BMC Geriatrics
SYSTEMATIC REVIEW	Open Access
What is known about the design, delivery and implementation of mental capacity training in care homes?: a scoping review
Nina Jacob, Michelle Maden, Alys Wyn Griffiths3*, Louis Stokes, Victoria Shepherd1, Ruaraidh Hill2, Sion Scott, Hayley Prout1, Cara Gates3, Liz Jones, Lesley Bethell5, Peter Hewkin5, Grahame Smith, Mishel Ingle3 and Nefyn Williams2
Abstract
To provide high-quality care to people living in care homes, it is crucial that care home staff possess the knowledge and skills necessary to apply the principles of mental capacity legislation. In order to achieve this, training must be delivered and implemented. This review aimed to identify what is known about the design, delivery and implementation of mental capacity-related education and training in care homes. A scoping review was conducted in line with Joanna Briggs Institute guidance, and reported in accordance with PRISMA-ScR. A total of 3055 records were retrieved by the search and independently screened by two reviewers. A total of 14 papers met the inclusion criteria and were included in the review. Results were synthesised and mapped to the TIDieR checklist. The results highlighted two key factors. Firstly, a standardised one-size-fits-all approach to mental capacity legislation training fails to take account of the diverse needs of both care home residents and staff. Secondly, understanding the relationships between these domains can help overcome barriers and enhance facilitators, leading to more effective training outcomes. The review highlights a knowledge gap, with limited research considering the design and delivery of mental capacity related training. This limits the development of consistent and effective training across the sector. Future research should consider issues of diversity among care home staff or residents, to ensure the appropriateness and applicability of training for all those who receive it.
Keywords Mental capacity legislation, Decision making capacity, Nursing homes, Care homes, Training, Education, Dementia
*Correspondence:
Alys Wyn Griffiths
alys.griffiths@sheffield.ac.uk
Introduction
Care homes across the UK provide accommodation alongside personal and/or nursing care [1]. Approximately 75% of older residents living in care homes have moderate to severe dementia or other cognitive impairment, and consequently, many of them will have impaired capacity to make decisions [2–4]. For this reason, it is crucial that care home staff can support residents’ decision-making, ensuring that any decisions made on their behalf are in accordance with underpinning ethical and legal frameworks. This enables them to support residents in making person-centred, ethical and lawful decisions [5, 6].
The Mental Capacity Act (MCA) 2005 [7] provides a legal framework to safeguard the rights of people in England and Wales who lack capacity to make decisions for themselves, whether temporarily or permanently. Equivalent legislation exists in other parts of the UK including the Adults with Incapacity Act (Scotland) 2000 (AWI) [8] and Mental Capacity Act (Northern Ireland) 2016 [9]. The MCA requires professionals to offer appropriate support to adults in their care to make decisions regarding their health, welfare, accommodation, and finances, as well as day-to-day matters, sometimes referred to as “small acts” of care [10].
The MCA Code of Practice (UK Government, 2007) [11] provides guidance on supporting decision-making and assessing capacity, including principles such as ‘best interests’. While the MCA and AWI are primarily used in care homes, the Mental Health Act (MHA) may also be relevant in some circumstances. The MCA and AWI focus on protecting the rights of individuals who lack the capacity to make decisions, whereas the MHA primarily concerns individuals with mental health conditions, regardless of their capacity to consent. In care homes, it is important to recognise that many individuals face issues that could be covered by either framework. This creates a complex legal landscape where both the MCA (and equivalent legislation) and the MHA must be considered when making decisions about care.
In the UK, care home staff include healthcare assistants who typically receive on-the-job training as no formal qualifications are required. In nursing homes, staff work alongside registered nurses to provide a balanced mix of personal care and clinical support. All staff who work with individuals with impaired or reduced capacity should undergo training on mental capacity legislation. However, there is considerable variation in the content and delivery of such training across care homes. Regulatory bodies have raised concerns about the limited understanding of mental capacity within social care, and evidence suggests that implementation of this legislation is lacking in practice [12]. Despite these concerns, there is limited research on best practices for training in mental capacity legislation, and how training approaches vary across the sector remains poorly understood.
Two previous reviews have explored mental capacity training in the UK social care context. The first, in 2013, focused on implementation of the MCA for those working with older adults, but did not address training methods for delivering high quality MCA-compliant care [13]. The second, a 2019 narrative review, evaluated the impact of MCA training on professional practice [14]. This scoping review builds on these by incorporating an additional decade of evidence to comprehensively map current best practices in mental capacity training in the UK care sector.
Review question
What is known about the design, delivery and implementation of MCA training and education in care homes, including equivalent mental capacity legislation in devolved nations?
Methods
A scoping review is an appropriate method to (a) identify the scope of available literature on a given topic; (b) provide an overview of concepts relating to the topic; and (c) identify gaps in the literature [15]. Given the limited literature exploring training surrounding the MCA, a scoping review of the available evidence, and evidence gaps, was considered most appropriate. This review was conducted in accordance with the Joanna Briggs Institute guidance for scoping reviews [16] and reported in accordance with PRISMA-ScR (scoping review extension) guidance [17]. The protocol was published on the OSF website [18].
Search strategy
Searches were conducted in MEDLINE, APA PsycINFO, Embase, CINAHL, Social Care Online, Social Policy and Practice, Health Management Information Consortium (HMIC), Scopus, Google Scholar, LENS.org and the NIHR Journals Library. Additional sources were identified by searching the National Grey Literature Collection (https://allcatsrgrey.org.uk/) and relevant care home organisation websites identified by authors.
An initial comprehensive search strategy using subject headings and free text terms that describe the MCA and care home settings was developed. Search terms were refined with the wider research team and stakeholders, with the search strategy adapted for each database and/ or information source (see Supplementary Material 1). Searches were limited to English or Welsh language. In addition, the reference lists of included studies were hand-searched, and citation searches were conducted on the included studies. Search results were downloaded into EndNote 19 and de-duplicated.
Screening
Using Covidence, two reviewers independently screened all retrieved titles and abstracts against the inclusion criteria. The full texts of selected records were retrieved and assessed against the inclusion criteria by two independent reviewers, with reasons for exclusion documented. Any disagreements regarding inclusion of abstracts or full-text articles were resolved through discussion between the two reviewers, with additional reviewers involved to reach a consensus if necessary.
Eligibility criteria
Participants
Care home staff working with older adults (including care, non-care and management) who are offered or have participated in mental capacity training with assessment, practice or implementation focus or component(s).
Exclusions Staff working in non-social care settings (such as secondary and tertiary hospital healthcare and the community, including peoples’ homes) or who work exclusively with younger adults (i.e. aged 65 or younger) or children.
Concept
Training and education programmes covering content around mental capacity legislation and assessment of mental capacity.
Context
Care home staff or management based in the UK who are offered or have participated in training with MCA (or equivalent legislation) assessment, practice or implementation focus or component(s). Hospice settings were excluded.
Publication types
Exclusions Systematic reviews relevant to the topic were checked for relevant primary studies and then excluded. Studies preceding the date of the MCA 2005 [7] or AWI Act (Scotland) 2000 [8] or MCA (Northern Ireland) 2016 [9] were excluded, dependent on country the training was tailored to.
Data abstraction
Two reviewers independently extracted relevant data on participants, concept, context, study methods, and key findings relevant to the review question (e.g., study design, demographics of care setting and overview of training delivered). Additionally, where applicable, components of the design, delivery, and implementation of training were mapped to the Template for Intervention Description and Replication (TIDieR) checklist [19]. Where data were available on the content of the training, this was mapped to the five key principles of the MCA; (1) Presumption of capacity; (2) Support to make a decision; (3) Ability to make unwise decisions; (4) Decisions must be made in the person’s best interest; (5) Least restrictive option should be used.
Analysis
After familiarisation, one reviewer (NJ) completed preliminary coding of the papers, which was checked by a second reviewer (HP). A codebook was developed and initially mapped to the domains of the TIDieR checklist to support systematic extraction and comparison of intervention descriptions. We also produced a summary table, structured around the TIDieR framework, to present these findings in a clear and accessible format (see Table 1). However, during coding, we noted that while many studies provided considerable detail on aspects related to how well the intervention was implemented (e.g., barriers and facilitators), there was limited information on tailoring, modifications, and particularly on the content of what was actually delivered. As a result, the analysis was extended to include additional inductively generated themes that better reflected the broader patterns emerging from the data.
We undertook a descriptive-level thematic synthesis, with coding and categorisation focused on identifying common implementation-related issues across studies rather than deep interpretative analysis. This allowed us to group codes into six thematic categories, with discrepancies resolved through discussion. The final themes are presented below and discussed with reference to the TIDieR checklist.
Results
The searches identified 3055 potentially eligible records of which, 1414 were duplicates. Following screening of 1641 titles and abstracts, 381 records were retrieved for assessment of the full-text publication. After review of the full-text publications, 14 papers were included in the review (see Fig. 1). Thirteen papers focussed on the MCA (2005) and one paper on the AWI (Scotland) Act 2000. No papers were identified that explored training relating to the Mental Capacity Act (Northern Ireland) 2016. Further characteristics of the included papers are summarised in Table 2. Descriptions of how the training was delivered, specifically the materials used, who provided it, and the mode of delivery was reported by eight papers [20–27]. The content of the training was less frequently reported with six papers [22, 23, 26, 28–30] detailing elements of what was delivered. Thirteen papers reported on barriers and facilitators to the implementation of mental capacity training in care homes.
Table 1 TIDieR data extraction
Brief name	Why	What materials	What procedures	Who provided	How	Where	When & how much	Tailoring	Modification	How well (actual & planned)	
Alzheimer's Society (2009).	Training resource for people implementing the MCA	Text based quiz to determine existing knowledge of the	Quiz	Aimed at people who have a basic understanding of the MCA	Text based resource	Not reported	Not reported	Training package encourages recipient to reflect and think about how they might feel if a decision was being made for them, and to tailor every decision to the individua	Not reported	Not reported	
Care Qual-	To assess how wel	- Pocket-sized	- MCA/DoLS train-	Varied by	-Training delivery	Health and	-Highly vari-	Some services	Not specified	-Large variation	
ity Commission (2012a)	providers, commissioners, and staff understand and implement the MCA and DoLS; identify barriers to training and practice; and ensure that care planning, consent, and best interest decisions comply with the legal framework.	quick reference guides- Consent and capacity checklists- Safeguarding policies- Booklets and leaflets- Codes of Practice (MCA and ΜΗΑ)- Information on staff intranet and in handbooks	ing sometimes integrated into general induction or unrelated training (e.g., fire safety)- Some organisations had tiered training (e.g., registered staff first, care workers later)- hformation dissemination via team meetings, handbooks, and noticeboards- Use of local leads and MCA champions	setting	methods varied widely: classroom sessions, informa briefings, use of written guides, intranet pages-
n some cases, learning was cascaded through staff meetings or led by designated champions	adult social care services across England including care homes, hospitals, and local authority- funded services.	able some training only during initia MCA rollout, others offered ongoing or refresher training- Some staff had no MCA/ DoLS training at all, while others had attended multiple sessions (e.g., tiered programmes)- Reports of out-of-date or missing training	offered tailored training by role (e.g., managers vs care workers)		in understanding and implementation- Some staff lacked awareness of basic MCA principles (e.g., confusing MCA with ΜΗΑ)- Training did not always translate to practice, as evidenced by unreported safeguarding incidents, misuse of DoLS, and misunderstandings around ‘sectioning’under the MCA	

Brief name	Why	What materials	What procedures	Who provided	How	Where	When & how much	Tailoring	Modification	How well (actual & planned)	
Care Qual-	To assess	Training materials	Training often	Not explicitly	Variable: some	Care homes in	Timing	Sometimes tar- Not specified	Delivery was	
ity Com-	implementation	not specified	contextualised	stated. Training	formal training	England	inconsistent.	geted by role	highly incon-	
mission	of DoLS, with a	in detail; often	within broader	was often	sessions (often		Some staff had	(e.g. manager	sistent. Some	
(2012b)	focus on training	embedded	care topics. Some-	recommended	years out of date),		training two	vs care worker).	homes had	
	levels among care	within broader	times delivered	by local com-	contextual/inte-		or more years	Often recom-	trained managers	
	home staff and	care topics (e.g.	initially at DoLS	missioning	grated training		prior with no	mended to se-	only, while others	
	management, and	dementia care,	introduction, but	teams (e.g. to	with other sub-		refreshers.	nior staff only.	had not delivered	
	to monitor uptake	safeguarding,	not systematically	managers), but	jects, or training		Others had not	No evidence	any training. Even	
	and effectiveness	consent, human	repeated. Some	delivery agents	planned but not		yet attended	of tailoring	when training	
	of training across	rights)	homes had no	or educators	yet delivered.		training. Train-	to individua	had occurred,	
	the sector.		training or only planned future training.	were not described.			ing generally viewed as a one-time event rather than ongoing professiona development	learning needs or experience level.	staff often lacked confidence or understanding of DoLS. Emphasis placed on the need for regular refresher training and better tracking (e.g. training matrices not updated). Indicates that even where training occurred, effectiveness and sustained understanding were limited.	
Care	To ensure staff un-	Not specified	- Training delivery	Varied across	- Combination of	Health trusts,	Not specified	Leadership and Not specified	Mixed outcomes:	
Quality	derstand and apply		varies by provider	organisations;	formal training	adult social care		organisationa	many staff	
Commis-	the MCA and DoLS		and sector - Use	includes lead-	and ongoing staff	providers, in-		culture tailored	demonstrated	
sion (2016)	properly to protect		of staff'champi-	ership (man-	support - Leader-	eluding nursing		approaches to	good under-	
	patients' rights and		ons'for menta	agers), staff	ship fostering	and residentia		embed training	standing of MCA/	
	promote person-		capacity training	champions,	culture valuing	care homes		and under-	DoLS, especially	
	centred care.		in some providers	and possibly	engagement	across England.		standing. Use	in outstanding	
	Address ongoing		- Documentation	external train-	and understand-			of champions	services - Many	
	gaps in training		and advo-	ers. Inspectors	ing - Champions			to support	services stil	
	and knowledge		cacy practices	note that	supporting peers			staff learning	had inadeguate	
	to improve quality		reviewed during	absence of	- Monitoring via			adapted to	training and	
	and safety of care		inspections	registered	CQC inspections			provider needs.	understanding	
			- Leadership engagement to support training and culture	managers often coincided with poor practice.					- Leadership presence correlated strongly with better training and practice	
Jacob et al. BMC Geriatrics (2025) 25:860	Page 5 of 20

Brief name	Why	What materials	What procedures	Who provided	How	Where	When & how much	Tailoring	Modification	How well (actual & planned)	
Davidson	To ensure staff	Printed materials	Varied by area:	Health Board	n-person group	Local authority	Yes - tailored	Yes - tailored	Ongoing updates	Training delivery	
et a	across health and	(47%), discussion	awareness-raising	officers,	training (lectures,	and NHS Health	by occupa-	by occupa-	encouraged.	was highly	
(2004)	social care under-	guides, Power-	seminars, full-day	social work	workshops, semi-	Board settings	tional role (e.g.,	tional role (e.g.,	Recognised need	variable across	
	stood and could	Point presenta-	specialist train-	departments,	nars, awareness	across 4 geo-	MHOs, CPNs,	MHOs, CPNs,	for refresher and	settings, with	
	apply Part 5 of the	tions, workshops	ing, case-based	some externa	sessions); some in-	graphic areas of	psychiatrists,	psychiatrists,	follow-up training	significant differ-	
	Adults with Inca-	(30%), video	workshops, team	trainers; oc-	formal peer learn-	Scotland	care home	care home	as legislation	ences in coordina-	
	pacity (Scotland)
Act (2000), with the	(5%) - quality and specificity of	briefings; some areas integrated	casionally joint NHS-LA teams.	ing and ongoing case-based discus-		staff); informa need-based	staff); informa need-based	evolved and staff experience	tion, content, and uptake. Voluntary	
	goal of improving	materials varied	procedures and	Area 1 had	sions. No remote/		follow-up	follow-up train-	grew. Some	participation led	
	capacity-related	across areas	guidance into	a dedicated	online training		training	ing emerged;	trai'ners hesitant	to uneven staff	
	decision-making in		training delivery	officer; Area	mentioned		emerged;	trainers re-	to deliver early	engagement,	
	practice			4 showed a coordinated LA approach. Inconsistent delivery in some regions			trainers reguested more occupationspecific content	guested more occupationspecific content	due to evolving guidance	often influenced by trainer reputation and individual enthusiasm. Many staff lacked confidence and reguested follow-up or role-specific sessions to support practical application. Key gaps included limited GP involvement and the absence of structured training for private care homes. Barriers such as staffing pressures, fragmented planning, and competing priorities hindered implementation. However, where delivered, training was well-received, and there was widespread recognition of the need for ongoing learning	

Brief name	Why	What materials	What procedures	Who provided	How	Where	When & how much	Tailoring	Modification	How well (actual & planned)	
Gough	To explore how	Workshops,	Training delivered	Training de-	Predominantly	Training	Not always	Training was	Suggestions	Many manag-	
and Kerlin	MCA training is	e-learning, DVD	primarily through	veloped with	face-to-face	occurred in	specified, but	not wel	included devel-	ers unaware of	
(2012)	implemented and	tools, and in	workshops. Some	support from	workshops. Some	local authority	training was	tailored to	oping flexible de-	how well staff	
	applied in residen-	some cases real-	follow-up discus-	a sub-regiona	use of digital tools	residential care	not manda-	job roles or	ivery options (e.g.	engaged with	
	tial care homes,	ife case scenario	sion sessions re-	development	ike DVDs or e-	settings in the	tory. Delivery	to the care	bite-size training	or applied the	
	and to identify bar-	discussions. Sug-	ported. Managers	group (strate-	learning modules.	East Midlands;	was irregular	context. MCA	at shift change),	training. Some	
	riers and enablers	gestions made	highlighted the	gic oversight),	Limited tailoring	often off-site	and varied	was treated as	integrating MCA	managers mis-	
	to effective training	for additiona	value of in-house,	local authority,	to learners' roles.	or in workshop	across settings.	a standalone	into induction,	understood MCA	
	and application in	tools: checklists	bite-size sessions	and indepen-	Suggestions in-	environments.	Follow-up was	topic, making	offering real-life	relevance (e.g.	
	practice. The study	or crib sheets	and workplace-	dent care	eluded integrated	Calls for more	not routine.	it harder for	case scenarios,	assuming it didn't	
	aimed to inform	for supporting	based learning	providers.	training formats,	workplace-	High staff turn-	staff to see	and creating	apply if residents	
	future strategic	decision-making	that connects	Delivery often	workplace sce-	based delivery	over disrupted	its relevance.	decision-making	were assumed to	
	and operationa	and document-	theory with care	uncoordi-	narios, and mixed-		continuity.	Integration	prompts.	have capacity).	
	approaches to	ing rationale.	contexts.	nated; some	method delivery			with other		Training seen as	
	training delivery.			care homes				care topics		more effective	
				had access				recommended		when supported	
				to dedicated						by e-learning	
				DoLS teams.						tools and followed by reflective discussions. High demand for better integration, application-based learning, and monitoring tools. Time, cost, and staffing cover remained significant barriers.	

Table 1	(continued)	
Brief name	Why	What materials	What procedures	Who provided	How	Where	When & how much	Tailoring	Modification	How well (actual & planned)	
Iliffe eta	To explore imple-	Not specified	Longitudinal gual-	Training pro-	Mixed methods:	Community-	Training was	Training was	Not specified,	Training was in-	
(2015)	mentation and	in detail, but	itative interviews	viders varied	Mostly didactic	based dementia	usually one-	not routinely	but implications	consistently deliv-	
	impact of the MCA	includes face-	with practitioners	- typically loca	training, although	services includ-	off; follow-up	tailored. Di-	from findings	ered and variably	
	across four demen-	to-face training,	(n = 272), people	authorities,	this was criticised	ing care homes,	or refresher	dactic formats	suggest the need	applied. There	
	tia care phases	supervision, and	with dementia	safeguarding	as ineffective.	and healthcare	training was	were often	to modify training	were significant	
	(pre-diagnosis to	resources from	(n = 16), carers	teams, or spe-	Very little training	settings across	rare. There was	seen as too	delivery toward	concerns about	
	end of life) in community settings.
Specifically:!)Identify implementation issues;2) Make recommendations on CPD and integration with adult safeguarding	local MCA/DoLS experts. Staff drew on loca safeguarding teams and DoLS professionals as valued resources. Didactic training was commonly used, though often criticised	(n = 15), and older people (n = 37). Interviews took place at two time points, allowing reflection on training experiences and changes in practice. The study also explored how practitioners learned about the MCA, challenges translating training into practice, and reliance on informal support.	cialist MCA/ DoLS leads.
Staff within local authorities were seen as important sources of support and guidance.	occurred through supervision or in practice-based reflective formats. Training delivery was variable and often one-off; gaps existed, particularly in hospital settings and high-turnover environments.	England.	a clear call for continuous, embedded learning processes. Longitudina design allowed exploration of training over a 9-12 month follow-up period.	general. The need for more occupation- and contextspecific training was highlighted. The lack of refresher or tiered training also limited practica application.	ongoing, embedded, and applied models.	poor uptake in high-turnover environments, lack of hospitalbased training, and minima use of the MCA in supervision. Training was not seen as relevant or welcome when overly abstract. Professionals often relied on informa or overloaded local knowledge sources. Practitio-	
ners highlighted the importance of integrating MCA training with broader safeguarding and care practices, and the risks of isolating it as a standalone topic. The need for continuous, experiential, and applied learning was strongly emphasised.
Brief name	Why	What materials	What procedures	Who provided	How	Where	When & how much	Tailoring	Modification	How well (actual & planned)	
Jayes et a (2022)	To support staff in legally-compliant assessments	Participants used informal (e.g., observation) and formal processes (e.g., the MCA functional capacity test, OPSI 2005, paragraphs 2-3) to assess capacity.	Staff use MCAST guides in formal/informa assessments	All care home staff & qualified nursing staff	Face to face	Five care homes across North West England	Not reported	High -tools and procedures adapted to each resident's communication needs	Not detailed - no timeline on adjustments made during rollout	Training boosted confidence; audits/CQC noted practice adherence	
Man-	To examine how	DH-issued scaf-	Training included	MCA Policy	Combination	Two loca	Training oc-	Tailored sup-	Not explicitly	Observed	
thorpe	commissioners and	folding resources	formal sessions	Officers, MCA	of face-to-face	authority case	curred during	port delivered	stated, though	variation in staff	
and Samsi	practitioners ap-	(e.g. implemen-	(delivered by	Champions,	training, tailored	study areas.	MCA roll-out	via MCA link	flexible adapta-	confidence	
(2009)	proached the early implementation of the MCA, highlighting strategies, barriers, and variation across two loca authority areas. The study emphasised the need for a sustained, multimethod approach to change and ongoing workforce development.	tation guides, PowerPoint slides, IMCA commissioning guidance), SCIE training resources, regiona workshops, audit tools, and tailored internal materials (e.g. MCA Leads group notes)	internal champions or externa freelance trainers), policy development, and support structures ike MCA Leads Groups. Approaches ranged from isolated training delivery to integrated reflective networks.	freelance trainers, MCA Link Officers, supported by Department of Health and SCIE resources.	support, peer reflection groups (e.g., Leads Group), and informa discussion		with ongoing support (e.g., LA1‘s MCA Leads Group continued two years postimplementation). Scope and freguency varied—some areas had standalone training; others embedded reflective practice.	officers, training adapted to workforce roles (e.g. learning disability, dementia care); MCA Leads used peer expertise within service settings.	tion to loca contexts and professional roles was encouraged.	and training impact. Training often seen as one-off event; concern about staff's ability to translate training into practice due to literacy, language, and learning styles. Highlighted need for multi-method, sustained learning.	

Brief name	Why	What materials	What procedures	Who provided	How	Where	When & how much	Tailoring	Modification	How well (actual & planned)	
Man-	To explore chal-	Written literature,	hformal/ad-hoc	Not specified	Mixed delivery	In care homes	Training	Some tailor-	Managers	Knowledge levels	
thorpe et	lenges staff face in	email communi-	training practices		modes: written	(no location	described	ing through	anticipated future	varied greatly;	
al (2011)	implementing the	cations, posters,	including peer		materials, team	specified)	as sporadic,	incident-driven	care plans and	confidence often	
	MCA, particularly	generic presenta-	discussions,		meetings, posters,		event-based,	discussions;	documentation	mismatched with	
	with people with	tions, one-day	notice board		informal peer		or delivered	anticipated	to include more	actual under-	
	dementia; to assess	workshops. Staff	information, and		discussion, some		'as needed)	introduction of	MCA guidance.	standing. Aware-	
	knowledge, train-	noted they were	incident-based		one-day work-		Generally no	MCA-informed	Informal modifi-	ness of concepts	
	ing, expectations,	inundated with	learning. Occa-		shops. Tended to		consistent or	care plans;	cations through	ike IMCA, DoLS,	
	and use of the	iterature but had	siona workshops		be reactive rather		comprehen-	emerging	practical applica-	and LPA was	
	MCA.	imited time to engage with it. No specific structured materials used across al	and presentations; often training seen as one-off events rather than an		than structured.		sive training programme.	awareness of IMCA and LPA responsibilities. Evidence ofa desire	tion of principles without structured training.	imited. Written guidance poorly received. Training perceived as 'events', not	
		homes.	ongoing process.					to adapt the Act's principles to support person-centred care.		continuous learning. Despite gaps, staff practices often aligned with MCA values in spirit. Practica understanding often relied on 'common sense' rather than forma legal knowledge. Recognition of a need for better integration of law and person- centred care	
Jacob et al. BMC Geriatrics (2025) 25:860	Page 10 of 20

Brief name	Why	What materials	What procedures	Who provided	How	Where	When & how much	Tailoring	Modification	How well (actual & planned)	
Man-	To support	MCA training ma-	hitia one-off	- Externa	η person training	- Local author-	-Initial train-	- Case ex-	Not specified	Basic training	
thorpe et	social workers in	terials; case law	MCA training;	trainers (MCA,	sessions - Case-	ity adult socia	ing delivered	amples used to		valued but	
al. (2013)	understanding and	examples; DOLs	Advanced DoLS	DoLS) - Adult	based discussions	care teams	shortly after	reflect real life		insufficient alone	
	applying the MCA,	and Best Interests	training for some;	safeguarding	and reflective	- Care homes -	MCA imple-	dilemmas		- Need for rein-	
	particularly menta	Assessor training	Informal cascad-	leads - Senior	practice - Peer	Mental health	mentation	-Training most		forcement and	
	capacity assess-	resources; Forms,	ing of training	practitioners	forums and team	services - Adult	(2007-08) -	effective when		refresher training	
	ments—new to	checklists, and	through active	and care home	meetings - In-	safeguarding	Some received	it included		noted - Applica-	
	their practice—and	templates for	case scenarios;	manag-	formal learning	settings	extended	debate and		tion inconsistent;	
	to address chal-	capacity assess-	Peer discus-	ers - Peer	embedded in		training (e.g.	practical ap-		learning through	
	lenges in dementia	ment; Peer-led	sion and team	colleagues	casework		one-day ses-	plication - Calls		peer support	
	care and adult	forums and in-	meetings; MCA	through team-			sions, modular	for more depth		more common	
	safeguarding.	ternal discussion materials	explanation to service users in some cases;
Manager-initiated
MCA forums	based learning			format) - DoLS and Best Interests training added later
- Peer forums and ongoing informal learning continued beyond initia training	on concepts ike'unwise de
cisions"- Recommendation for reflective, practice-based training, not purely didactic		than formal supervision - Lega iteracy and confidence varied; more advanced training associated with higher competence	
Man-	To explore and	-Initial MCA	- Initial training on	Trainers during	Formal training	Care homes	hitial train-	Emphasis	Not specified	-Initial training	
thorpe et	improve dementia	training materials	MCA offences at	initial MCA	initially; Informa	and dementia	ing in 2007.	on raising		delivered but not	
al. (2015)	practitioners'and	(2007) covering	implementation -	rollout (2007)	peer discussions	care settings in	Follow-up	awareness		sustained or regu-	
	safeguarding staff's	new offences -	Ongoing training	- Local safe-	and local safe-	London and SE	interviews and	using media		larly refreshed -	
	understanding and	Case studies from	was lacking or	guarding adult	guarding meet-	England	qualitative	coverage due		Many newer staff	
	application of the	notable prosecu-	inconsistent - Use	coordinators	ings; Use of media		data collection	to lack of for-		unaware or un-	
	MCA's criminal of-	tions (e.g., Lon-	of high-profile	(SACs) sharing	case reports as		over 3 years.	mal sustained		informed about	
	fences, enhancing	don care home	media cases in	knowledge	communication		No consistent	training		offences - Reli-	
	protection against	case) - Training	training to high-	and case	tools; Interviews		ongoing train-			ance on media	
	abuse and neglect	presentations	ight potentia	examples -	and longitudina		ing for new or			case publicity	
	of people lacking	including media	prosecution -	Care home	qualitative meth-		existing staff			rather than forma	
	capacity.	reports illustrating judicial responses to abuse and neglect	Informal sharing of cases among practitioners	managers and dementia
practitioners exchanging information
informally	ods to explore understanding over time		noted			ongoing training imited sustained knowledge and understanding	

Brief name	Why	What materials	What procedures	Who provided	How	Where	When & how much	Tailoring	Modification	How well (actual & planned)	
Man-	To understand how	Training materi-	In-house training	Not specified	Face-to-face	Training con-	Most training	Minimal tailor-	Not reported,	Staff showed	
thorpe et	training, under-	als not clearly	(usually a single		sessions (e.g. in-	ducted within	described as	ing reported.	though the find-	variable levels of	
al. (2016)	standing, and prac-	remembered	afternoon); some		house afternoons),	care homes	one-off, with	Training did	ings suggest that	knowledge and	
	tice around the	by participants;	external written		written self-	in South East	no ongo-	not appear	training lacked	confidence, highly	
	Mental Capacity	reference to	modules over		directed learning	England	ing process.	adapted to role	adaptation or	dependent on role	
	Act (MCA) evolved	written modules,	months; informa		modules; largely		Training	or level of staff.	updating over	and tenure. Man-	
	in care homes over	paperwork in	learning through		passive delivery		often dated,	Participants	time.	agers were most	
	time, and to assess	offices (e.g., forms	inspection		with limited active		forgotten, or	suggested		confident;junior	
	staff confidence,	for capacity	processes, discus-		follow-up or appli-		minimal. Se-	greater focus		staff often unsure	
	knowledge, and	assessments, LPA	sions with other		cation. No digita		nior staff more	was placed on		or unaware of MCA	
	perceived respon-	info); no reported	professionals,		or structured		familiar with	Advance Care		responsibilities.	
	sibility. Highlights	use of online	or trade press.		online engage-		MCA due to	Planning (ACP),		High staff turnover	
	gaps in lega	MCA resources	Little reference		ment reported.		job responsi-	to the neglect		meant significant	
	iteracy, the role	or national mate-	to structured				bilities;junior	of other as-		attrition in follow-	
	of organisational	rial distributed to	or standardised				staff gener-	pects of MCA.		up, highlighting	
	structures, and	care homes.	materials				ally lacked	Training design		instability in care	
	systemic barriers to						confidence.	often missed		workforce and	
	implementation.							care assistants' decision-making roles, lega responsibilities, and practica realities.		risk to sustained implementation. A key barrier was lack of confidence and lega iteracy among staff, particularly in relation to ACP and decision-making.	
Stanley et	To explore how	Training materials	Not specified; in-	Not specified;	Training delivered	Not specified -	Not speci-	Strong empha-	Not specified	Not reported but	
al. (2008)	MCA principles can	included a Best	eluded reflections	Reflections	through written	developed for	fied. Materials	sis on tailoring		tools and check-	
	be supported in	Interests Checklist	from practitioners	based on	materials, case	broader training	designed	communication		ists were used	
	everyday care, par-	to guide practi-	and family carers.	co-production	examples, and	use in health	for ongoing	and decision-		and valued	
	ticularly by using	tioners through		of training	structured tools	and social care	use, rather	making support			
	practical tools and	decisions,		resources	ike the checklist.	settings.	than one-off	to individua			
	approaches to	prompting reflec-		with carers,	Also encouraged		delivery	needs, espe-			
	enable communi-	tion on capacity,		practitioners,	reflection and			cially for people			
	cation and support	previous wishes,		and individu-	ongoing use			with non-verbal			
	best interest	consultation		als with lived	of materials in			communication.			
	decisions.	with others, and documentation.		experience	practice.			Encouraged carers to seek and use knowledge from family and others to understand what matters to the person			
Jacob et al. BMC Geriatrics (2025) 25:860	Page 12 of 20

Fig. 1 PRISMA flow diagram

Design of mental capacity training
Content
Training content was not typically provided, with limited updates since the MCA’s implementation, despite requests for revisions as the Act evolved [21, 26]. A similar pattern was observed with the AWI in Scotland [22]. Manthorpe and Samsi (2009) [25] noted that initial MCA rollout included a series of training guides and information to support implementation, although these are not publicly available. When reported, training typically covered general topics such as understanding capacity, ‘best interests’ decision-making, and the legal aspects of mental capacity legislation [22, 23, 26, 28–30]. However, it was also noted the scope of the MCA made it challenging to cover all elements, resulting in a general overview being dominant [29], rather than detailed information. For instance, the guide produced by Alzheimer’s Society (2009) [28] explains that implementing the MCA involves considering whether someone has the mental capacity to make a specific decision rather than a general assessment of mental capacity and encouraged creative thinking under the fifth statutory principle of the MCA.
Stanley and Manthorpe (2008) [30] suggested that understanding an individual’s perspective requires considering their past wishes, alongside those of their family and friends. Additionally, since the MCA encourages those assessing capacity to review and revise their decisions, training content should focus on equipping staff with key decision-making skills. While various approaches were reported in the papers, a combination of case studies and group discussions was considered the most effective method [23, 25, 28, 30] with participants noting that discussions allowed them to think through elements of capacity and identify where capacity might be

Table 2 Study characteristics
Authors (year)	Location	Approach/methodology	Summary	Included themes	
Alzheimer’s Society (2009)	England and Wales	Learning resource and training material	Training resource for people implementing the MCA	Content;
Structure;	
Care Quality Commission (2012a)	England	Report	CQC report on the monitoring of the deprivation of liberty standards	Content;
Structure;
Format;
Structural factors;
Cultural factors;
Staff level	
Care Quality Commission (2012b)	England	Report	CQC report on how the deprivation of liberty standards were implemented and used	Content;
Format;
Structural factors;
Staff level	
Care Quality Commission (2016)	England	Summary of report	CQC reflections on observed practice of implementing DOLs and wider MCA across health and social care	Structural factors;
Cultural factors;
Staff level	
Davidson et al. (2004)	Scotland	Qualitative study	The views of key stakeholders on factors that might facilitate or inhibit the implementation of Part 5 of the Adults with Incapacity (Scotland) 2000	Content;
Structure;
Format;
Structural factors;
Cultural factors;
Staff level	
Gough and Kerlin (2012)	England	Qualitative study	The views of managers of care homes about the delivery, content and implementation of MCA training	Content;
Structure;
Format;
Structural factors;
Cultural factors;
Staff level	
Iliffe et al. (2015)	England	Longitudinal qualitative study	Explore issues relating to implementation of the MCA over a 5 year period with those working with people with dementia and their carers and to make recommendations regarding training and practice	Structure;
Format;
Structural factors;
Cultural factors;
Staff level	
Jayes et al. (2022)	England	Qualitative study	Identify the challenges & support needed by care home staff around MCA and explore if MCAST toolkit can support decision making	Structure;
Cultural factors;
Staff level	
Manthorpe and Samsi (2009)	England	Case study	Case study of two local authorities looking at the initial roll out, implementation and training of the MCA	Content;
Structure;
Format;
Structural factors;
Cultural factors;
Staff level	
Manthorpe et al. (2011)	England	Qualitative study	Views of care home managers’ and workers’ of knowledge and use of the MCA	Structural factors;
Staff level	
Manthorpe and Samsi (2013)	England	Longitudinal qualitative study	Views of social work and related practitioners about the expectations, experiences and challenges of implementing the MCA	Content;
Format;
Staff level	
Manthorpe and Samsi (2015)	England	Longitudinal qualitative study	Views and knowledge of dementia care practitioners of the new criminal offences created by the MCA	Content;
Structural factors	
Manthorpe and Samsi (2016)	England	Longitudinal qualitative study	View and experiences of dementia care staff working in care homes of the MCA five years after it was implemented	Structure;
Format;
Structural factors;
Cultural factors;
Staff level	
Stanley and Man- thorpe (2008)	England	Commentary	Reflections on writing the initial training materials for the MCA	Content;
Cultural factors	

misunderstood [25]. Case-studies and practical scenarios were particularly beneficial in helping staff apply theoretical principles in real-world settings, including assessing capacity, determining who should be involved in ‘best interests’ decisions, recording ‘best interests’ consultations, gathering information, and making decisions using the least restrictive options [20, 22, 23, 25, 26, 28–30].
Checklists were also found to be helpful in informing ‘best interest’ decisions [23, 30]. These include considering relevant circumstances, considering whether the decision can be delayed until the person regains capacity (where appropriate), encouraging participation, considering the person’s wishes, feelings, beliefs, and values, and consulting with family and others involved in the person’s welfare. Additionally, checklists emphasised that ‘best interest’ decisions should be informed by in-depth knowledge of the person receiving care or treatment [30].
Structure
Eight papers reported on the structure of the training program. An effective training program should adopt a systematic, multi-method approach, integrating formal teaching, informal discussions, and case examples [25]. Two studies emphasized workplace-based training, focussing on real-world scenarios [23, 27. Real-life case studies were valuable for post-training discussions, helping staff apply their learning [23]. Ongoing support can be enhanced through a variety of accessible learning resources, including discussions, share-and-learn approaches, and group activities tailored to staff at all levels and from diverse backgrounds [22, 23, 25]. This multi-method approach reinforces the acquisition of new concepts, deepens practical understanding, and guides decision-making [22].
One study highlighted e-learning’s value for managers, enabling them to monitor staff’s progress and identify areas of weakness [23]. However, a separate study found that staff rarely mentioned online materials, such as those provided to care homes in England to supplement training [27].
Two notable text-based approaches were the MCAST toolkit [31], a paper-based resource that helps professionals document person-centred capacity assessments and support individuals with communication difficulties and an Alzheimer’s Society [28] resource that features quizzes and case studies to assess and test MCA knowledge. These tools can help to evaluate the impact of training on knowledge development, an issue raised by Gough and Kerlin [23].
Conventional workshop-based training was criticised for being too abstract and impractical [23–25]. In contrast, bite-sized training, delivered in small doses during appropriate times, such as shift changes, was valued for its flexibility and cost-effectiveness [23]. A pocket-sized MCA reference guide offered staff quick access to key principles [20],, whilst in Scotland, a consolidated approach with clear guidelines, forms and checklists all integrated into a single, accessible resource was recognised as crucial for effective staff training [22].
Delivery of mental capacity training
Eight papers discussed the delivery of MCA training. While frequency varied, training was often treated as a ‘one-off event’ [21, 24–27]. Staff received initial training when the Act was first implemented, but this was not updated, leaving new staff without this crucial input [21]. Given the developments in capacity case law, training should reflect these changes and be seen as a continuous process informed by supervision rather than a single event [21, 24, 26]. The distinction between introductory and ongoing training was also emphasised [25]. In Scotland, ‘next stage’ training including follow-up and refresher courses was deemed essential. Ultimately, training should be continuous, supporting staff to apply new information [21].
There was no consensus on the format of training. Some argued it should be delivered in isolation and not combined with other exercises [21], while others suggested it should be integrated with topics relevant to daily care-home work, such as dementia care and managing challenging behaviour [22, 23]. It was further highlighted that training in social care typically involves integrating new knowledge into daily work rather than merely imparting information [24–26].
Implementation of mental capacity training
Of the 13 studies that discussed the implementation of MCA training, it was largely from the perspective of the barriers and facilitators to effective implementation. Our synthesis identified two overarching categories of barriers or facilitators: system domains and staffing domains.
System domains
These relate to the overarching structure and culture of a care home organisation, including how it interacts with its environment. System domains focus on macro-level factors influencing how MCA training is implemented and embedded into a care home.
Staff domains
These focus on individual care home staff, including the skills, ability and confidence of staff members. This domain examines how individual factors influence the implementation and success of MCA training.
System level barriers and facilitators
Structural factors
Key barriers identified in ten papers included high workload, staff turnover and shortages, the cost and time involved in delivering training and competing priorities. The most common issues across all nations were staff shortages, high turnover, and the large number of staff requiring training [12, 20–24, 29, 32]. High staff turnover made it difficult to monitor training, and managers noted the challenge of releasing staff for training, especially in smaller care homes with smaller budgets and fewer staff to provide cover [12, 23].
Differences in training were observed between different forms of provider, with some reports indicating that private care homes often lacked responsibility for providing training [24]. Consequently, a lack of training was routinely reported across studies, with responsibility falling on a small number of staff most committed to capacity legislation, rather than generating change at an institutional level [12, 20–23, 25, 27, 32]. In Scotland, staff training on the AWI was not mandatory and consequently level and uptake of training depended largely on the trainers’ enthusiasm and reputation [22].
Facilitators to address these issues included investing in a dedicated team to deliver training [20, 22, 23] and designating staff with responsibility for safeguarding training within each organisation [12, 25, 26, 32]. In-house training was also a considered cost-effective solution [25].
To foster change at the institutional level, Commissioners can gain insights into local activity by developing or using existing audit tools [25]. Such tools would help measure and review provision of training, assess compliance with the MCA, and serve as benchmarks for improvements. Commissioners could also monitor indicators of partial or patchy training, such as complaints, adult safeguarding referrals, serious case reviews, and the reports of Court of Protection visitors.
Cultural factors
Barriers and facilitators related to workplace culture, particularly concerning system-level commitment to training on the both the MCA and AWI, as well as organisational readiness for change, were identified in nine papers. Despite challenges posed by high staff turnover, there was an appetite for training among employees, observed across all nations [22, 25]. However, some managers regarded the training as irrelevant to their care home, indicating a lack of awareness of the MCA’s relevance to their roles [23, 24]. Additionally, there was evidence that the MCA was not routinely used during staff supervision, highlighting the need for its integration into line management and supervision meetings [24].
Cultural barriers also included a lack of trust in trainers [24]. The absence of a designated person responsible for delivering training and unfamiliarity with trainers affected the uptake of training [32]. Addressing these issues requires building trust with trainers, ensuring a dedicated team is responsible for training, and making the relevance of the MCA clear to all staff, including managers [20, 27, 30]. Strong links between Independent Mental Capacity Advocates (IMCAs) and care homes were also found to help cascade knowledge, with IMCAs taking on some responsibility for training in certain care homes [25].
Several studies highlighted the value of having ‘joined up’ training between health and social care to address barriers around workplace culture [22, 31]. In Scotland, an integrated approach, where training is delivered in partnership between NHS trusts and social care/social work was seen as beneficial. Improved communication between social care and healthcare staff may facilitate partnership working across professional boundaries, enabling the delivery of holistic, seamless care [22].
Staff level barriers and facilitators
While system domains focused on the overall structure and culture, staff domains focus on individual experiences, reflecting on the training received and their confidence in translating mental capacity legislation into practice. This distinction was discussed in 11 papers. Notably senior staff and managers were more likely to receive training, but there was no formal system in place to ensure this knowledge was cascaded to all staffing levels [12, 20, 21, 26]. There was also confusion among junior staff regarding the differences between the Mental Health Act (MHA) and MCA [20].
Training received by junior staff often failed to translate effectively into practice [20]. Many lacked confidence in applying the MCA, although they felt they could consult someone for urgent or difficult issues [12, 24, 25, 27]. Some were reluctant to take responsibility for decisions under the MCA, highlighting a lack of confidence and legal literacy [27]. There were also concerns about staff’s ability to learn from written materials, potentially due to literacy and language barriers [25, 27]. Additionally, uncertainty about adult learning principles and limited experience with self-directed learning were noted [25]. Trainers may also face demands for traditional classroom-based training methods, as managers may favour these approaches due to limited exposure to other models of self-directed learning [25].
More experienced senior staff talked of their familiarity with the MCA and its provisions [12, 27]. Not surprisingly, managers were the most confident in their knowledge of the MCA, which they described as stemming from discussions with other professionals and inspection requirements, as well as information gleaned from training [12, 27].
Interestingly, it was reported that staff who had not received training under the AWI (Scotland) created additional challenges for those who had [22]. Additionally, a lack of training among healthcare professionals, particularly GPs, made communication between health and social care more challenging [22]. To address these issues, facilitators suggested that training should be customised to the specific roles of staff and follow a tiered approach, where information is tailored to an individual’s role rather than providing a general overview of the capacity legislation [20, 22, 23, 25]. At the same time, this approach should maintain a common language across training to facilitate better and more effective learning [25]. Such training would promote collaborative, interdisciplinary practices as best practice, whilst recognising that current UK legislation does not specify which disciplines or seniority levels should assess mental capacity [31].
Discussion
We aimed to review the existing literature of the design, delivery and implementation of MCA (or equivalent legislation) training within care homes and the barriers and facilitators that support this. This review highlights two important factors. Firstly, a blanket approach to training is not sufficient for care homes; key domains must be addressed to ensure more effective implementation of training in practice. Secondly, understanding how these different domains interact can help inform more comprehensive strategies to reduce barriers and strengthen the factors that support successful implementation. When staff lack understanding or fail to implement the MCA appropriately, residents may lose opportunities to make everyday choices, undermining their autonomy and the Act’s principles. As noted in the introduction, supporting “small acts” of care is crucial - without this, residents risk disempowerment and a diminished sense of control over their daily lives.
This review found that a standardised one-size-fits-all approach to mental capacity legislation training fails to take account of the diverse needs of care home residents and staff. Care homes vary in terms of staff expertise, residents’ needs and organisational priorities; consequently, training on mental capacity legislation should be tailored to meet these unique issues. There was limited agreement within the literature on the most appropriate format or frequency of training. While various approaches were reported in the papers, a combination of case studies and group discussions was considered the most effective method for strengthening the application of the key principles of mental capacity legislation. Staff reflections of e-learning were often negative [27]. This aligns with existing research considering optimal ways to provide dementia awareness training to social care staff, which found that staff generally dislike online-only formats, favouring face-to-face training that include practical application relevant to their daily work, such as demonstrating examples of good or poor practice [33].
Differences in training format remain, with some advocating for standalone training and others for it its integration into broader topics relevant to daily care-home work, such as managing challenging behaviour or promoting resident’s rights. These discrepancies likely reflect variations in staff role, care home environment or organisational culture, highlighting the need for further research to understand their impact on training effectiveness.
Newly appointed NHS healthcare staff often have patchy knowledge and lack baseline knowledge of the MCA, highlighting the importance of early training on mental capacity legislation [34]. This is crucial as care staff often defer decisions to colleagues, suggesting limited confidence and awareness of their responsibilities under the MCA [35]. Those entering the role may have less prior care experience and shorter inductions than those working in healthcare. Addressing these issues is essential in a sector where hierarchical structures are prominent and junior staff are unlikely to challenge more senior staff [36].
It is also worth noting that the lack of training among healthcare staff impacts social care, with one study reporting a notable gap in training for GPs on the AWI in Scotland. However, this could be attributed to Scotland’s more integrative approach to mental capacity legislation and training, where the AWI explicitly encourages multidisciplinary collaboration across health, legal and social services. In Scotland, the emphasis is on joint training of professionals from multiple sectors, whereas the MCA tends to focus more narrowly on decision making processes, particularly in assessments of capacity for specific decisions. Consequently, at the time of publication of the one paper exploring AWI, the lack of training in certain roles or sectors was more apparent in Scotland, where collaborative working is more heavily emphasised. Concerns about the gaps in knowledge of the AWI across the health, social work and social care workforce has led to a new national approach to learning and training on applying the requirements of the AWI [37].
The review also identified additional domains – such as staff engagement, content relevance and organisational factors– and how these might be utilised to overcome barriers to training. For instance, the lack of training and awareness of MCA relevance to staff roles emerged as a key barrier. High turnover of a staff, a common characteristic of many care homes, exacerbates this issue, emphasising the need for regular, in-house training. Repeated introductory training, along with more advanced experiential-focused courses, were deemed necessary to enhance learning and consolidate its application in real-world care. Understanding the feasibility of implementing this model of training should be undertaken.
The review also shed light on significant operational barriers to MCA training, particularly the lack of time and availability of senior support. In additional to the hierarchical issues identified above, the challenges within both for-profit and not-for-profit care homes may lead to limited budgets or resource constraints which can deprioritise training. To address these challenges, it is important to embed MCA training and learning from this into the daily routines of the care home, such as incorporating it into clinical supervision, team meetings and ongoing professional development. This approach would encourage staff to robustly and continuously reflect on their practice learning with the aim of improving the care they deliver. Additionally, the role of leadership is crucial, without visible and consistent support from senior managers the nuanced and considered approach that is needed for MCA training is unlikely to be fully realised.
The training of staff, the delivery of person-centred care practices, and the assessment of decision-making capacity in older adults are a global concern, particularly in residential care settings [38]. Ireland’s Assisted Decision-Making (Capacity) Act 2015 reflects a broader international shift toward functional, right-based approaches to capacity assessment, as observed in not only the UK’s legislation but also Canada and Australia [39] However, implementation challenges persist. International evidence highlights gaps in training in practice. In India, limited protocols contribute to inconsistent assessments in dementia care [40], while UK healthcare professionals report uncertainty in assessing capacity among people due to insufficient guidance. These findings underscore the need for well-designed, practical capacity training opportunities in care homes that align with legal and ethical standards.
Statutory differences exist between the legal frameworks governing mental capacity [41], and the evolving implementation of related training. Although the MCA has been in place for over 15 years and the AWI in Scotland even longer, training has not been updated to reflect the evolving understanding and case law. This gap will likely be exacerbated with the transition from the Deprivation of Liberty Standards (DOLs) to the Liberty Protection Standards (LPS) and the updated Code of Practice as outlined in the CQC’s State of Care report (2022–2023) [42]. Similarly, the AWI Act has been under long-standing consultation in Scotland, reflecting ongoing efforts to modernise the legislation to better align with current needs and practices. In Northern Ireland, the MCA has only recently been implemented, so it is arguably too early to assess its full impact. Nonetheless, as legal frameworks evolve, training must adapt to ensure that all staff are adequately prepared to apply mental capacity legislation in practice.
The findings of the present review focus on the design and delivery of training, which are complemented by our systematic review focusing on the barriers and facilitators to the practical implementation of mental capacity legislation [43] which outlines what supports and hinders such legislation being enacted within residential care homes in the UK.
Limitations and future directions
This review focused on the design and delivery of mental capacity training in the UK context, meaning that the implementation of such legislation in other geographies is not explored. The review identifies a gap in the literature; despite the MCA being in place for nearly two decades and the AWI even longer, only thirteen papers focussing on training related to mental capacity legislation in care homes were identified. Limited evidence exists on both the content and development of training, highlighting a critical issue: the lack of knowledge sharing between organisations. This lack of cross-organisation collaboration may hinder the development of consistent and effective training across the sector, negatively impacting care quality.
None of the included papers considered staff or resident diversity. As the population ages, and the demand for professional care increases, the social care sector increasingly relies on more ethnically diverse teams, often including immigrant workers [44]. Having a diverse staff team, in terms of gender, ethnicity, sexual orientation or age, is known to improve quality of care [45], and therefore, considering the role of culture within training and implementation of mental capacity legislation is crucial, and currently remains unexplored.
A lack of training for external healthcare professionals, including GPs, highlights systemic issues beyond care homes, where there is no current ‘usual model’ across organisations. Future research should explore interprofessional training models, where care home staff and healthcare workers receive joint training and different roles and responsibilities are outlined. This could help clarify roles, address concerns around hierarchical structures and build confidence in challenging poor practice. Additionally, research should seek to understand the optimal strategies of training social care staff about mental capacity legislation and how to support the translation of this learning into practice.
Conclusion
This systematically based scoping review demonstrates significant inconsistencies in the delivery and implementation of mental capacity training within care homes in
the UK. These inconsistencies are likely to be exacerbated by a lack of shared leaning across the sector, with each organisation developing its own approach to training, often delivered in isolation. To ensure that mental capacity training is not only consistent in quality but also effective, there is a need to develop standardised frameworks that can be adapted to the specific needs of an individual care home, with the overall aim of embedding training and learning into everyday practice of the care home. Further research should establish an in-depth understanding of MCA training across England and Wales, to begin to unpick the current state of training and develop recommendations for improving content, delivery and implementation within the sector.
Supplementary Information
The online version contains supplementary material available at h t t p s: / / d oi . o r g / 1 0. 1 1 8 6 / s 1 2 8 7 7 - 0 2 5 - 0 6 4 7 6 - 6.
Supplementary Material 1.
Acknowledgements
We wish to acknowledge members of the Lay Advisory Group, Peter Hewkin, Judith Anstiss, Marie-Claire Hunter, Saiqa Ahmed and Sandra Barker, who worked alongside us throughout the conduct of this review.
Authors’ contributions
NJ and AWG wrote the main manuscript text. MM conducted all searches. NJ, HP LS and MM read the articles at the eligible phases of the review, NJ and HP extracted data. AWG resolved discrepancies. All authors reviewed the manuscript.
Funding
This project is funded by the NIHR Health Services & Delivery Research programme (NIHR152800). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Data availability
Data sharing is not applicable to this article as no datasets were generated or analysed.
Declarations
Ethics approval and consent to participate
Ethical approval was not required for this study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 17 January 2025 / Accepted: 12 September 2025
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