Assessing Capacity – Reflections on Developing the Toolkit

3rd May 2024

I was there at the beginning

It was way back in 2007 when I qualified as a social worker. The MCA had just come out and professionals were still getting to know it. When I carried out my first mental capacity assessment I was working in an older person’s mental health team. I was newly qualified and I had a colleague to support me with the assessment. I can’t remember what the details of the assessment were, but I think we did it in a care home, so I’m guessing the decision was around accommodation. I couldn’t tell you what the outcome was or how well the assessment was written up, but I’m pretty sure by today’s standards, it would have been rubbish!

Since those early days when I was bursting with energy and had a full head of hair, the MCA has become a central piece of legislation, integrated into all health and social care processes. The MCA has been a key part of my social work practice from my first role job, through to working in the learning disabilities team, and finally working in the deprivation of liberty safeguards team. I must have completed hundreds of capacity assessments over the years on a whole range of topics, the most common ones being around safeguarding and accommodation. I’ve had the privilege of being a practice educator; supporting students on placement and helping them undertake assessments of capacity. 

Real life is messy

There has always been a big difference between learning the concepts of a capacity assessment – remembering what the two-stage test involves and figuring out the causative nexus – and then applying it in real life. The difficulty is real life can’t be learned from a textbook. People are all different with different histories, different personalities, different abilities, and different goals/aspirations. One approach to assessing capacity may work for one person, but not the next. We need to be flexible and creative in our approach to assessments. I was reminded of this while updating the MCA Toolkit.

We’re always learning 

As health and social care professionals, we are always learning. There are always things we can take away, reflect on, and use to develop our practice. This for me was one of the unexpected benefits of working on this project. The main activity in developing the toolkit saw my colleagues and me attending a day centre for people living with learning disabilities. We undertook creative tasks to help ensure these people’s voices and perspectives were incorporated into the Toolkit, thus making it even more inclusive. At one point during the day, we were creating collages around the theme of holidays. I asked the person next to me; if she could go anywhere on holiday, where would she love to go. She told me she liked the beach. She went on to talk about how her family holidays are usually beach holidays. I noticed she had a picture of Disneyland Paris in her hand. When I asked her about it she said she’d always wanted to go there. Given the choice of Disneyland or a beach holiday, she told me she’d like to go to Disneyland. She preferred Disneyland to a beach holiday, but I got the sense she said the beach because that was what she usually did. In other words, that the was ‘right answer’. She didn’t say Disneyland until I specifically asked her about it. 

The importance of creativity 

This reminded me of the importance of being creative when carrying out mental capacity assessments. Sometimes someone may say something because it’s what they’ve always done, or it’s what they believe to be the ‘correct’ answer. I reflected on my conversation with this person and came up with a cunning plan: If I wanted to find out her views about where she wanted to go on holiday, as part of an assessment, I could help her explore the issues from different perspectives. I ask questions such as: ‘Where would Mum pick?’, ‘What would your social worker do?’, ‘Where would you love to go?’. We could even get the craft materials out and use images to explore the options. 

This may help or it may not, but like most things in health and social care, we don’t have a definitive answer. We are all learning all the time, and that’s the good thing about the MCA Toolkit – it can help fill in the gaps and ensure we do our best for the people we are working with. 

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