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.

Sections 1 to 5 apply across service types. Sections 6 and 7 are an additional care-home DoLS module. Hospitals should adapt that module to their own managing-authority and clinical-governance arrangements. Section 8 checks that services outside a care home or hospital use the correct court or legal route instead of treating DoLS as a general authorisation. Mark a genuinely out-of-scope row Not applicable, but record why.

The legal definition of deprivation of liberty changed on 2 June 2026. The checklist tests the current multifactorial approach and must not be completed using the former Cheshire West single "acid test" alone. Where the facts or legal route remain uncertain, record the uncertainty and obtain supervisory-body or legal advice.

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.

The PDF is designed for printing, or for completing on screen with a PDF viewer's Fill & Sign, Markup or comment tools. Use those tools to tick boxes and type into the lines.

Service details

Field	Local entry
Service name
Location
Date completed
Completed by
Registered Manager
Clinical Lead or Care Lead
MCA and DoLS Lead, where used
Service type and care-home status
Supervisory body, where applicable
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. Restrictions and least restrictive care

Check	Evidence to review	Status	Action owner	Due date
Material restrictions are individually identified rather than hidden inside routine care.	Restriction register, care-plan sample, observation.
Each restriction has a clear purpose, lawful basis, named owner and review date.	Restriction record, care plan, legal-authority record.
The person's wishes, feelings, communication and response to the restriction are recorded.	Daily notes, communication plan, review record.
Less restrictive options are considered and the reasoning is recorded.	Best-interests record, risk assessment, review note.
Blanket restrictions are challenged and replaced with person-specific decisions.	Policy, staff interview, audit sample.
A new, increased or unrecorded restriction is escalated on the same shift.	Handover record, incident sample, staff interview.

6. Care-home DoLS screening and application

Complete this section where the service is a care home for adults. Hospitals should adapt it to their own arrangements. Services outside a care home or hospital should mark it Not applicable and complete section 8.

Check	Evidence to review	Status	Action owner	Due date
Screening uses the current post-2 June 2026 multifactorial approach, not the former single acid test.	Screening template, completed sample, staff briefing.
The record considers the type, duration, effects and manner of restrictions, including their combined effect.	Screening record, care plan, observation evidence.
The person's contentment, objection, wishes and ability to understand and express a view are actively explored and recorded.	Communication record, review note, consultation evidence.
Lack of MCA capacity is not treated as automatically answering the separate Article 5 consent question.	Screening reasoning, manager interview, advice record.
Borderline or seriously doubtful cases are referred for supervisory-body or legal advice.	Referral, advice note, governance record.
The managing authority uses the correct supervisory body and its current form or digital route.	Local procedure, submitted application, receipt.
A standard request is made in advance where possible, and an urgent route is used only where lawfully required.	Application sample, urgent-authority record, manager rationale.
Any urgent authority, linked standard request, extension and exact expiry are recorded and actively tracked.	Application tracker, Form 1 or local equivalent, correspondence.

7. Authorisation, representation and review

Check	Evidence to review	Status	Action owner	Due date
Every application has a live status, reference, owner, follow-up date and outcome.	DoLS tracker, supervisory-body correspondence.
Granted authorisations are reflected accurately in the care plan.	Authorisation, care plan, staff handover.
Every condition has an owner and completion evidence.	Conditions tracker, care records, governance review.
The relevant person's representative and IMCA or advocacy arrangements are recorded where applicable.	Appointment record, contact note, IMCA referral.
The person and representative receive accessible information about rights, review and challenge.	Information record, communication evidence, staff interview.
Objection, distress, changed capacity or materially changed arrangements trigger prompt review.	Daily notes, review request, revised screening.
CQC is notified when the application outcome is known, including a withdrawn application.	CQC submission, reference, DoLS tracker.
Expiry and further-authorisation dates are monitored before authority ends.	Tracker, reminders, further request.

8. Community route and possible unauthorised deprivation

Check	Evidence to review	Status	Action owner	Due date
Services outside a care home or hospital do not use DoLS as their authorisation route.	Local procedure, staff interview, case sample.
A possible community deprivation is escalated to the commissioner, local authority or legal adviser for the correct court route.	Escalation record, legal advice, Court of Protection evidence.
A care plan, placement agreement, family agreement or best-interests record is not treated as court authority.	Case record, staff interview, governance check.
The service tracks the outcome or withdrawal of a Court of Protection application and notifies CQC, even where another organisation made the application.	Court correspondence, CQC submission, notification reference.
Staff know how to report an objection, increased restriction or possible unauthorised deprivation on the same shift.	Staff interview, handover, incident process.
Immediate action protects the person and reduces any restriction that is not necessary and lawful.	Incident record, safeguarding note, revised care plan.
The service considers safeguarding, incident, duty of candour and CQC routes against the facts.	Decision record, notifications, action log.
Evidence and advice are preserved, and corrective actions have owners and due dates.	Record bundle, advice note, improvement action.

9. 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 and DoLS 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.
Relevant staff understand the post-2 June 2026 multifactorial approach and the difference between MCA capacity and Article 5 consent.	Training record, competence check, staff interview.
Care-home managers know the current application, rights, review, expiry and CQC notification routes.	Manager interview, local procedure, tracker.
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.

10. 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.
Restrictions, screening decisions and DoLS records are sampled where relevant.	Restrictions audit, DoLS tracker, case 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, MCA, DoLS and authorisation-expiry actions.	Governance minutes, dashboard, tracker.
Learning links to training, supervision, safeguarding and record keeping.	Linked records, action evidence.

11. 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 restriction has the weakest lawful basis or least restrictive reasoning?
Which DoLS, court, representation, condition or expiry control needs action?
What would a CQC inspector see if they asked for the consent and liberty evidence trail today?

12. Action log

Action	Source check	Owner	Due date	Completion evidence

13. 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.