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Case study: What do we mean by ‘decision specific’?

Man in electric wheelchair looking out to the sea

We all make many thousands of micro-decisions on a daily basis, from the way we make a cup of tea to what we watch on TV. However, when it comes to decision making, the Mental Capacity Act (2005) is ‘decision specific’. This means that it relates to a specific decision made at a specific time. It does not refer to decision-making more broadly. This raises the question: how specific do we need to be when we assess capacity?

A familiar character

To help us unpack some of the issues around this question, I’d like to introduce you to a familiar character…

  • Wheezy the Penguin is 92-year-old and lives in a nursing home near his family.
  • He has a diagnosis of Chronic Obstructive Pulmonary Disorder (COPD) and has had several Cerebral Vascular Accidents (CVAs), also known as strokes.  This has left him with significantly reduced mobility, and he is reliant on staff to support his movements between bed, chair and toilet.
  • Following his most recent stroke, staff have noted a significant decline in Wheezy’s short-term memory and processing skills. This has been formerly assessed by the professional teams, who have diagnosed Vascular Dementia, presenting with moderate cognitive impairment.
  • Wheezy has been observed by team members to be increasingly confused during times of manual handling, from which the team discussed whether he can provide informed consent on what support he needs to move about.

At this stage, the team recognise that a Mental Capacity Assessment is required for Wheezy, as there is a reasonable belief that he is not able to provide informed consent for manual handling support. The initial decision to be addressed is: ‘can Wheezy make an informed decision regarding support for manual handling, including the use of a hoist?’


Broadly speaking, an unspoken ‘rule of thumb’ to support practitioners in daily practice is to assess for a commonly grouped cluster of decisions, such as:

  • Manual handling
  • Consent for photography
  • Personal care support
  • Medication
  • Management of ‘small’ finances
  • Household hygiene
  • Etc…

This approach can be found within the Mental Capacity Act (2005) itself in the ‘clustering’, or grouping of decisions for Lasting Powers of Attorney (LPA) and Deputyships to either ‘Property and Finance’ or ‘Health and Welfare’. Although it is equally recognised that it could be argued that this does undermine the element of ‘decision specific’.

Assessment questions should be carefully tailored to that individual’s needs and preferences around that ‘cluster’ of decisions. For example, if regarding ‘personal care’, it may encompass teeth, toileting, and bathing. Another example may be ‘household hygiene’, which may include laundry, hoovering, polishing, and dusting, cleaning kitchen items following use and disinfecting surfaces.

However, caution is required. While it can be useful in certain cases to group together related elements for the purpose of certain Mental Capacity Assessments, we should never standardise this approach, or apply a ‘one size fits all’ philosophy that presumes incapacity, counter to the five core principles of the Act

Our response to the case scenario

As each person and their circumstances are unique, including what they may or may not be able to provide consent for, allowances need to be made in the assessment with appropriate graded support:

  • If Wheezy was able to provide informed consent for manual handling in terms of repositioning in bed and associated movements for personal care needs, this should be a consent form, or signature of agreement to the care plan section.
  • Equally, this would be the same if Wheezy was able to provide informed consent for use of his wheelchair, including the lap strap for safety when moving.
  • However, in our case study example, if he was not able to give informed consent for the use of a hoist to transfer from his bed to his wheelchair for activities, appointments, or other needs, then this would need a specific mental capacity assessment only for the use of the hoist, not for manual handling as a whole. 

Find out more

For help and support with Mental Capacity Assessments, as well as training for your team, please do get in touch.

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