Practice Examples and Resources for Complex and Major Decisions

1. Using these Examples and Resources

The examples in this section of the guidance are all real examples of Local Authority social work practice that has taken place when;

  1. Supporting people to make their own decisions; or
  2. Assessing mental capacity.

Where available a link to the actual practice resource that was used is included at the end of the example.

The examples and resources should;

  1. Be used as helpful guidance to support you to think creatively about some of the steps that it may be practicable for you to take when deciding if a person is able to make their own decision; and
  2. Not be used to dictate or restrict your practice in any way.

Practice examples do not use the real names of the people involved and full confidentiality is maintained.

All available resources are provided in downloadable word format and practitioners have given their full permission for the resources to be used, reproduced or adapted for purpose.

2. Bob’s Story

Peter was a man in his 40’s who had learning disabilities and mental health issues. He had lived in the same care home for 10 years. This was not without issue and Peter did behave in ways that placed other resident’s at risk on occasion. Following a more serious incident the Registered Manager of the care home made a decision that Peter could no longer live there.

The Registered Manager did not tell Peter that he had to leave the care home, because he was worried that Peter would become distressed or angry, and that this could place the other residents at greater risk. There was significant evidence to support this decision.

The allocated social worker therefore needed to find a way to establish whether Peter was able to make his own decision about where to live without letting him know that he had to leave the care home until it was absolutely necessary to do so.

The social worker knew that Peter liked to feel helpful, and also that he liked to read cartoon style story books with his support workers. Using a communication passport that was available in the care home and professional advice from a Speech and Language Therapy colleague the social worker created a short picture story book based upon Peter’s situation, using a fictional character called Bob.

The social worker planned to ask Peter if he would read the story so as to be helpful in its development and, through the course of reading the book regularly test out his understanding of the situation and available options.

The social worker spent some time with Peter to build a rapport before she introduced the book. As hoped Peter was receptive to reading the story and he became familiar with its content over the course of several weeks, as his support workers and an independent advocate also read it with him frequently.

The social worker started to ask him key questions about the situation in the story to test his;

  1. Understanding of the relevant information;
  2. Ability to retain the relevant information; and
  3. Ability to use the relevant information to make a decision about what ‘Bob’ may like to do.

Peter also agreed to visit examples of each of the available options in the story, which included another care home, a supported living scheme and a private tenancy. This helped Peter to contextualise the pictures used in the story so that his ability to use the relevant information could be better tested.

Ultimately Peter was not able to understand the relevant information and was deemed to lack capacity to make a decision. However, when visiting the potential options for ‘Bob’, Peter had been visibly enthusiastic about the private tenancy. The social worker decided to ask Peter is he might ever want to live in a place like that, to which he said yes and asked her to help him to do so. Peter also repeated this on several occasions to his support workers and advocate.

Although Peter lacked capacity, the subsequent Best Interest decision that was made took into account the views that he was expressing and he was supported to move into his own tenancy.

Click here to access Bob’s story, in a downloadable word format that can be used or adapted as required.

3. Paul’s Story

Paul was a man in his 30’s with a mild learning disability but severe physical impairments, which included being unable to speak or communicate verbally in any way, no fine motor skills and very limited gross motor skills. On an everyday basis, Paul made choices and decisions by raising his left arm to indicate ‘yes’ and his right arm to indicate ‘no’.

Historically, practitioners had made assumptions about Paul’s ability to make specific or complex decisions and on one such occasion he had been placed into a care home under Best Interests, where he had now been for some years.

Paul was showing signs that he was unhappy and bored at the care home. The Registered Manager felt that he would be much better supported in his own home, and had spoken to Paul about this possibility already. From these initial conversations it was the manager’s view that Paul wanted to explore moving on and was able to make this decision for himself. However, Paul’s family did not agree and were worried that;

  1. Paul’s safety would be compromised if he moved; and
  2. That Paul didn’t understand the implications of a move (in terms of changes to his routine, the people he would live with and the staff that would be supporting him).

The social worker spent some time with Paul to better understand his bespoke communication needs and the things that were important to him.

The social worker then used a story book approach to talk to Paul about his current situation, his future options and all of the positive and negative implications over a period of several weeks, with support from staff at the care home to reinforce the relevant information in between planned visits.

The social worker proceeded to ascertain Paul’s views and test his ability to make a decision through a series of simple 2 choice questions, that he could answer using his preferred method of communication (arm raises). Through doing so the social worker was satisfied that;

  1. He was bored a lot of the time;
  2. He was unhappy about not being able to do all of the things he likes to do;
  3. He did not that he could not always do the things he wanted to do because of other residents.

Paul was also able to demonstrate that he;

  1. Understood the nature of the decision to be made;
  2. Understood the implications of staying at the care home or moving on (both positive and negative implications);
  3. Could carry over the information (remember it from day to day);
  4. Could use the information to make a decision; and
  5. Could communicate his decision.

The social worker had no doubts that Paul was able to make the decision, and was able to demonstrate this to his family who, despite their own concerns acknowledged this and proceeded to provide their support to Paul during his subsequent move.

Click here to access Paul’s Story, in a downloadable word format that can be used or adapted as required.

4. Jacob’s Story

Jacob was a man in his 50’s who was living in a care home. He got on particularly well with another resident and the other resident had in fact clearly stated on several occasions that he wanted for himself and Jacob to leave the care home and move into their own tenancy together. The other resident was clearly able to make this decision but staff were concerned that Jacob may lack capacity to do so.

Jacob had a diagnosis of Autism and anxiety. He was also a selective mute and used his own form of sign language to communicate, although this was sometimes deemed unreliable or inconsistent. Jacob also found it difficult to maintain concentration for more than a few seconds at a time, making it problematic to talk to him about the decision at any length.

The social worker had to establish whether Jacob was able to make a decision about moving into a house with the other resident.

The social worker took some blank pieces of paper when she went to visit Jacob. She planned to draw some visual aids by hand in Jacob’s presence, in the hope that by doing so he would be interested in what she was doing, and therefore better able to concentrate on it.

The social worker drew a crude outline of a house on a piece of paper. She indicated to Jacob that this house was the care home he lived in by placing photographs of all the residents (provided by the care home) into the drawing, which included a photograph of Jacob.

The social worker then drew a crude outline of another house on a different piece of paper. She explained to Jacob that the second house was another place to live.

She then moved the photograph of the resident who wanted to live with Jacob from the current care home into the new house, explaining to Jacob that the other resident might move from the care home into another house.

The social worker asked Jacob how he felt about that and Jacob immediately reached across to his own photograph and moved it into the second house. The social worker asked Jacob if this meant he wanted to move into another house too, and he was able to communicate that he did.

The social worker then took a photograph of another resident and moved it across to the second house. She asked Jacob if he wanted this person to move to the new house as well, to which Jacob proceeded to move the photograph back to the current care home. This exercise was repeated for each resident with a similar outcome.

The social worker then put the photograph of the first resident (who wanted to live with Jacob) back into the care home, leaving the photograph of Jacob alone in the second house.

The social worker asked Jacob if he wanted to stay in the second house by himself. Jacob immediately gave a ‘thumbs down’ sign and the social worker then decided to give Jacob his picture and ask him to put it where he wanted it to be. Jacob put his picture into the new home but then reached across and took the photograph of the other resident from the current care home and returned it also.

This exercise demonstrated to the social worker that;

  1. Jacob had some understanding of the situation beforehand from listening to conversations that were taking place with the other resident;
  2. Jacob understood the decision to be made and the available options;
  3. Was able to use the information to make a decision (even if how he had done so was not clear);
  4. Retain the information and focus on it long enough to make a decision; and
  5. Communicate his decision.
The social worker repeated the exercise when she visited Jacob the following week, and the outcome remained consistent. Thus, the social worker was able to determine that on the balance of probability, Jacob was able to make a decision about moving to another house with the other resident.

5. Amy’s Story

Amy was a young female aged 17 who was planning her transition from the family home to her own tenancy. She was very keen to start managing as many aspects of her own finances as possible, a role that had always been undertaken by her parents.

They were very concerned that Amy;

  1. Would not be able to recognise different coins and notes;
  2. Did not possess adequate mathematical abilities;
  3. Would not ensure that essential expenses were paid; and
  4. Would be at high risk of financial exploitation.

Amy’s goal was nonetheless recorded in her Education, Health and Care Plan (EHC Plan) and a decision was made to establish what elements of her finances she could;

  1. Manage without support;
  2. Manage with support;
  3. Be supported to learn to manage; and
  4. Not manage.

The social worker could not identify a comprehensive tool that would support him to carry out a full assessment of Amy’s abilities, so he devised his own that could be used to;

  1. Assess Amy’s current abilities;
  2. Assess any change in her abilities over time; and
  3. Assess her potential abilities to manage her future finances.

He arranged to meet with Amy at school, at home and also at the local supermarket to explore her current abilities.

Amy had limited independent abilities, but listened to advice provided by others and remembered this from one day to the next. The social worker felt that her lack of ability was therefore related to her lack of experience and exposure to financial matters.

He decided to pause the assessment to allow the staff at school to provide Amy with relevant experience over the next few weeks.

He then repeated the original exercise and found that Amy’s abilities were much improved.

After several months he introduced some of the newer financial concepts to Amy, such as rent and utility bills. Amy found it very difficult to grasp these out of context, as she was still living at home.

The social worker determined that, at the time she moved Amy had capacity to manage her day to day finances with the advice of others, but was not able to manage more complex financial matters.

Plans were put into place to continue developing Amy’s abilities and confidence after the move, and these were tested at regular intervals to ensure that she was supported to manage increasing levels of her finances over time.

Click here to access the Mental Capacity Assessment for Finances tool, in a downloadable word format that can be used or adapted as required.

6. John’s Story

John was a man in his 60’s with a recent diagnosis of Alzheimer’s disease. He had Type 1 diabetes and relied on daily injections of insulin to maintain his health. John lived in an extra-care scheme (housing with care).

John had always taken small risks with his health by eating a few biscuits with a cup of tea each day. However, he had always limited the number of biscuits he ate and been careful to monitor for signs that his insulin levels were affected.

The staff at the care home had noticed that John was;

  1. Buying more biscuits than normal; and
  2. That they did not appear to be lasting as long.

When they reminded John about the health risks associated with eating too many biscuits he seemed to understand this and maintained that his health was important to him. However, he continued to eat more and more biscuits and staff became increasingly concerned that John was not able to recall the information he was being given. They wanted to limit the amount of biscuits available to John at any one time by keeping them in a locked cupboard.

The social worker was asked to establish whether it was in John’s Best Interests to keep the biscuits locked away, but first she needed to confirm whether John;

  1. Lacked capacity; or
  2. Was making an unwise decision.

The things that the social worker set out to determine were;

  1. If John still understood the health risks of eating biscuits; and
  2. If so, whether he was able to retain this information; and
  3. If so, whether he was using this information to inform his decisions about eating more biscuits.

The social worker recognised that she was not best placed to provide relevant information to John about the health risks associated with eating more biscuits. She spoke to the District Nurse who agreed to meet with John in order to provide him with relevant information and establish whether he could still understand the health implications of eating too many biscuits.

The District Nurse provided John with some leaflets and easy read information and, after talking this through with John felt that he understood his condition and the risks involved.

Over the course of a week, the social worker asked the care staff to;

  1. Make a record of the number of biscuits that John was eating; and
  2. Make a record of the number of biscuits that John said he was eating.

This record showed a significant difference between the number of biscuits that John was actually eating, and the number that he remembered to have eaten, which suggested to the social worker that John had either;

  1. Not retained the information provided to him by the District nurse; or
  2. Not used the information in the course of his decision-making; or
  3. Made an unwise decision.

The social worker approached the District Nurse again and arranged to meet jointly with John. The nurse asked John some questions to test if he had remembered the information she had provided previously, but John could not recall their conversation. The nurse provided the same information to John again, and again he seemed able to understand the information at the time that it was given.

The social worker monitored the situation in the same way as before over the coming days and there was no evidence that John was acting on, or using the medical information that was given to him, despite the fact that historically he had always done so.

The social worker concluded that, at the time that John was eating the biscuits he lacked capacity, on the basis that he could not retain the relevant information or remember how many biscuits he had eaten.

The social worker was still keen for John to be able to make his own decision about locking the biscuits away if at all possible, so she met with him and asked him;

  1. How many biscuits he wanted to eat with his cup of tea; and
  2. If he were to ever eat more than that, whether he would want for the biscuits to be locked away.

John told the social worker that he had always looked after his health and would never eat more than 3 biscuits each day. He went on to say that is he ever did eat more (which he was adamant he would never do) that he would want someone to prevent him from doing so.

Given John’s history of only eating 3 biscuits, and how important it has always been to him to maintain his health a decision was made in his Best Interests to lock his biscuits away after he has eaten 3.

7. Neil’s Story

Neil was an 18 year old male with a mild learning disability. He had recently moved from the family home into a supported living scheme. Previously his parents supported him at all times, but the assessment that was carried out to establish his eligible needs determined he only required support at key times of the day.

Neil had started to go out on his own several evenings a week to the local pub. His parents were very concerned about his ability to do so, and wanted the Local Authority to reconsider providing him with some support.

Neil was described to the social worker as a person who makes judgements about friends based on their outward appearance and how friendly they appear to be, rather than any of their true qualities. They were concerned that he would not recognise potentially risky people or be able to protect himself from financial exploitation.

The social worker needed to establish whether Neil was able to make his own decisions about new friendships, particularly in relation to the potential risk factors that he considered (or did not consider) when doing so.

The social worker prepared a simple tool to test out Neil’s parent’s theory that he forms his friendships based on appearance alone.

The tool comprised 4 photographs of human faces, 2 of which appear traditionally friendly and 2 of which traditionally unfriendly. Several personal qualities were then attributed to each face, some of which appeared to match the outward appearance of the face and some of which did not.

Neil was asked to consider all of the information and decide who he felt would be a good person to have as a friend. This simple test evidenced that Neil;

  1. Did judge friendships based on outward appearance; and
  2. Gave no weighting to personal attributes at all.

However, the social worker did not want to make a decision that Neil lacked capacity to decide who would be appropriate to befriend and she felt that with the right support he may be able to learn how to do this for himself. 

The social worker was able to secure some additional funding so that Neil’s male support worker could accompany him to the pub and support him to learn the important social skills required to form good friendships. 

Click here to access the tool used (Faces and Qualities), in a downloadable word format that can be used or adapted as required.

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