Archived: Highfield

Highfield is a residential care home providing accommodation with personal and nursing care for up to 34 people. The home was arranged across two floors with lift access to the upper floor. The service provides support to people with a range of needs, including people with physical disabilities and people living with dementia. At the time of our inspection there were 24 people living in the service.

People’s experience of using this service and what we found

The service did not always deploy enough staff to fully meet peoples’ support needs. There were not always enough staff to support people in a timely manner who needed assistance with their meals. Activities were limited due to staffing levels and there was a lack of social engagement with people.

People told us they felt safe living in Highfield and people received safe care and treatment from staff who knew them well. Medicines and infection control were both managed safely, and lessons were learned when things went wrong. People were protected from the risk of abuse by well trained staff.

People were involved in decisions about their care and they received care which promoted their dignity and encouraged independence. Relatives told us they were involved in their relative’s care plans and were kept up to date with changes, either in the service or with their relative’s care or health.

Effective quality assurance processes were in place to monitor the service and regular audits were undertaken. Staff had received appropriate training. A new registered manager had been appointed since our last inspection. People, relatives and staff all told us they found them approachable and supportive with an open-door policy.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 15 January 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service. As a result, we undertook a focused inspection to review the key questions of safe, effective and well led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has not changed following this focused inspection and remains good.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Highfield on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The registered manager worked at the service each day and was supported by a deputy manager. A registered manager is a person who has registered with CQC to manage the service. Like registered providers they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our last comprehensive inspection of this service took place in June 2017. Following this inspection, the key areas of Effective and Caring was rated as Good, while the areas of Safe, Responsive and Well Led were rated as Requires Improvement, together with the overall rating of the service.

A further inspection of the service took place in November 2017. This was a focussed inspection concentrating only on the key areas of Safe and Well-led and did not look at whether the service was Caring, Effective or Responsive. At that inspection, staff followed correct and appropriate procedures to promote the safe management of medicines; there was clear guidance for staff and protocols about the administration of medicines which were followed. People were supported in a safe environment and risks identified for people were managed in a way that enabled people to live as independent a life as possible. Accidents and incidents were consistently reviewed, and any potential safeguarding concerns were investigated, and referrals made to the local authority. The service was clean and potential infection control risks addressed. Recruitment procedures were robust and care planning had established people's needs and reflected their wishes about how they wanted to be supported. Staff felt there was good communication and they were clear about their roles. They felt well supported by the registered manager. Feedback was sought from people, relatives and professionals about how the service was run. Audits and checks were carried out each month by the registered and area managers, which were effective in identifying and addressing concerns and driving forward improvements. Following this inspection, the key areas of ‘Safe’ and ‘Well-led’ were rated as Good.

This inspection, completed on 12 and 15 October 2018, was a comprehensive inspection. We looked at all five key areas of the service. Improvement had been made in communication. However, additional steps in the systems and processes used to assess and monitor the operation of the service needed to be taken. This was to ensure the progress made in the service was further developed and sustained. The registered manager and the provider checked all areas of the service regularly to make sure it met the standards required. However, processes were not always effective in rectifying the cause of faults.

The management of people’s medicines was safe. Risks had been identified and action had been taken to manage them. Records about people and the care they received were accurate, complete, held securely and easily accessible to staff when they needed them.

Staff were kind and caring and treated people with dignity and respect. They took time to get to know each person well and provide the care people wanted in the way they preferred. People received the care and support they wanted at the end of their life.

Assessments of people’s needs and any risks had been completed and care had been planned with them, to meet their needs and preferences and keep them safe. Accidents and incidents had been analysed to look for patterns and trends. The registered manager worked in partnership with local authority safeguarding and commissioning teams, and a clinical nurse specialist for older people and acted on their advice to develop the service and improve people’s care.

Staff knew the signs of abuse and were confident to raise any concerns they had with the registered manager or provider. People were not discriminated against and received care tailored to them. A process was in operation to investigate and resolve complaints to people’s satisfaction. People had enough to do during the day, including activities to keep them physically and mentally active.

Changes in people’s health were identified and people were supported to see health care professionals, including GPs when they needed. People were offered a balanced diet of food they liked and that met their cultural needs and preferences. Staff supported people to be as independent as they wanted at mealtimes.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice. The registered manager knew when assessments of people’s capacity to make decisions were needed. Information was available to people in a way their understood to help them make decisions and choices. Staff treated people with dignity and gave them privacy. The registered manager understood their responsibilities under Deprivation of Liberty Safeguards (DoLS), and had applied for authorisations when there was a risk that people may be deprived of their liberty to keep them safe.

There were enough staff to provide the care and support people needed when they wanted it. New staff were recruited safely. Disclosure and Barring Service (DBS) criminal records checks had been completed to make sure staff were suitable for their role. Staff were supported meet people’s needs and had completed the training they needed to fulfil their role.

Staff felt supported by the registered manager and were motivated. A member of the management team was always available to provide the support and guidance staff needed. Staff worked together to support people to be as independent as they wanted to be. All the staff we spoke with told us they would be happy for their relatives to live at Highfied. The views of people, their relatives, staff and community professionals were asked for and acted on to continually improve the service.

The service was clean and staff followed infection control processes to protect people from the risk of infection. The building was well maintained and plans were in operation to maintain and improve the environment. People were able to use all areas of the building and grounds.

The registered manager had informed CQC of significant events that had happened at the service, so we could check that appropriate action had been taken.

Services are required to prominently display their CQC performance rating. The provider had displayed the rating in the entrance hall and on their website.

Further information is in the detailed findings below.

Highfield is a nursing home for up 34 older people some of whom may live with dementia illnesses, physical and sensory impairments as well as other conditions such as diabetes and epilepsy. The home is located in a rural setting outside the village of Bekesbourne. There were 26 people in residence at the time of this inspection.

This service was last inspected on 20 and 21 June 2017 when it was rated as ‘Requires Improvement’ overall. This was because medicines were not managed safely; information about a dose of medicine was missing, some instructions were confusing and protocols about the administration of some medicines were not always complied with. Risks to people had not been properly assessed or minimised and specialist advice intended to reduce risk was not always complied with. Accidents and incidents were not consistently reviewed. A matter that should have been reported to the local authority safeguarding team was not. Areas of the service and some equipment were not clean and posed a potential infection control risk, shortfalls in aspects of recruitment processes, previously pointed out, remained incomplete. Although there had been some improvement to quality assurance, checks were not fully effective, they had failed to identify the concerns evident at the last inspection or address some concerns highlighted at previous inspections. At this inspection we found required improvements had been made.

Staff followed correct and appropriate procedures to promote the safe management of medicines; there was clear guidance for staff and protocols about the administration of medicines were followed. We however identified recording of the use of some prescribed creams as an area that required improvement.

People were protected from the risk of abuse because staff had received safeguarding training and were aware of how to recognise and report safeguarding concerns. Any potential safeguarding concerns were investigated and referrals made to the local authority. We however identified access of visitors to the service as an area that required improvement.

The service and equipment used was clean and hygienic; some floor coverings previously of concern had been replaced in some areas of the service.

Staff knew about whistle blowing and were confident they could raise any concerns with the provider or outside agencies if needed.

People were supported in a safe environment and risks identified for people were managed in a way that enabled people to live as independent a life as possible. Personalised care plans, risk assessments and guidance were in place to help staff to support people safely. Health needs were kept under review, appropriate referrals were made when required, staff knew about and followed recommendations and instructions made by health care professionals.

An appropriately robust system to recruit new staff was in place and made sure staff employed to support people were fit and suitable to work at the service. There were sufficient numbers of staff on duty to make sure people were safe and received the care and support that they needed.

Staff felt there was good communication and they were clear about their roles. They felt well supported by the registered manager. Feedback was sought from people, relatives and professionals about how the service was run.

A number of audits and checks were carried out each month by the registered and area managers, which were effective in identifying and addressing concerns and driving forward improvements. The service notified us of events when they were supposed to and had displayed previous inspection rating.

Highfield is a nursing home for up 34 older people. It is set in a rural location on the outskirts of the village of Bekesbourne. There were 20 people living at the service at the time of this inspection, some of whom lived with dementia type illnesses, impaired mobility, sensory impairment and other conditions such as epilepsy and diabetes.

Accommodation is set over two floors and upstairs bedrooms can be accessed by a passenger lift. However, because of reduced occupancy, the first floor was unoccupied and everybody was accommodated on the ground floor where there is a communal seating area, quiet lounge and dining area.

The last full inspection of Highfield took place in June 2016 where the service was rated overall as ‘Requires Improvement’. Each of the five key areas looked at were rated Requires Improvement with the exception of ‘Caring’ which was rated as ‘Good’. Improvement was needed because we found five of our regulations were breached. These related to concerns about people’s nutritional and hydration needs not being appropriately monitored with issues arising not acted upon and failure to ensure care plans reflected people’s needs and wishes to guide staff in accordance with best practice. There was a failure to ensure protocols for some medicines were in place or have effective systems for the assessment and administration of pain relief. People were placed at risk because of the condition of some parts of the building where improvement was required and some safety measures were not observed. Staffing levels placed people at risk of becoming isolated and the service had not fulfilled its statutory obligation to accurately inform the Commission of the number of deaths occurring of people registered at the service. Following this inspection requirement actions were made and the management of the service submitted actions plans to us setting out how and when improvements would be made.

A further inspection of the service took place in November 2016. This was a focussed inspection concentrating only on the key areas of ‘Safe’ and ‘Well-led’. However, during that inspection we identified concerns about ‘Caring’, so we included this key area in the inspection too. Following this inspection, each of the three key areas looked at were rated as ‘Inadequate’ as well as an overall ‘Inadequate’ rating for the service. This was because there were continued breaches of our regulations relating to insufficient staff; adequate improvement had not been made to aspects of the building, as well as some lapsed safety critical checks, we also found medicines were sill not managed safely. In addition to these continued breaches of regulation we found other new breaches of our regulations. These related the failure to minimise risk to people through referrals to health specialists; the failure to ensure people were protected from neglect and abuse by appropriate referral of incidents to safeguarding authorities; the failure to have robust recruitment processes in place to ensure staff were suitable to work with vulnerable people; the failure to meet some people’s care and social needs and the failure to ensure management processes identified and improved the quality and safety of the service provided, some of which stemmed from a failure to maintain accurate and complete records about people.

The decline in the standards and ‘Inadequate’ rating of the service meant it was placed into ‘Special Measures’. Services in special measures are kept under review and immediate action may be taken to propose to cancel the provider's registration of the service. The latest inspection of this service found some improvement had been made. People and relatives gave positive feedback about the service, however, some aspects of practice potentially placed people at risk and further improvement was needed.

There was a registered manager in post; this was the same person who had been responsible for the day to day running of the service when the both of the previous inspections took place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Medicines were not managed safely, information about a dose of medicine was missing, some instructions were confusing and protocols about the administration of some medicines were not always complied with.

Risks to people had not been properly assessed or minimised and specialist advice intended to reduce risk was not always complied with.

Accidents and incidents were not consistently reviewed. A matter that should have been reported to the local authority safeguarding team was not.

Areas of the service and some equipment were not clean and posed a potential infection control risk.

Shortfalls in aspects of recruitment processes, previously pointed out, remained incomplete.

Poor communication had impacted upon the care and support some people needed; incontinence equipment had not been available and some people did not receive the care and support they required.

Elements of care planning did not fully establish some people's needs or reflect their wishes about how they wanted to be supported.

Although there had been some improvement to quality assurance, checks were not fully effective, they had failed to identify the concerns evident at this inspection or address some concerns highlighted at previous inspections.

There were sufficient staff to meet people’s needs. Staff had received training in a range of topics and this had been regularly refreshed. Supervisions and appraisals had taken place to make sure staff were performing to the required standard and to identify developmental needs.

People’s rights had been protected by assessments made under the Mental Capacity Act (MCA). Staff understood about restrictions and applications had been made to deprive people of their liberty when this was deemed necessary.

People enjoyed their meals, any risks of malnutrition or dehydration had been adequately addressed.

Staff treated people with kindness and respect for their privacy and dignity. Staff knew people well and remembered the things that were important to them. There were a range of activities.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The service is a nursing home for up 34 older people some of whom may live with dementia type illnesses, physical and or sensory impairments. The home is located in a rural setting outside the village of Bekesbourne. There were 23 people in residence at the time of inspection.

This service was last inspected on 2 and 3 June 2016 when it was rated as ‘Requires Improvement’ overall.

There was a registered manager in post. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Risks to people had not been properly assessed or minimised. This included environmental risks, those associated with being unable to reach call bells; and risks from medicines being poorly managed.

There were not enough staff deployed to meet people’s needs effectively and recruitment processes did not ensure that only suitable staff were taken on.

Accidents and incidents had not been consistently reviewed by the registered manager so that preventative actions could be considered. Not all staff understood their responsibilities around keeping people safe from abuse or neglect, and advice had not always been sought from the local authority when people had unexplained injuries.

Most staff were kind and respectful but not all staff acted to meet people’s needs appropriately.

People’s independence was not actively promoted and some people stayed in bed all the time; when they could have been supported to get up. There was a lack of consideration about older people’s needs and of those of people living with dementia. Their experiences could have been improved with more thought.

There had been a lack of effective leadership in the service for the last two months. This had resulted in the development of a poor culture amongst staff and to people receiving a reduced standard of care in some cases. The provider had reacted to the situation, but at the time of our inspection, support mechanisms put in place for the registered manager and staff had not produced sufficient improvement.

We identified a number of breaches of Regulations. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

This service was last inspected on 19 May 2014 when we found the provider was meeting all the regulations. There was a registered manager in post. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were treated with kindness and respect by staff but shortfalls in some areas of practice meant that people could be placed at risk. Observations and discussion with staff and relatives showed that there was not enough staff to meet the needs of people living in the home. The lack of flexibility within the staff team led to isolation for those people who stayed in their rooms either by choice or because there were not enough staff, space or appropriate equipment available to enable them to transfer to specialist seating and sit out in communal areas.

Medicines were mostly managed well but improvement was needed with protocols for administration of some medicines. How people were supported with their hydration and nutrition needs was not always well documented to show the action was taken.

Care plans to show how people’s health needs for everyday support and end of life care was supported by staff practice. The Care Quality Commission (CQC) were not notified as required regarding the death of a service user still registered as a resident of the service,

The provider had identified a need for investment in the premises and plans were in hand for some upgrading to take place. We considered however, that some repairs and maintenance needed to be progressed sooner as they posed a risk to people in the home and or their visitors. We asked the provider to ensure that immediate action was taken to address sunken flooring outside the dining room which posed a tripping hazard, and also wear and tear on some wooden handrails which left people at risk from splinters in their hands.

Staff had received fire training, they understood fire procedures and how to evacuate the building and they attended fire drills. We have made a recommendation that the provider seek further advice from the fire service in regard to some of these arrangements.

Quality assurance audits were undertaken, to monitor service quality and address any issues highlighted from, we have recommended that timescales for addressing shortfalls be reviewed to ensure those that impact on the quality of support and experience of care people receive are dealt with as soon as possible.

Staff were working to the principles of the Mental Capacity Act 2005 (The MCA provides a framework for acting and making decisions on behalf of people who lack mental capacity to make particular decisions for themselves), but decisions made in the best interest of people were not always well documented in care plans and we have made a recommendation around this.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager had referred a number of people for assessment for DoLS authorisations but these were still to be processed. The registered manager understood when an application should be made and the service was meeting the requirements of the Deprivation of Liberty Safeguards.

People were provided with a wide range of activities but not everyone was able to access these, some people nursed in their rooms were at risk of isolation and we have made a recommendation for improved recording in this area to judge the level of interactions with other people they have.

People and their relatives felt able to raise concerns and felt these would be addressed but improvements were needed in the way complaints were recorded and managed and we have made a recommendation for this.

People told us they felt safe and liked the registered manager and staff that supported them. Relatives told us they had no concerns about the service and were satisfied with the overall standard of support provided. They felt confident in the quality of care and said they were kept fully informed by the service and that communication was good.

Recruitment processes ensured only suitable staff were employed. Staff received induction and a range of training to give them the knowledge and skills they needed. Staff felt listened to and supported staff received regular formal supervision and met regularly with their registered manager, records of these discussions were made available to view.

Staff were able to demonstrate they could recognise, respond and report concerns about potential abuse. The premises were clean. All necessary checks tests and routine servicing of equipment and installations were carried out.

People ate a varied diet that took account of their personal food preferences. Their health and wellbeing was monitored by staff that supported them to access regular health appointments when needed.

People said their needs were attended to by staff when and if they required it. People respected each other’s privacy. People were supported to maintain links with the important people in their lives and relatives told us they were always consulted and kept informed of important changes.

We have made five recommendations:

We recommend that the provider seeks support and training for the management team to be able to review the current development plan for the service and prioritise shortfalls to ensure those that currently and directly impact on the quality of support and experience of care people receive are dealt with as soon as possible.

We recommend that the provider seeks advice and guidance from a reputable source, about the management of isolation and provision of activity and stimulation to people nursed in their rooms.

We recommend that the provider seeks guidance in respect of recording best interest decisions in keeping with current best practice.

We recommend that the provider consider current fire legislation and guidance in relation to the frequency of fire drills for day and night staff and the content of evacuation plans for people and take action to update their practice accordingly.

We would recommend that the provider seek guidance form a competent source suggestions for best practice around meaningful effective signage and décor for people with dementia.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We viewed the communal rooms and some of the bedrooms on the ground floor. The manager told us that the first floor was out of use whilst maintenance work and alterations were being carried out. We saw that the premises were visibly clean in all areas and provided a pleasant environment.

We found that the company had comprehensive procedures in place to check that people had consented to the care and treatment provided for them. People who lacked the mental capacity to make decisions about where they lived or the care that they needed had been appropriately supported by their family members or advocates, and by health and social care professionals, to make decisions on their behalf and in their best interests. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS).

We inspected medication management and found that appropriate procedures were in place to ensure that people received the right medicines at the right time, with the support of trained nursing staff.

Is the service effective?

People living in the home had suitably detailed care plans which covered all aspects of their care and treatment. This included individual needs assessments, and people's preferences in regards to their care. We saw that people or their representatives had been involved in all aspects of their care planning.

We found that people were supported by other health and social care professionals to provide them with additional care or treatment as needed.

The home provided people with choices for their dietary needs. We saw that menus were sufficiently varied to provide a nutritious diet. People said 'The food is very good here', and 'There is plenty of choice and the cooks do a very good job'.

The home had an on-going training plan in place. We saw that staff kept up to date with required training subjects such as health and safety, moving and handling, fire safety, infection control, and food hygiene. Staff carried out other training to enable them to provide effective care. This included subjects such as understanding dementia, safeguarding vulnerable adults and the Mental Capacity Act 2005.

Staff were provided with support through individual supervision meetings, through staff meetings, and through yearly appraisals.

Is the service caring?

People that we talked with spoke highly of the staff and the way in which they cared for them. People's comments included 'The staff are very nice and helpful'; 'The staff always come if I ring my call bell'; and 'I am very well cared for. I am very pleased to be here.'

We saw that staff spoke to people respectfully and listened to them. They showed kindness and interest in what people were saying.

Care plans showed that staff were informed about people who preferred to have specifically male or female staff to assist them with their personal needs, and staff adhered to this.

We observed staff assisting people with eating and drinking at lunch time. We saw that they did not rush people and engaged them in conversation so as to make the meal a pleasant experience.

Is the service responsive?

The home employed an activities co-ordinator who arranged for a variety of different activities to be available. We saw that care staff also took part in assisting people with activities during the day of our visit. This included three people enjoying karaoke singing with one of the staff; and two people being taken out in the grounds in their wheelchairs.

The staff encouraged people to eat with others at meal times, and to take part in activities with other people so as to prevent them from becoming socially isolated. However, they also respected people's decision to stay in their own rooms, and checked that they had the things in reach that they needed.

We viewed residents' meeting minutes, and saw that the home implemented changes as a result of listening to people. For example, people had said that they would like to go out more, and the manager was making arrangements to provide this more easily.

People that we spoke to said that if they had any concerns they could 'speak to anybody', and expected their concerns to be dealt with appropriately. We saw that the home had a formal complaints procedure, and the manager carried out investigations and responded to people appropriately.

Is the service well-led?

The company and the manager had systems in place to provide on-going monitoring of the home. This included care plan reviews, and checks for the environment, health and safety, fire safety, staff training needs and medication management.

Staff said that they worked well together as a team and were supported by the management structure. We saw that they interacted well with each other as well as with the people living in the home. The manager and deputy manager provided daily support working alongside the nursing and care staff.

Staff had individual supervision with their heads of department, which enabled them to discuss any training needs or raise any issues.

The company carried out a monthly review of the home to check that it was meeting the essential standards of quality and safety, and to identify any required changes.

We observed staff interacting with people who use the service in a sensitive manner and saw that they explained the care they delivered at a level individuals could understand. We observed People eating their meals at lunch time and found that people had a choice of dishes from the menu and that drinks were readily available throughout the day. Some people preferred to stay in their rooms and we saw that staff checked on their needs throughout the day.

We found that the home was clean and free from infection and that the provider was in the process of replacing the flooring in some people's rooms. Staff were able to demonstrate their understanding of infection control processes and we saw that policies and procedures were followed.

People who could, had signed their care plans and the correct processes and legal requirements for those who could not fully understand their care needs had been followed under the Mental Capacity Act (2005).