Independent Mental Capacity Advocate Research Articles

Managing DNACPR Recommendations in Residential Care: Towards Improved Training for Social Care and Capacity Professionals

Abstract The use of ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) recommendations has come under scrutiny during the COVID-19 pandemic, and the Care Quality Commission (CQC) has issued a call for new standards, guidance and training. One group for whom new training is required is ‘capacity professionals’ working in and with residential care facilities. These professionals (including Independent Mental Capacity Advocates and Best Interests Assessors) typically have a social work background and have specialist training regarding the 2005 Mental Capacity Act, the provisions of which have a direct relevance to DNACPR recommendations. We report on a survey and focus groups that probed the experiences of this professional group during the pandemic. We recruited 262 participants by approaching civil society organisations in which capacity professionals are well represented; twenty-two participated in follow-on focus groups. We used manifest content analysis and descriptive statistics to analyse the results. Our findings contribute to an emerging picture of what transpired in residential care homes during the first year of the pandemic and help to provide an empirical and normative basis for the development of the new guidance and training for which the CQC has called.

What's in this Issue

What's in this Issue

Is there a broader role for independent mental capacity advocates in critical care? An exploratory study.

This research explores the current and potential future role of independent mental capacity advocates (IMCAs) in critical care. The Mental Capacity Act (MCA) of 2005 introduced IMCAs as advocates for patients without anyone to represent their best interests, but research suggests that this role is not well understood or implemented. No existing research explores the role of IMCAs in critical care or their potential use when families are judged 'appropriate to act' on the patient's behalf. It is suggested that families may not be best placed to advocate for their sick family member when they themselves are in a state of shock. To investigate existing levels of knowledge and awareness of the MCA and understanding of the role of IMCAs in critical care as a prelude to considering whether the role of IMCAs might usefully be extended. The concept of 'IMCA clinics' is introduced and explored. A small-scale qualitative study using thematic analysis of 15 interviews across two NHS sites and a survey of IMCA services were undertaken. Some knowledge of the MCA was evident across both study sites, but training on MCA remains unsatisfactory, with confusion about the role of IMCAs and when they should become involved. Overall, participants felt that the broader involvement of IMCAs on a regular basis within critical care could be useful. There was evidence of good practice when instructing IMCAs, but further work needs to be conducted to ensure that critical care staff are informed about the referral process. It was clear that expanding the role of an advocate warrants further investigation. Further training on the role of IMCAs within critical care is required, and good practice examples should be shared with other units to improve referral rates to the IMCA service and ensure that vulnerable patients are properly represented.

The Advantages and Disadvantages of Different Models of Organising Adult Safeguarding

Professionals express divergent views about whether adults at risk are best served by safeguarding work being incorporated into social workers’ casework or being undertaken by specialist workers within local area or centralised teams. This paper draws on findings from the final two phases of a three-phase study which aimed to identify a typology of different models of organising adult safeguarding and compare the advantages and disadvantages of these. We used mixed-methods to investigate four different models of organising adult safeguarding which we termed: A) Dispersed-Generic, B) Dispersed-Specialist, C) Partly-Centralised-Specialist and D) Fully-Centralised-Specialist. In each model, we analysed staff interviews (n = 38), staff survey responses (n = 206), feedback interviews (with care home managers, solicitors and Independent Mental Capacity Advocates) (n = 28), Abuse of Vulnerable Adults (AVA) Returns, Adult Social Care User Survey Returns (ASCS) and service costs. This paper focuses on qualitative data from staff and feedback interviews and the staff survey. Our findings focus on safeguarding as a specialism, safeguarding practice (including multi-agency working, prioritisation, tensions, handover, staff confidence and deskilling) and managing safeguarding. Local authority (LA) participants described and commented on the advantages and disadvantages of their organisational model. Feedback interviews offered different perspectives on safeguarding services and implications of different models.

Making adult safeguarding personal

Purpose – The purpose of this paper is to ascertain what efforts Adult Safeguarding Leads (ASLs), generic advocates, and Independent Mental Capacity Advocates are making to involve service users in decisions about protective measures, and to investigate whether the Adult Safeguarding service is delivering outcomes, which are valued by its users. Design/methodology/approach – Semi-structured interviews with a sample of key stakeholders. Findings – ASLs are making efforts to involve service users in the complex and demanding process of safeguarding. These efforts, however, are shaped by their understandings of the difference between “residential” and “community” settings. Research limitations/implications – The study is based in a single County Council, albeit in a large county, and involves a limited number of service users. Practical implications – Clarification is needed of what it may mean to adopt a person-centred approach to adult safeguarding, and the responsibilities of ASLs when individuals with ca...

A future care planning initiative to improve the end of life care of patients on the complex care ward of a district general hospital

Medically led, patient-centred, future care planning for patients predicted to be in their last year of life is possible on the complex care ward of an acute hospital, where patients often wait for social care placement into a nursing home. When the patient lacks the mental capacity to engage in the planning discussions themselves, meetings can take place between the multidisciplinary geriatric team and either those close to the patient or an independent mental capacity advocate. Participants in the meeting should use any existing advance care planning information, as appropriate, to develop 'best interests advice' (which can be referred to at a later date when a best interests decision needs to be made for the patient). Any future medical care plan should be reviewed for applicability and validity if the person's condition changes (improves or deteriorates), if the patient or those close to the patient request it, or 6-12 months after the initial plan is made. Education, training and support must be provided to ensure acceptance and understanding of the PEACE (PErsonalised Advisory CarE) process and general end of life care in the community. Specialist palliative care services are often best placed to provide this.

Variation in local trust Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policies: a review of 48 English healthcare trusts

ObjectivesTo explore Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policies from English acute, community and ambulance service Trusts for evidence of consistency and variation in implementation of national guidelines between healthcare...

An exposition of the Mental Capacity Act 2005 in Britain : Focusing on Lasting Powers of Attorney and Independent Mental Capacity Advocate service

An exposition of the Mental Capacity Act 2005 in Britain : Focusing on Lasting Powers of Attorney and Independent Mental Capacity Advocate service

Guidelines for withdrawal of ventricular assist devices

BackgroundAdvanced heart failure is one of the most common causes of admission to hospital. Patients may be treated with cardiac transplantation but, due to an unprecedented shortage of donor organs,...

What do NHS staff learn from training on the Mental Capacity Act (2005)?

Purpose. Many studies have reported that professionals have a limited understanding of mental capacity issues. Implementation (in England and Wales) of the Mental Capacity Act (MCA) (2005) presents a challenge to services. The aim of this study was to evaluate the extent to which National Health Service (NHS) staff benefited from attending MCA training courses.Methods. Participants were assessed before and after MCA training using a structured interview, which included three scenarios describing mental capacity dilemmas, four vignettes addressing the role of the Independent Mental Capacity Advocate (IMCA), and 16 true–false items.Results. Interview performance improved post‐training, but this could be largely ascribed to an increased awareness of mental capacity issues, with minimal improvements in the knowledge that would be needed to undertake the assessments. Nine areas were identified where there remained significant gaps in participants’ knowledge post‐training. Participants with experience of dealing with mental capacity issues performed better than those without.Conclusions. The results suggest that methods other than formal training events may be needed to prepare health staff to implement new legislation.

Independent advocacy, neuro‐disability and spirituality? A history of advocacy with a case study from the Independent Mental Capacity Advocate (IMCA) service

Purpose – This paper aims to show the particular difference Independent Mental Capacity Advocates (IMCA) can make towards specific decisions which some acquired brain injury clients, who are eligible for the IMCA service, experience.Design/methodology/approach – A case study is highlighted in which the role of the IMCA is described against the background of a selective literature review on the history of advocacy in relation to its emergence as a profession. This analysis references issues of spirituality and culture.Findings – Themes raised in the case are discussed with reference to ongoing research and these are related to the best interests of clients, and to reflexivity as a basis for the professionalisation of advocacy.Research limitations/implications – IMCA practitioners are instructed in well‐defined “best interests” situations, where an individual has no capacity, support or representation, or requires safeguarding measures in relation to certain decisions. In these cases, social, cultural, emot...

Judgements about deprivation of liberty made by various professionals: comparison study

Aims and methodA group of lawyers, psychiatrists, best interest assessors and independent mental capacity advocates were asked to make binary judgements about whether real-life situations in 12 vignettes amounted to deprivation of liberty. Kappa coefficients were calculated to describe the level of agreement within each professional group and for the total group of professionals.ResultsThere was total agreement between all professionals about deprivation of liberty in only 1 of the 12 cases. The overall level of agreement for judgements made by all professionals was ‘slight’ (κ=0.16, P < 0.01).Clinical implicationsThere are practical difficulties involved in making reliable deprivation of liberty judgements within the Deprivation of Liberty Safeguards (DoLS) legislation. A clear interpretation of deprivation of liberty is necessary to facilitate professionals' decision-making in this area.

Consent

Failure to provide sufficient information to a patient when seeking consent can result in a claim in negligence. When determining what information to provide, you should be guided by what this particular patient needs to know in order to make an informed decision. Adult patients must be assumed to have capacity to give or withhold consent unless they are clearly unable to comprehend, retain or weigh in the balance the necessary information. Adults without capacity come under the protection of the mental Capacity act (adults with incapacity (Scotland) act in Scotland). as a result, they may when competent have nominated someone to make healthcare-related decisions on their behalf. If nobody has been appointed in this way by a patient it may be necessary to consult an independent mental capacity advocate. An adult with capacity has the right to refuse treatment on rational grounds, irrational grounds or, indeed, no grounds at all.

Safeguarding people’s rights under the Mental Capacity Act

People who lack capacity to make certain decisions have a statutory right to be represented by an independent mental capacity advocate (IMCA). However, there is concern among the organisations that provide IMCA services about the lower than expected number of referrals (instructions) by trusts in the NHS. The authors discuss possible reasons for the low instruction rate and how this could be improved. A case study of a woman with mental health problems is used to demonstrate how the role of the IMCA works in practice.

Knowledge of Advocacy Options within Services for People with Learning Disabilities

Background The aim of this study was to evaluate the extent to which care managers in learning disability services understand the role of the Independent Mental Capacity Advocate (IMCA) service, and the difference between the newly created statutory IMCA and existing general advocacy (GA) services. Method There were 22 participants from three community teams within learning disabilities services, all but one of whom had attended training on the Mental Capacity Act (2005). Participants completed a questionnaire based on a set of nine scenarios where they were asked to identify the appropriate professional to contact in relation to the situation described, and to explain what their role would be. Results Respondents’ understanding of these issues was generally poor. There was a substantially less than 50% correct response rate for identification of scenarios that called for an IMCA referral, and respondents’ ability to discriminate between the roles of GA and IMCA was limited. Only around half of the respondents correctly identified that the function of advocacy is to represent the client’s views, and a significant minority incorrectly attributed decision-making functions to the IMCA. Only a single participant identified the statutory requirement to involve an IMCA in relation to a change of long-term accommodation (where the person lacks capacity and has no other non-professional support), and none of the participants identified this as a statutory requirement in relation to serious medical treatment. Conclusion A better understanding of the statutory functions of the IMCA service may require a different approach to Mental Capacity Act training.

Independent advocacy and the “rise of spirituality”: views from advocates, service users and chaplains

The Mental Capacity Act (2005) and the amendments to the Mental Health Act (1983) in 2007–which came into effect in 2007 and 2009, respectively, in England and Wales–made it a statutory duty for the NHS and local authorities to refer to advocacy services. This is part of a growth in advocacy which coincides with an increase in literature on mental health and spirituality. Independent advocates and spiritual care coordinators (or chaplains) provide expressions of advocacy. For Independent Mental Capacity Advocates, social, cultural and spiritual factors are influential. Research involved a literature review on the history of advocacy and interviews with over 30 advocates, chaplains and service users and subsequent grounded theory analysis. The attested “rediscovery of the spiritual dimension in health and social care” was supported by overlaps in the practices of advocates and chaplains. This highlighted shortcomings around the professionalisation of advocacy in relation to culture and spirituality.

Capacity to Communicate: Sense's three‐year project training independent mental capacity advocates in communication skills

Sense, the leading national charity that supports and campaigns for children and adults who are deafblind, set up the Capacity to Communicate Project in response to the new role of independent mental capacity advocates created by the Mental Capacity Act 2005 (HM Government, 2005). The project provided training and information, harnessing best practice around communication and advocacy for people who lack capacity and who have little or no formal communication, in particular those with a dual sensory loss. As part of the training, advocates were asked to submit a written assignment. These case studies, including some adult protection cases, have given us valuable information about the nature and process of independent mental capacity advocacy and what can be done to improve this relatively new statutory role, in particular developing better understanding, skills and processes around communication in order to represent and protect vulnerable adults.

Mental Capacity Act (England and Wales) 2005: The Emergent Independent Mental Capacity Advocate (IMCA) Service

Mental Capacity Act (England and Wales) 2005: The Emergent Independent Mental Capacity Advocate (IMCA) Service

From the conference.

Many older people are not being given access to a mental capacity advocate when decisions about their care are made - even though it is required by law. Older people who lack the capacity to make their own decisions about treatment or accommodation, and have no friends or family to represent their best interests, must have access to a qualified independent mental capacity advocate (IMCA).

Mental Capacity Act 2005: views and experiences of learning disability psychiatrists

Aims and MethodPostal questionnaires were sent out to 66 learning disability psychiatrists to assess their knowledge and experience of the Mental Capacity Act 2005.ResultsA response rate of 55% (n = 36) was achieved; 22 (61%) respondents felt that patient care had improved; 16 (44%) felt workload had increased. Despite 79% (n = 23) of the respondents feeling that the training for the Act was adequate, only 19% (n = 7) were aware of the situations where patients had to be referred to the Independent Mental Capacity Advocate (IMCA) service and only 53% (n = 19) were aware that the Act currently does not cover patients who fall in the ‘Bournewood gap’.Clinical ImplicationsLearning disability psychiatrists are still not conversant with significant parts of the Act and this raises questions about the adequacy of the training delivered. Implementing the Act should improve patient care but will have implications for the workload of professionals.