Consent and mental capacity procedure checklist

Source anchors

How to use this checklist

Use this checklist to audit whether consent and mental capacity decisions leave a clear, lawful evidence trail. It can be used quarterly, after a consent incident, after a complaint, after a safeguarding concern, before governance review, or before an inspection-readiness review.

This checklist is not only about signed forms. It checks whether the person was supported to decide, whether information was understandable, whether refusal was respected, and whether best-interests decisions were properly reasoned.

For each row, record:

Met: evidence is current and complete.
Part met: evidence exists but has a gap or needs follow-up.
Not met: evidence is absent or the control is not working.
Not applicable: the service does not carry out this activity.

Every Part met or Not met item should create an action with an owner and due date.

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Service details

Field	Local entry
Service name
Location
Date completed
Completed by
Registered Manager
Clinical Lead or Care Lead
MCA Lead, where used
Period reviewed

1. Consent process and information

Check	Evidence to review	Status	Action owner	Due date
Staff know when consent is required.	Staff interview, induction record.
Consent information explains the proposed care or treatment, risks and alternatives where relevant.	Leaflet, consent template, record sample.
Information is provided in a way the person can understand.	Accessible format record, communication note.
Consent is voluntary and free from pressure.	Record sample, staff interview.
Consent is reviewed when care, treatment, risk or wishes change.	Review note, care plan.
Higher-risk procedures have suitable written or structured consent records.	Consent form, clinical record.

2. Capacity assessment

Check	Evidence to review	Status	Action owner	Due date
Capacity is presumed unless there is evidence to question it.	Record sample, staff interview.
Capacity assessments are decision-specific and time-specific.	Capacity assessment sample.
The person is supported to decide before capacity is judged absent.	Support record, communication note.
The two-stage capacity test is recorded with reasoning.	Capacity assessment sample.
Unwise decisions are not treated as lack of capacity.	Refusal record, supervision note.
Capacity assessments are reviewed where the decision or person's condition changes.	Review record.

3. Refusal, withdrawal and safeguarding

Check	Evidence to review	Status	Action owner	Due date
Refusal or withdrawal is respected where the person has capacity.	Refusal record.
Consequences and alternatives are explained and recorded.	Record sample.
Safeguarding, coercion or undue influence is considered where refusal appears concerning.	Safeguarding decision note.
Staff know how to stop or pause care safely where consent is withdrawn.	Staff interview, procedure.
Repeated refusal triggers review of risk, communication or care planning.	Care plan review, risk assessment.
Complaints or incidents about consent are linked to learning actions.	Incident or complaint sample.

4. Best interests and lawful authority

Check	Evidence to review	Status	Action owner	Due date
Best-interests records show the decision, options and reasoning.	Best-interests record sample.
The person's wishes, feelings, beliefs and values are considered.	Record sample.
Relevant people are consulted where appropriate.	Consultation note.
Less restrictive options are considered.	Best-interests record.
Attorney, deputy, advance-decision or IMCA routes are checked where relevant.	LPA, deputy, advance-decision or IMCA evidence.
Legal or safeguarding advice is sought for complex or contested decisions.	Advice note, escalation record.

5. Training and staff competence

Check	Evidence to review	Status	Action owner	Due date
Staff taking consent have role-appropriate training.	Training matrix.
Staff who assess capacity are competent for the task.	Competence record, supervision note.
MCA Lead or named adviser is available where the service needs one.	Role list, procedure.
Staff know when to escalate consent, refusal or capacity concerns.	Staff interview, escalation route.
Consent and MCA learning from incidents or complaints is shared.	Team briefing, supervision note.
Consent templates and staff guidance are reviewed against current guidance.	Template review, governance minutes.

6. Audit and governance

Check	Evidence to review	Status	Action owner	Due date
Consent audit runs at a stated cadence.	Audit schedule, completed audit.
Capacity and best-interests records are sampled where relevant.	MCA audit sample.
Audit actions have owners, due dates and completion evidence.	Action log, improvement actions.
Consent or MCA risks are added to the risk register where needed.	Risk register, governance minutes.
Registered Manager reviews overdue consent or MCA actions.	Governance minutes, dashboard.
Learning links to training, supervision, safeguarding and record keeping.	Linked records, action evidence.

7. Summary judgement

Question	Answer
Which consent or capacity decision has the weakest evidence trail?
Which service activity carries the highest consent risk?
Which refusal, withdrawal or best-interests decision needs review?
Which consent or MCA action is overdue?
What would a CQC inspector see if they asked for consent evidence today?

8. Action log

Action	Source check	Owner	Due date	Completion evidence

9. Completion

Sign-off	Name	Date
Completed by
Reviewed by Registered Manager

This checklist is a working tool. It does not replace live regulator guidance, legal advice, professional standards, safeguarding advice, advocacy advice or clinical judgement.