests governance in residential care
Context: A care home struggled to evidence best interests decisions around personal care refusals.
Support approach: Best interests governance was strengthened.
Day-to-day delivery detail:
- Structured best interests meetings introduced.
- Family and professional involvement recorded.
- Decisions reviewed regularly.
How effectiveness is evidenced: Reduced complaints and clearer audit trails.
Operational Example 3: Restrictive practice oversight
Context: A supported living service used covert medication for a person with advanced dementia.
Support approach: Governance focused on restriction oversight.
Day-to-day delivery detail:
- Best interests decisions formally recorded.
- Regular multi-disciplinary reviews held.
- Plans developed to reduce restriction.
How effectiveness is evidenced: Clear justification, regular review and improved commissioner confidence.
Embedding MCA governance into quality systems
Strong MCA governance in dementia services relies on:
- Leadership oversight.
- Staff competence and confidence.
- Audit and review mechanisms.
- Clear documentation standards.
When embedded effectively, MCA governance protects rights while enabling safe, person-centred dementia care.