Considerations and Top Tips for Supported Decision Making and Mental Capacity Assessment

When undertaking supported decision-making or mental capacity assessments, it is important to distinguish between macro and micro decisions, as this can influence both the assessment process and the level of support required.

Macro decisions are significant, ongoing decisions that have continuing implications over time. These decisions do not end once paperwork is completed and may require future, unplanned, or urgent interventions as circumstances change.

Examples of macro decisions include:

1. Choosing where a person will live long-term (care home, supported living, or independent living);
2. Health and medical treatment plans, such as surgery or ongoing medication regimes;
3. Management of Property and Financial Affairs, like paying bills, managing pensions, or selling property.

Micro decisions are one-off decisions with no ongoing requirements once the decision is made. They are often more immediate and limited in scope.

Examples of micro decisions include:

1. Deciding what to wear on a particular day;
2. Choosing what to eat for a single meal;
3. Signing a one-off consent form, like making a Will or agreeing to attend a social event.

Understanding this distinction helps social workers to determine:

1. The complexity of the decision;
2. The level of support required;
3. Whether a single assessment is sufficient, or whether capacity may need to be reviewed over time (especially for macro decisions).

The following tips are intended to support good practice in line with the principles and legal requirements of the Mental Capacity Act 2005.

Tip 1

When providing relevant information, do not hesitate to use simple or crudely drawn images (for example, stick figures) if this supports the person’s understanding. Be creative and flexible with the resources available to you.

Tip 2

If you receive conflicting advice about the best way to communicate with a person, ensure you try all suggested methods. This will allow you to make an informed professional judgement about what works best for that individual.

Tip 3

Do not be concerned if a person’s preferred method of communication appears illogical or unconventional to you. If it is reliable and meaningful for them (for example, unusual signs, gestures, or sounds), it should be respected and used.

Tip 4

If you identify a new or improved method of communication or gain new insight into the person through supported decision-making, ensure this is clearly recorded. Update the mental capacity assessment, Care and Support Plan, or Care Plan so others can use this information to support the person consistently.

Tip 5

Where a person uses objects of reference to support decision-making, always use the object that is familiar to them. Do not replace it with a similar object, a photograph, or an alternative you consider more logical, as this may significantly reduce their ability to engage with the decision.

Tip 6

Be open to meeting the person in a non-traditional or informal setting if this helps them feel more at ease (for example, a café or community space). However, remain mindful of privacy, confidentiality, and potential distractions.

Tip 7

Where appropriate, involve carers or support workers in assessments, particularly when considering retention over an extended timeframe. This is especially important for macro decisions, where understanding and retention may need to be demonstrated across multiple occasions. The person may also communicate more effectively with someone they trust.

Tip 8

If a person has specific or complex communication needs and the most effective method of communication is unclear, you should delay major or complex decisions particularly macro decisions until appropriate specialist support is in place (for example, assessment by a Speech and Language Therapist).

Tip 9

Use a simple pros and cons list to help the person weigh up options. This can be particularly useful when supporting the person to engage with more complex or ongoing decisions and when testing their ability to use and weigh relevant information.

Tip 10

Do not feel pressured to include someone in the assessment or supported decision-making process if the person has clearly indicated verbally or through their behaviour that they do not want them to be present. Refer to Principle 2 of the Mental Capacity Act, which emphasises taking all practicable steps to support the person to make their own decision, and seek managerial support if required.

Tip 11

Be prepared to appropriately challenge poor practice where it is clearly inconsistent with the principles or legal requirements of the Mental Capacity Act. This is particularly important in relation to macro decisions, where flawed assessments can have long-term and wide-ranging consequences. Seek guidance from your manager where necessary.

Tip 12

Make use of the experience and expertise of colleagues, particularly those with more experience in capacity assessments. Share good practice, resources, and learning from previous assessments, especially where they relate to complex or ongoing decisions, to support consistency and continuous improvement.