Consent and Capacity Policy

Consent & Capacity Policy

HAUS OF ÄSTHETIK

Safe (Preventing Harm & Protecting Patients)

Effective Date: 10th May 2025
Review Date: 10th May 2026
Approved by: Managing Director

1. Purpose

HAUS OF ÄSTHETIK is committed to ensuring that Informed Consent is obtained and documented for all aesthetic procedures in compliance with the Mental Capacity Act 2005 (MCA), CQC guidelines, and NICE best practices. This policy sets out procedures for obtaining valid Consent, assessing patient capacity, and managing cases where patients lack the ability to make informed decisions about their treatment.

This policy is aligned with:

   • Mental Capacity Act 2005 & MCA Code of Practice

   • Care Quality Commission (CQC) Regulation 11 – Need for Consent

   • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

   • National Institute for Health and Care Excellence (NICE) Guidance NG108 – Decision Making & Consent

   • Save Face Clinical Standards for Consent & Ethical Practice

   • General Medical Council (GMC) & Nursing & Midwifery Council (NMC) Ethical Standards

This policy ensures that all practitioners operate within legal, ethical, and professional boundaries when obtaining and recording Consent for treatments.

 

2. Scope

This policy applies to:

   • All clinical staff performing aesthetic treatments.

   • Agency, temporary, and subcontracted personnel providing clinical services.

   • Senior Leadership Team (SLT) responsible for clinical governance.

   • All patients receiving treatments at HAUS OF ÄSTHETIK.

 

3. Legal & Regulatory Requirements

3.1 Mental Capacity Act 2005 & Decision Making

Under the Mental Capacity Act 2005, a person is assumed to have Capacity unless proven otherwise. A person lacks Capacity if they are unable to:

   • Understand the information relevant to the decision.

   • Retain that information long enough to make a decision.

   • Use or weigh the information to make a decision.

   • Communicate their decision.

If a patient lacks Capacity, a best interests decision must be made in accordance with the MCA Code of Practice.

3.2 CQC Regulation 11 – Need for Consent

   • Valid Consent must be obtained before any treatment is provided.

   • Consent must be informed, voluntary, and given by a competent individual.

   • Patients must be provided with clear, accurate, and evidence-based information.

   • Consent must be adequately documented.

 

4. Obtaining Informed Consent

4.1 Principles of Informed Consent

For Consent to be valid, it must be:

   1. Given voluntarily – The patient must not be coerced or pressured.

   2. Informed – The patient must understand the risks, benefits, and alternatives.

   3. Specific – The Consent must be for a defined procedure.

   4. Documented – A written record must be kept.

4.2 Consent Process at HAUS OF ÄSTHETIK

 1. Pre-Treatment Consultation:

      o Explain the nature, purpose, and risks of the procedure.

      o Discuss alternative options and allow time for questions.

      o Provide a cooling-off period before Consent is finalised.

   2. Assessment of Understanding & Capacity:

      o Use open-ended questions to confirm comprehension.

      o Provide written information in plain language.

      o Offer additional explanations if needed.

   3. Signing of Consent Forms:

      o Consent must be signed before treatment.

      o Practitioners must countersign the form.

      o A copy must be retained in the patient’s record.

   4. Post-Treatment Consent Verification:

      o Document any complications or changes in patient expectations.

      o Ensure the patient understands their post-treatment care and follow-up.

 

5. Managing Patients Who Lack Capacity

5.1 Assessing Capacity

   • If concerns arise about a patient’s ability to give Consent, a capacity assessment should be conducted.

   • Use the two-stage test:

      1. Does the patient have an impairment affecting their ability to decide?

      2. Does this impairment prevent them from making a specific decision?

5.2 Best Interests Decisions

If a patient lacks Capacity:

   • The treatment must be in their best interests.

   • Involve family members or advocates where appropriate.

   • Document all decision-making steps clearly.

   • If needed, refer to an Independent Mental Capacity Advocate (IMCA).

5.3 Refusing Treatment & Right to Withdraw Consent

   • Patients have the right to refuse or withdraw Consent at any time.

   • The refusal must be documented, and no treatment should proceed against the patient’s will.

   • If the patient lacks Capacity but has previously been given an advance directive, this must be respected.

 

6. Special Considerations

6.1 Patients Under 18

   • No aesthetic procedures will be performed on individuals under 18, in compliance with The Botulinum Toxin and Cosmetic Fillers (Children) Act 2021.

   • Parental Consent is not sufficient to override legal age restrictions.

6.2 Patients with Mental Health Concerns or Body Dysmorphic Disorder (BDD)

   • All patients must undergo psychological screening for signs of BDD.

   • Those displaying BDD tendencies must be referred to a mental health professional before proceeding.

   • Practitioners must not proceed with treatment if a patient presents unrealistic expectations or obsessive tendencies.

6.3 Patients Under the Influence of Drugs & Alcohol

   • Consent cannot be obtained if a patient is under the influence of alcohol or recreational drugs.

   • Appointments should be rescheduled, and a capacity assessment should be conducted at a later date.

   • If substance misuse is suspected, practitioners should document concerns and refer patients to relevant support services where appropriate.

6.4 Emotional Reactions & Vulnerable Decision-Making

   • Patients experiencing emotional distress due to divorce, bereavement, or relationship breakdown may be at risk of making impulsive decisions.

   • Practitioners must assess the patient’s emotional state and provide a cooling-off period before proceeding with treatment.

   • If a patient appears to be making decisions based on external pressures or emotional distress, treatment should be postponed until they can provide calm and rational Consent.

 

7. Documentation & Record-Keeping

   • All consent forms will be obtained and securely stored on the Insync Insurance consent and documentation portal.

   • Verbal Consent must be recorded in clinical notes.

   • Where Capacity is questioned, complete documentation of assessments must be retained.

   • All consent forms must be stored securely in patient records.

   • Verbal Consent must be recorded in clinical notes.

   • Where Capacity is questioned, complete documentation of assessments must be retained.

 

8. Staff Training & Compliance Monitoring

   • Annual Consent & Capacity Training for all staff.

   • Quarterly audits of consent records to ensure compliance.

   • Immediate corrective action plans for any deficiencies found.

 

9. Review & Continuous Improvement

   • This policy will be reviewed annually or after any significant regulatory update.

   • The governance team will oversee compliance with consent procedures.

   • Patient feedback and incident reports will inform future updates.

 

10. Conclusion

• HAUS OF ÄSTHETIK is committed to ensuring ethical, legal, and professional standards in obtaining informed Consent. This policy provides transparency, patient safety, and compliance with regulatory standards.