Consent management in residential care homes

Ensuring compliance & dignity: effective consent management in residential care settings

It is both a legal and moral imperative that care and treatment should only be provided with the consent of the individual being cared for. Those living in residential care should be supported to make their own decisions about their care, or decisions should be made in their best interests, in line with the latest legislation and guidance.

Working closely with residents and their families, it is important that care home providers ensure residents understand their rights and have full knowledge of the care being provided.

To manage consent in accordance with regulations, we must first understand how consent is defined. The Care Quality Commission (CQC) gives context to consent within the Health and Social Care Act 2008, Regulations 2014: Regulation 11. This regulation ensures that all people using the service, and those lawfully acting on their behalf, have given consent before any care or treatment is provided.

How is consent given in residential care?

The individual giving the consent must have the necessary knowledge and understanding of the proposed care or treatment, with the information provided in a way that they can understand. This may include various forms of verbal or non-verbal communication, such as spoken or written language, sign language, symbols, or pictures.

This information should be provided by someone with the knowledge and understanding of the care treatment, including the risks, complications, alternatives, and the answers to any questions asked. Consent is not a one-time given, it is reassessed throughout a care plan and may be withdrawn at any time.

For residents who are unable to give consent, for reasons including learning disability, brain injury, or dementia, the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) must be followed. In such cases, care plans are independently assessed to ensure they are in the best interest of the individual, and the person acting on behalf of the patient or resident should consider all options to best support their basic rights and freedoms. Staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.

How is consent effectively managed in residential care settings?

To begin a journey of full compliance with a patient or resident, a ‘consent to care and treatment policy’ should be put in place. This policy requires that care providers gain the consent of residents to carry out any proposed care and treatment. Residents and their representatives will sign a contract agreement and will be consulted on any changes to regain consent, where necessary.

All care home staff must have appropriate training on the home’s consent policy, safeguards, and wider MCA training. An MCA and DoLS policy and procedure should be put in place with training, levels of responsibility, and standard authorisations. The aim of the policy is to ensure that individuals in care are able to live with as much freedom as possible, in line with their assessed need for care, and to ensure that their independence is maximised within their capabilities. Staff will carry out their duty to provide optimum care that meets the needs of the individual and protects their human rights.

Best practices for consent management:

  • Fully involve residents, their families, and decision makers in their care – give them all the facts they need to make informed decisions.
  • Ensure staff are sufficiently informed of a resident’s communication needs when seeking consent, so that they can explain the proposed care in a way that the individual will be able to understand.
  • Respect the right of an individual to refuse consent at any time, and regularly review all consent decisions to account for changing capacity and detail how a person can be supported to make choices.
  • Keep time-stamped digital documentation of signed consent.
  • Regularly audit and review consent processes.
  • Ensure staff receive training about the Mental Capacity Act and safeguards, with regular updates and refresher courses.
  • Continually seek verbal consent, even when a consent plan is in place and even if activities seem insignificant. For example, asking a resident if they are happy for you to put their socks on now.

Carer talking with a female care home resident
Regularly seek verbal consent during routine care.

Evidencing & managing consent using Blyssful care home software

Consent is a legal requirement that regulatory bodies such as CQC will check during their inspections, demanding documented evidence such as consent to care, treatment records, assessments of mental capacity, DoLS forms, and appropriate policies and procedures. Further, should there be for a breach of the consent regulations, the CQC has the ability to prosecute, following a warning notice or other regulatory action.

Evidencing and managing consent is made easy with Blyssful, the latest digital care management software from Ablyss. The software provides a full electronic history of consent, with information easily accessible for auditing purposes and CQC inspections.

One of the unique features of Blyssful is the way the software can be tailored, allowing the user to create a custom consent structure and process to suit their individual business requirements.

The consents icon is available under the main dashboard for each resident, and records all consents given, who they were given by, and whether a Best Interest Assessor (BIA) has been established to make decisions on behalf of the resident. Additionally, there is a secondary dashboard available for the purpose of reviewing the DoLS high priority related items, allowing staff to meet these needs.

Each time consent is gained, it can be easily logged on the Blyssful care management system. Supporting documentation can also be added for a complete record, providing date and time stamps for the duration of a treatment plan.

Comprehensive auditing tools, including a dashboard section on auditing DoLS, supports regular internal auditing. This allows residential care providers to remain compliant ahead of each regulatory inspection, be that held by the CQC in England, the CIW in Wales, the Care Inspectorate in Scotland, or the RQIA in Ireland.

Consent is not just necessary from a legal standpoint, it is also vital to ensure that residents have full independence, knowledge, and control over their own care. This grants them autonomy and confidence, as well as the dignity and respect of agreeing to treatment before it is given to them.

The personalised and humanised approach to consent, offered by Blyssful, maximises freedom and supports conversations between residents, staff, family, and friends to ensure the best care for that person is agreed upon and carried out.

If you would like to find out more about Blyssful’s consent recording and auditing features, or if you would like a demonstration of Blyssful with one of our expert team, please do not hesitate to get in touch.

Article by Sally White
Ablyss Co Founder

Ablyss Systems

Ablyss Systems Ltd
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