Mental capacity refers to an individual's ability to make their own decisions, while restrictive practices are actions that limit a person's freedom or autonomy, often applied when someone lacks capacity and it is deemed necessary in their best interests and to prevent harm.
What is Mental Capacity?
Mental capacity is the ability of an individual to make their own decisions, including complex life choices, daily routines, or specific actions at a given moment. Under the Mental Capacity Act 2005 (MCA), the law outlines who can make decisions for individuals who lack capacity and how those decisions should be made.
Key Principles of the Mental Capacity Act 2005
The MCA is built on five core principles that must always be considered when making decisions for someone who lacks capacity:
- Presumption of Capacity: Every adult must be assumed to have capacity unless it is established otherwise.
- Support to Make Decisions: An individual must be given all practicable help to make their own decision before they are deemed to lack capacity.
- Unwise Decisions: An unwise decision does not automatically mean a person lacks capacity. People have the right to make choices that others might consider unwise.
- Best Interests: Any act done for, or any decision made on behalf of, a person who lacks capacity must be in their best interests.
- Least Restrictive Option: Before making a decision or acting for someone who lacks capacity, consider if there is a less restrictive way to achieve the desired outcome.
Assessing Mental Capacity
Assessing mental capacity is a decision-specific and time-specific process. It involves a two-stage test:
- Stage 1: Diagnostic Test
- Does the person have an impairment of the mind or brain? (e.g., a mental health condition, learning disability, dementia, brain injury, stroke, intoxication).
- Stage 2: Functional Test
- Does the impairment prevent the person from being able to make a specific decision at a specific time? This is broken down further into whether they can:
- Understand the information relevant to the decision.
- Retain that information long enough to make a decision.
- Use or weigh that information as part of the decision-making process.
- Communicate their decision (by any means, e.g., speech, signs, blinking).
- Does the impairment prevent the person from being able to make a specific decision at a specific time? This is broken down further into whether they can:
What are Restrictive Practices?
Restrictive practices are actions taken to limit a person's liberty or freedom of movement. While sometimes necessary for safety, they must always be a last resort and used in the least restrictive way possible, especially when an individual lacks the capacity to make decisions that might put them or others at serious risk.
Restraint as Defined by the Mental Capacity Act 2005 (Section 6(4))
The Mental Capacity Act 2005 provides a specific definition of restraint, which is crucial for understanding when an action qualifies as a restrictive practice under the law:
Section 6(4) of the Mental Capacity Act 2005 states that restraint is when someone uses force (or threatens to) to make someone do something they are resisting, and when someone's freedom of movement is restricted, whether or not they are resisting. This is only permissible after all other less restrictive means of achieving the desired outcome have been tried.
Types of Restrictive Practices
Restrictive practices can take various forms, including:
- Physical Restraint: Directly holding a person, using specialist equipment (e.g., bed rails, lap belts), or physically blocking their movement.
- Chemical Restraint: Administering medication specifically to control a person's behavior or movement, rather than for a therapeutic purpose directly related to a health condition.
- Environmental Restraint: Modifying the environment to restrict movement or access, such as locked doors, keypad entry systems, or limiting access to certain areas.
- Psychological/Coercive Restraint: Using threats, intimidation, or manipulation to control a person's actions.
When are Restrictive Practices Justified?
For a restrictive practice to be lawful and ethical when dealing with someone who lacks mental capacity, it must meet stringent criteria:
- Necessity: It must be necessary to prevent harm to the person themselves or to others.
- Proportionality: The degree of restraint or restriction must be proportionate to the likelihood and seriousness of the harm.
- Least Restrictive: All other less restrictive options must have been explored and tried first, and deemed ineffective. This directly aligns with Section 6(4) of the MCA.
- Best Interests: The practice must genuinely be in the person's best interests, considering their wishes, feelings, beliefs, and values.
The Interplay: Mental Capacity and Restrictive Practices
The connection between mental capacity and restrictive practices is fundamental. Restrictive practices are primarily considered when an individual is assessed as lacking the mental capacity to make a specific decision and there is a need to protect them from significant harm.
For example:
- If a person with dementia consistently tries to leave a care home and is at high risk of harm outside (e.g., getting lost, injury), and they lack the capacity to understand these risks, then a restrictive practice (like a secure door system) might be considered. However, staff must first explore all less restrictive options, such as diversion, activity engagement, or increased supervision.
- If an individual with a severe learning disability repeatedly puts themselves in danger (e.g., consuming non-food items), and they lack capacity to understand the danger, supervised access to food or secure storage of harmful items might be deemed necessary.
The core principle guiding any decision to use restrictive practices is the "best interests" of the person, always seeking the "least restrictive" option available. This ensures that a person's autonomy is respected as much as possible, even when their capacity is impaired.
Ensuring Ethical and Lawful Practice
To ensure that restrictive practices are used ethically and lawfully, care providers must:
- Conduct thorough and specific capacity assessments.
- Document all decisions, including the rationale for any restrictive practice and the less restrictive options considered.
- Involve the individual (if possible), their family, and relevant professionals in the decision-making process.
- Regularly review the necessity and proportionality of any restrictive practice.
- Focus on person-centred care, aiming to reduce the need for restrictive practices over time by addressing underlying causes of challenging behaviours.
| Principle | Description |
|---|---|
| Necessity | Is the restrictive practice absolutely essential to prevent harm? |
| Proportionality | Is the level of restriction appropriate to the risk of harm? |
| Least Restrictive | Have all other, less intrusive, alternatives been tried and failed? |
| Best Interests | Is the practice genuinely for the benefit and well-being of the individual? |
