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Some practice nurses lack training in mental capacity laws, finds CQC

  • 8 Comments

Lack of awareness among nurses about legislation on whether a patient is able to consent to treatment, as well as insufficient recruitment checks on new staff, are among issues exposed at GP surgeries by regulators.

The Care Quality Commission yesterday published a further 50 reports on the quality of care provided by GP practices in different parts of the country, as part of its rolling inspection programme.

It said it had ordered a handful of practices to ensure all staff were trained to understand the Mental Capacity Act 2005, after inspectors found some workers were not aware of it.

The legislation allows healthcare professionals to make decisions about care on behalf of patients, but only if it has been proven that patients are unable to do so.

At Forest End Medical Centre in Bracknell, while GPs knew of the act, not all nurses were aware of it or understood its core parts, said the CQC.

“Some nurses we spoke with did not understand the key parts of the legislation and were not sure how to implement it”

CQC

In its report on the practice, the CQC said: “Some nurses we spoke with did not understand the key parts of the legislation and were not sure how to implement it in their practice.

“There was no protocol on the Mental Capacity Act for staff to refer to in order to follow the principles of the act.”

Similarly, at the Waterfield Practice in Bracknell, the regulator found some nurses and GPs did not understand when they should be using the act or the principles underlying it.

Staff at the Binfield Surgery, also in Bracknell, were “not certain” whether they had received any training on the Mental Capacity Act, and there were no certificates available to suggest they had, said inspectors.

At the same practice, less than half of patients responding to a recent national survey reported that nurses were caring, noted the CQC. Inspectors were told by its manager that nurses were struggling to deal with an increasing patient caseload.  

“Where we have required improvement, we will expect the practice to take the necessary steps to address the issue, and we will return at a later date”

CQC

Meanwhile, the regulator also discovered that three nurses who had been assessed as needing Disclosure and Barring Service checks – which decide whether staff are safe to work with children based on their criminal record – had failed to apply for them.

Other practices failing to carry out basic staff checks included the Mariso Medical Practice in Lincolnshire, which provided no evidence that clinicians were registered with professional bodies or that references had been obtained upon hiring them.

The Shrubbery Surgery in Gravesend was also unable to protect patients from “the risks associated with the recruitment of staff who may be unfit or unsuitable for their role” after the regulator found  the practice did not hold employment history checks, references, and photographic identification for all its staff.

Despite the CQC’s assessment that these practices and two others required improvement in its latest inspections, it found more than 40 other GP surgeries were providing “good” or “outstanding” services.

The reports published yesterday are from the regulator’s second round of GP inspections. Findings from the first batch were published in November.

Nigel Sparrow, the CQC’s senior national GP advisor, said: “We know that the vast majority of England’s GPs are providing a service which is safe, effective, caring, responsive and well led. 

“If that is what we find on inspection we give it a rating of ‘good’, and I congratulate the GPs and staff in these practices,” he said.

“Patients should be able to expect high quality and consistent care from every GP practice. Where we have required improvement, we will expect the practice to take the necessary steps to address the issue, and we will return at a later date to check that those improvements have been made,” he added.

  • 8 Comments

Readers' comments (8)

  • michael stone

    It isn't only practice nurses who have problems understanding and implementing the MCA - even the recently revised BMA/RCN/RC(UK) Joint CPR Guidance, misrepresents the law about the decision-making authority of welfare attorneys ! See the 01/12/14 - 14:16 piece at:

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj=viewThread&threadID=748&forumID=45

    There is also a question about the MCA which has just appeared on the Dignity In Care website, about the MCA - does anybody 'want to have a go at it' ?

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj=viewThread&threadID=756&forumID=45

    The question someone posted was this:

    Service user cutting own hair
    07/01/15 - 15:52
    rosie morse
    Hello, we have a dilemma with a service user and I wondered if anyone could give advice? She has a learning disability and lives in a supported living service. She has access to a 'lady shave' which she uses for her legs. However recently she has been using it to shave the very front section of her hair and half of her eyebrows. This has had an impact on how others see her and treat her in the community. Its not an ironic fashion statement, more a very 'bad'? hair cut. In terms of her dignity and the negativity she receives in the public we want to support her to have a more appropriate hair cut at a salon. We have her best interests at heart, however in terms of choice it doesnt sit right with me. The staff here want us to lock away the razor and complete a restrictive practise to say why. Should I just let her keep the razor, or should we protect her dignity in terms of the way she looks? Advice please!

    I think the real problem with the MCA, is what I've explained at the link below - it is VERY problematic for front-line HCPs [in some situations], if they actually try to do what the MCA appears to say:

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj=viewThread&threadID=741&forumID=45

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  • Hi Michael

    What response did the nurse get to her query about the service user?

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  • michael stone

    Jodie's mate | 9-Jan-2015 3:05 pm

    The discussion has only just started - copying andf pasting the responses so far, they are (I've not got time to 'tidy up. any cut & paste errors):

    The link is:

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj=viewThread&threadID=756&forumID=45


    Service user cutting own hair
    07/01/15 - 15:52
    rosie morse
    Hello, we have a dilemma with a service user and I wondered if anyone could give advice? She has a learning disability and lives in a supported living service. She has access to a 'lady shave' which she uses for her legs. However recently she has been using it to shave the very front section of her hair and half of her eyebrows. This has had an impact on how others see her and treat her in the community. Its not an ironic fashion statement, more a very 'bad'? hair cut. In terms of her dignity and the negativity she receives in the public we want to support her to have a more appropriate hair cut at a salon. We have her best interests at heart, however in terms of choice it doesnt sit right with me. The staff here want us to lock away the razor and complete a restrictive practise to say why. Should I just let her keep the razor, or should we protect her dignity in terms of the way she looks? Advice please!
    Reply
    Re: Service user cutting own hair

    08/01/15 - 12:30
    mike stone
    Hi Rosie,

    I'm not sure if I will have [online] time later today, but if not I'll give you my own understanding of the law re this tomorrow [I hope] - this one isn't entirely simple, and I think you could well get differing opinions.
    Reply
    Re: Service user cutting own hair

    08/01/15 - 13:21
    mike stone
    Hi again Rosie,

    Here is my 'take' on this - I tend to analyse the Mental Capacity Act in connection with end-of-life, not this type of care situation, so I'm thinking and writing as I go.

    Point 1 - 'learning difficulties'.

    This term seems to cover an awful lot - but having a learning difficulty, does not automatically equate to a lack of mental capacity: mental capacity as a concept/test, is decision-specific.

    In this case, and in fact for any situation, the issue is: 'Does the person understand the consequences of his/her decision ?'. If the answer is 'yes', then the person possesses mental capacity, and legally the decision is the person's to make. So you would need to try and find out, does she understand that the way she is cutting her hair, is causing her to be treated 'negatively in public' ? If she knows that, but answers 'so what - I don't care [how other people see/treat me] then it looks as if it is her decision. It is arguably still her decision, even if that 'negative treatment' might include something like 'people attacking you physically' provided she understood the risks and consequences of such physical attacks.


    If she doesn't understand the 'negative consequences', then she doesn't have capacity to make the decision herself. But, anyone making the decision, would have to consider (balance against the direct consequences of her cutting her own hair in this way) things including:

    a) Would taking the shaver away from her, cause her distress and to resent the staff ?

    b) If she has her hair cut at a salon, does she have to pay for this ? By which I actually mean, would she be left with less money to spend on other things [which she might value more than a salon hair cut] ?

    The MCA as I read it, is all about the consequences of actions as understood or not by the individual, and almost entirely it is 'selfish' - care homes obviously have some 'problems with' this, but the MCA doesn't require that a person 'is nice to everyone else': if she has the mental capacity to understand that her haircut would distress other people, but 'doesn't give a damn about that', then my understanding is that the MCA cannot be used to stop her.

    I would try to persuade her to get her hair cut at a salon, even if the first time she isn't herself paying for that: then you can ask 'can you see the difference ?' (if she answers 'yes' that suggests capacity re this hair-cutting issue, whereas if she can't 'see' an obvious difference, that suggests a lack of capacity for 'haircutting'). But if she wants to cut her own hair, however 'weird that makes her look', I think you are on dodgy legal ground if she understands the consequences of cutting her own hair and you prevent her from doing that.

    I'm not sure if that helps - but, 'off the top of my head', that would be my 'take' on the legal situation, here.
    Reply
    Re: Service user cutting own hair

    08/01/15 - 13:43
    rosie morse
    Thank you Mike. She appears not to understand how some of her actions are percieved and does lack MC in certain areas. Staff have 'best interest' guidleines for areas such as healthy food choices. In my professional opinion I would say she does not have MC around the impact the shaving of her hair has on her appearence. Also I think some staff here are worried about what others may think of them. Is this a reflection upon them? Do people think they are responsible for cutting her hair like that? Thanks again, Rose
    Reply
    Re: Service user cutting own hair

    08/01/15 - 20:01
    Rita Umney
    Hi Rosie, this is an unusual situation, one I have not had deal with, the idea of taking away the razor is tricky, but I agree with the fact that they may have made themselves more vunerable re: comments and taunts it is a question of MCA and their understanding, you do not say if she has family/friends that may talk with her.
    hope it gets sorted
    Rita
    Reply
    Re: Service user cutting own hair

    09/01/15 - 10:24
    mike stone
    I'm not sure that in [legal] principle, 'Also I think some staff here are worried about what others may think of them. Is this a reflection upon them? Do people think they are responsible for cutting her hair like that?' should have an influence: but I'm sure that in reality, that type of thing DOES have an influence (there are very similar issues to that, around CPR in my EoL area).

    The MCA is, to be frank, 'often a sod to work with' if you are the front-line staff: it promotes patient autonomy, but I think it is quite hard to explain to many people/relatives 'I know it seems weird, but the law actually says ...'.

    I hope this problem is resolved to the satisfaction of her and the staff - but I also hope that many more people will 'throw their opinions about this one in here', because this is a really 'interesting question and discussion'.
    Reply
    Re: Service user cutting own hair

    09/01/15 - 15:51
    JOHANNES NANG-BAYI
    Hi Rosie,I shared this with my staff and this is what we think:
    First of all will to look into her background, it could be that she was a hairdresser or have ever worked in a salon or even just got interest in hair dressing. If there is no relation at all then will look into the the kind of hair style she used to have before coming to live there.The second thing we will do is, get a hair dresser to the home and engage her to watch and see her reaction then advice her that she could have a proper hair do from the person. If this works then she could then have regular visits from the person.Thirdly, as she has not got Capacity we will lock the razor away in her 'Best Interest'and supervise her in cutting or having a hair do.RegardsJohannes



    On Thursday, 8 January 2015, 20:01, Dignity Champions forum wrote:


    Message sent by Rita Umney.

    Hi Rosie, this is an unusual situation, one I have not had deal with, the idea of taking away the razor is tricky, but I agree with the fact that they may have made themselves more vunerable re: comments and taunts it is a question of MCA and their understanding, you do not say if she has family/friends that may talk with her.
    hope it gets sorted
    Rita







    Reply
    Re: Service user cutting own hair

    09/01/15 - 19:47
    sarah nelson
    Hello Rosie

    I have read with interest the service users situation,have you and staff used pictures to explain her haircut,like how she wore her hair before and after she has shaved her hair,also could she have some sensory feeling when she uses the razor on her hair and eyebrows.Just a suggestion to use pictures explain accessible to her of what she is doing,remember all accessible ways of communicating information have to be utilised before lack of mc can be assessed.

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  • I think these responses are good- measured and patient centred.(Speaking as someone whose role is to promote the MCA)

    I'm going to check out this website, it looks interesting, many thanks

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  • michael stone

    Jodie's mate | 12-Jan-2015 8:39 am

    I think they are good as well - although I am much less sure of '.. Thirdly, as she has not got Capacity we will lock the razor away in her 'Best Interest'and supervise her in cutting or having a hair do.RegardsJohannes'.

    I write extensively about the MCA (usually on the DIC website), because I think many/most HCPs misrepresent it: for example, section 4(9) is clearly [when I read the Act] a legal duty, not a legal power; people seem to ignore the fact that the Act applies to 'family carers' but the Code of Practice doesn't; etc.

    You can join DIC for free, basically by giving them an e-mail address -however, to post stuff, you need to use the name you registered under (no 'anonymous' on DIC).

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  • michael stone

    Hi again Jodie's mate,

    Dignity In Care is at:

    www.dignityincare.org.uk

    As you promote the MCA, I would be very interested in your position about the correctness or otherwise of my PDF file which can be downloaded from (the discussion title is 'This is why professionals struggle with the Mental Capacity Act' - and you can download the PDF file, without joining the website):

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj=viewThread&threadID=741&forumID=45

    Unfortunately, I’ve just checked and my e-mail address seems to be absent in that one – if you read the file and want to tell me ‘where I’m wrong’ [or, perhaps, right], you can find my e-mail address at the end of this BMJ piece:

    http://www.bmj.com/content/347/bmj.f4085/rr/654490

    If the hair-cutting piece gets enough replies, I think it could be used as a ‘teaching aid’ – as I commented there

    ‘I do think that this particular situation, highlights a quite complex issue re 'mental capacity', and it is well-worth pondering !

    Whether most staff who work in the NHS have got the time 'to ponder over issues, to arrive at the best answer' is a different - and also interesting - question !’

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  • I will certainly look at your pdf file Michael, thanks.

    I don't think there's a right or wrong regarding what is done about this woman's hairstyle (although I admit the best interest element doesn't seem to be "least restrictive")

    I think a court would be more interested in if the process had been carried out correctly

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  • michael stone

    Liz Taylor has just added her contribution to that debate - I've exchanged e-mails with Liz, but even so i'm not quite sure of Liz's day job (I suspect, a social worker - but it has never come up as a direct question).

    I'm not sure that Liz is right, about there not being 'a correct answer' to this one: I think that unless mental incapacity is established, there is a clear answer (it is up to the lady herself); if the lady lacks capacity, I would agree that the answer is less clear, and that then different people could legitimately arrive at different answers.

    Here is Liz's contribution:

    Re: Service user cutting own hair

    13/01/15 - 09:24
    Liz Taylor
    what a challenge, there is a real issue around the challenges of respecting Dignity in this case. There are as I see it two main themes, the Dignity of the service user in terms of the potential outcomes on how others might see her, and her capacity to understand that; and the Dignity of staff in terms of how people who are outside the situation may perceive their actions or 'lack of action'. It is always a difficult one and there is no one answer. None of us who are commenting have full knowledge of the situation, and the life choices that have been made by and on behalf of the individual concerned, and as such it becomes really difficult to make any helpful comments. [not helpful in itself I know]. I do think the use of pictures as suggested may be helpful, as would having a wider best interest type discussion about the outcomes and what may happen in terms of choices. There is a conflict for me in terms of this may be one of the few areas where the individual still has control over her life and I have an innate reluctance to take that away from anyone, even if I don't agree with the outcome on a personal level. Maybe the real key is the degree to which leaving the razor in place has a negative impact on the individual in terms of the reactions of others, versus the potential negative impact of taking the razor away and thus taking that little bit of control and choice away.
    I am sorry if this is not helpful in terms of providing answers, but this is a real dilemma and there is no right or wrong answer. I do hope you find a way forward that enables you to continue to provide choice and self determination as well as the duty of care that you so clearly take seriously. Best Wishes

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