Understanding mental capacity
Understanding mental capacity

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Understanding mental capacity

1.2 Balancing risk with well-being

Graham (2016) argues that mental capacity legislation is increasingly used for its safeguarding measures, ‘inasmuch that people are often assessed in relation to health and social care outcomes when elements of risk to the person are deemed to be present … the ability to make a decision is a central tenet to well-being in older adults’ (Graham, 2016, p. 152). This suggests that, in the care of older people who may lack mental capacity, safety is commonly prioritised over personal preferences and choices, especially when they want to make what may seem to be an unwise decision.

The person assessing the capacity of the older person to make a decision must make sure that disagreeing with the person’s choice is not interpreted as meaning that the person lacks capacity. A balance must be struck between what may be in a person’s best interests, especially in terms of their safety, and allowing the person to make their own decision. 

One important part of undertaking a capacity assessment of an older person is to understand the narrative about how they have lived their lives. The unique ‘story’ for each person contains clues that give both context to their current choices and evidence of previous decision making. It can reveal what they think contributed to their well-being in the past.

Mental capacity legislation incorporates and celebrates these person-centred approaches, but in the daily realities of providing care, especially when a person’s mental capacity is generally poor or fluctuates (as is commonly the case with dementia), sometimes the ‘person’ themselves can become lost. This is a particular risk in residential care, where the many organisational and administrative tasks demanded of staff can divert attention away from person-centred relationships. You see a glimpse of this in the next activity. 

Activity 2 Capacity in residential dementia care

Timing: Allow about 30 minutes

Watch the video below which is a clip from the 2009 BBC series Can Gerry Robinson Fix Dementia Care Homes?

In the video, Gerry Robinson – a management guru with a wealth of business experience – visits a residential care home for older people with dementia in Torquay. Gerry attempts to engage with the residents but is alarmed to find that the range of activities in the home is very limited and apparently driven more by institutional routines than the expressed choices of the residents. 

Download this video clip.Video player: The lack of activity in residential care for older people
Skip transcript: The lack of activity in residential care for older people

Transcript: The lack of activity in residential care for older people

INTERVIEWER
The first time I was looking at was Woodland House in Torquay. It is a dimension nursing home for 24 residents. It's privately owned, funded mostly by the local authority. It's typical of the kind of home perhaps, half of us will end up in.
Are you interested in the birds?
MAN
There's some there.
INTERVIEWER
Oh, yeah.
CAREGIVER
Doris, head this way, my love.
INTERVIEWER
When I got to Woodlands, the residents had just had breakfast. And what struck me straight away was that people were just sitting there and not doing anything.
Are you all right? What's your name?
This lady is very troubled. That's better.
Were you a soldier?
LES
No.
INTERVIEWER
What were you?
LES
I might have flew a Spitfire.
INTERVIEWER
Did you?
LES
Yeah. And shot six down.
INTERVIEWER
Did you?
LES
I did. You see, I was very proud of it.
INTERVIEWER
Was that frightening, being a part of a Spitfire?
LES
No. It was exhilarating.
INTERVIEWER
Was it?
LES
Yes.
INTERVIEWER
So the home had one of our country's Spitfire heroes amongst them. And although Les's life is now spent in the corner of this lounge, he still remembered his extraordinary past.
And alongside Les were doctors, caterers, company directors-- all sorts of people with interesting pasts. But it felt as though nothing that had happened in their lives mattered anymore. Here they were like broken vessels sitting in this room with absolutely nothing to do.
Thelma, What did you do when you were younger? What was your job?
THELMA
I can't tell you.
INTERVIEWER
No?
THELMA
No, I can't.
INTERVIEWER
Can you remember what you used to do at all when you were a young girl? Do you remember?
THELMA
Yeah. I can remember all right.
INTERVIEWER
What did you do?
THELMA
Oh dear. I don't tell lies. I didn't tell lies.
INTERVIEWER
No.
I've just been talking to Thelma, who obviously I'm not getting very much from.
Are you wanting through here? There we go.
Do you-- do you ever-- do you have a sense of her personal history at all?
CAREGIVER
No, I don't. I know she used to-- actually, her husband told me she used to cook. But that's all I know really about Thelma.
INTERVIEWER
Do you know has there ever been a time where you thought if I knew a a little bit more it would be helpful or does that not seem--
CAREGIVER
I suppose everything-- every aspect like-- well, yes, I suppose it would be. I suppose the more you know, the better really.
End transcript: The lack of activity in residential care for older people
The lack of activity in residential care for older people
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List the ways in which it might be possible to engage more successfully with the residents in this home. Try to think of ways of ensuring that any decisions are based on the best possible opportunity for residents to express their views and wishes. Make notes in the box below.

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Now watch the video below, another clip from the same series, which gives a more positive picture.

Download this video clip.Video player: Residential care for older people: some positive experiences.
Skip transcript: Residential care for older people: some positive experiences.

Transcript: Residential care for older people: some positive experiences.

INTERVIEWER
There was one resident at Woodland who stood out for me. Daisy seemed to have an unusually strong air of well-being.
Don, do you come in every day?
DON
I come here from 2:00 till 8:00.
DAISY
Ah, help.
DON
And I don't let nothing stand in the way of those hours when I want to come and see her. It don't matter who it is.
DAISY
Help.
DON
I've told everybody here. The ones that come to mind-- my house doctor with NHS, whoever they are. It's no good you coming to us in those hours that I'm coming up here, because I won't be seeing you. And I'm seeing Daisy, and that's it.
INTERVIEWER
And what gives you the strength to do that?
DON
Pardon?
INTERVIEWER
What gives you the strength to do that?
DON
Because I love the girl. That's why.
DAISY
You love me.
DON
Yes. I do love her very much, and I can't see no point in standing up in front of the vicar, being the big guy and saying--
DAISY
The vicar.
DON
--till death us do part and all that. And then the next minute you're gone and knocking about with someone else.
DAISY
Help.
DON
I don't believe in that rubbish because she's a lovely person. If I'd have let these people-- or whoever, wherever she went-- put her in the corner and forget about her and say, oh, she's lost her marbles and all that [INAUDIBLE], she wouldn't be as bright as she is today. Yet she does answer and-- don't you, Daisy?
DAISY
Pardon?
DON
You do answer me, don't you?
DAISY
Oh yes.
DON
See?
DAISY
Yes. Help.
DON
What's your name, then?
DAISY
Pardon?
DON
Is your name Daisy?
DAISY
Daisy.
INTERVIEWER
Daisy, are you happy?
DAISY
Am I happy?
INTERVIEWER
Yes.
DAISY
Yes.
INTERVIEWER
Through her husband Don, Daisy was getting that one thing that so many people in dementia care homes don't get, that meaningful one-to-one contact. And unquestionably, this was keeping her as with it and connected as she was.
DAISY
(SINGING) Happiness, happiness, la, la, la, that you possess.
DON
Who sang that then?
DAISY
[VOCALISING] Just a little happiness.
INTERVIEWER
Quite simply, the system needed to be Don.
DAISY
Happiness.
DON
Yes. All right, dear.
INTERVIEWER
I had been looking throughout the industry to see if I could find anywhere that was providing care that really managed to make residents feel alive and happy. I'd heard about a home in Warwickshire that tried to do exactly that.
Merevale House is a residential home for 35 people with dementia. Merevale was partly the inspiration of David Sheard, a care consultant.
It was brilliant. These residents were really living in their home and actually helping to run it.
DAVID SHEARD
Everybody working here sees themselves as an activity worker-- whether they are in the kitchen, whether they are in the office, whoever-- and that that's their main focus of the day is to connect to people, to occupy people. And yet, all the tasks will be dealt. You know, people will eat. People will be dressed. People will have help with personal care.
But what seems to be so hard is to get across in this care sector how you unhook from the task. And what seems to happen is managers seem to need to hang on to that task. Because if that's their safety blanket to run the place, and yet they're working with people who are not seeking order, whose lives are in a different order to ours, and that, therefore, surely demands that we change our order. And yet, somehow people, as you say, want to hold onto to theirs.
INTERVIEWER
And the great thing is it's not about the money. Merevale doesn't cost more to run than most residential homes. And yet, that involvement of people in running their own homes not only makes good emotional sense, but it makes good business sense too.
This home is rated as excellent, and so it's always full. The staff are well-treated and they feel part of it, so recruitment costs and training costs are low. On every level, they've created a place where people want to be.
End transcript: Residential care for older people: some positive experiences.
Residential care for older people: some positive experiences.
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How might the care arrangements in this home make it easier to make a more accurate assessment of the capacity of the older people compared to those in the first video? Make notes in the box below.

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Comment

In the first video, the residents have very little to occupy themselves and are not very engaged with either the staff or each other. Gerry Robinson hinted that this might be related to the institutional need to prioritise safety above the quality of people’s lives. The staff may also not be aware of the variety and richness of the backgrounds of the residents, which makes it even harder for the staff to engage with them.

The exception seems to be Daisy, shown at the beginning of the second video. Daisy’s husband Don maintains substantial daily care and commitment, keeping her connected and contented. The residential home in Warwickshire, in contrast to the first home, showed staff and residents collaborating to run the home together, providing structure and ‘order’ reflecting the needs and rhythms of the residents, rather than of the managers and staff. This makes good business sense as well as emotional sense, creating a place where residents and staff want to be. 

In the next section, you will consider more particularly issues of decision making and older people.

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