Best Interests Decisions in Adult Social Care: Making Complex Decisions Defensible
Best interests decision-making is where services are most likely to face scrutiny: not because staff lack compassion, but because process, evidence and governance are often weaker than people assume. If you want a strong foundation, align practice with your mental capacity, consent and best interests decision-making approach, and keep it consistent with your organisation’s core principles and values. Done well, best interests decisions protect the person’s rights, reduce conflict, and stand up to challenge. Done poorly, they become “meeting notes” that don’t show how the decision was reached, what alternatives were tested, or how the person’s wishes were weighted in practice.
What “best interests” looks like in day-to-day service delivery
In adult social care, best interests is not a one-off event. It is a decision-specific process that must be revisited when circumstances change (health, cognition, risk profile, family involvement, or placement stability). Operationally, good best interests practice has four visible features:
- Clear decision statement: exactly what is being decided, in plain language, and why it matters.
- Options and least restrictive analysis: what alternatives were considered and what was tried before escalation.
- Evidence trail: how the person’s wishes, feelings, beliefs and values were identified and weighted.
- Governance and review: who authorised the decision, how it was monitored, and what would trigger review.
Where services go wrong is usually not the meeting itself; it’s the lack of structured preparation and the absence of “proof points” that the person was supported to participate and that less restrictive options were actively explored.
Operational example 1: Best interests decision about residence when family conflict is high
Context: A person with moderate cognitive impairment is settled in supported living. A family member insists the person must move to a care home “for safety,” while staff observe reduced distress and improved functioning since the move into the community. The person cannot clearly weigh the risks of different settings, and capacity for the residence decision is assessed as lacking.
Support approach: The service frames the best interests question tightly: “Where should X live over the next 3 months to maintain safety and wellbeing while enabling maximum independence?” Options are listed: remain with increased support, short-term step-up, respite placement, care home placement, or alternative supported living with enhanced staffing.
Day-to-day delivery detail: Staff use accessible formats to support participation (photo prompts of each option, short conversations at consistent times, and an advocate session). The keyworker gathers “lived evidence” of the person’s preferences through routine: when do they appear calmer, what routines matter, what triggers distress, and what happens when different support intensities are used. The service also runs a structured two-week “enhanced support trial” in current accommodation (extra checks, falls reduction measures, medication oversight, and night-time reassurance) to test whether risk can be mitigated without moving.
How change is evidenced: The best interests record includes objective indicators (incident logs, falls data, medication errors, sleep pattern notes) and qualitative evidence (staff observations, advocate feedback, the person’s repeated statements about wanting to stay near familiar places). The decision outcome is time-limited with a clear review trigger: if night-time incidents exceed an agreed threshold or physical health deteriorates, the decision returns to the best interests forum.
Operational example 2: Best interests decision about contact and access when there are safeguarding concerns
Context: A person lacks capacity around contact decisions due to severe mental illness and cognitive impairment. A relative repeatedly requests unsupervised visits and access to financial information. There are safeguarding concerns (coercion indicators, controlling behaviours, and a history of financial exploitation).
Support approach: The service separates decisions: (1) “contact and visits,” (2) “sharing information,” and (3) “support with finances.” Each has a decision statement, a risk assessment, and a least restrictive plan. The best interests meeting includes safeguarding lead input and uses a rights-based approach, balancing protection with relationships that matter to the person.
Day-to-day delivery detail: The service implements supervised visits in a calm, structured setting with agreed ground rules (no discussion of money, no removal of documents, staff present, and a clear end time). Staff brief the person beforehand using simple choice prompts and debrief afterwards to check emotional impact. Information sharing is limited to what is necessary and lawful, with a single point of contact to prevent staff being pressured on shift. A parallel plan is put in place to strengthen the person’s financial safeguards (appointeeship review, spending plan, and monitoring for unusual withdrawals).
How change is evidenced: The service records the person’s emotional state before and after contact, incident patterns, and any coercion indicators. Governance evidence includes a safeguarding escalation log, management sign-off for any restriction, and a scheduled review date to test whether supervision remains proportionate. The file clearly shows why less restrictive options were unsafe at that time.
Operational example 3: Best interests decision about medication administration and refusals
Context: A person with fluctuating cognition refuses essential medication intermittently. Staff are concerned about deterioration and hospital admission risk. Capacity is assessed as lacking for the specific decision at points of acute confusion, but may be regained at other times.
Support approach: The service uses a “supported decision first” pathway: simplify information, offer at optimal times, use familiar staff, and explore the person’s reasons for refusal. Best interests is used only where capacity is lacking at the time and risk is significant.
Day-to-day delivery detail: Staff document the pattern: what time refusals happen, what explanations work, and whether pain, nausea or anxiety is driving refusal. They agree a consistent script with the GP/pharmacy and use non-coercive prompts (choice of drink, quiet environment, and offering later rather than repeated pressure). Where best interests administration is agreed (rare and time-limited), the service sets out who can authorise it, what must be tried first, and how the person’s distress will be minimised. Any restrictive element is clearly recorded and reviewed.
How change is evidenced: The MAR is supported by narrative notes that show attempts at supported decision-making, outcomes of different approaches, and clinical escalation when thresholds are met. Audit checks confirm that best interests administration is not becoming “routine” without fresh decision-making.
Commissioner expectation: a defensible, repeatable decision-making process
Commissioner expectation: Commissioners typically expect best interests decisions to be consistent across the provider, not dependent on which manager is on duty. In practice, that means a standard template, clear thresholds for escalation, evidence that alternatives were tried, and review dates that are actually met. They also look for measurable stability indicators (reduced incidents, improved engagement, reduced avoidable admissions) linked to the decision taken, not just “we held a meeting.”
Regulator / Inspector expectation: lawful, person-centred practice that reduces restriction
Regulator / Inspector expectation (CQC): Inspectors will look for evidence that the person was supported to be involved, that decisions are decision-specific, and that restrictions are the least restrictive option for the shortest time. They will also expect governance: management oversight of restrictive elements, clear recording of rationale, and learning when things go wrong. The strongest files show a living process—capacity reassessed when appropriate, decisions reviewed, and staff practice aligned to rights and dignity.
Governance and assurance mechanisms that make best interests “inspection ready”
To make best interests work at scale, providers need routine governance:
- Quality sampling: monthly audit of a small number of best interests records against an internal standard (decision clarity, options tested, evidence quality, review date met).
- Restriction register: a log of restrictions linked to best interests decisions (what, why, authorisation, review date, reduction plan).
- Practice supervision: reflective supervision that tests whether staff understand decision-specific capacity and how to evidence “supported decision first.”
- Escalation pathways: clear triggers for involving safeguarding, clinical partners, or legal advice where risk or dispute is escalating.
The aim is not paperwork; it’s to show that best interests decisions are rights-based, proportionate, reviewed, and consistently applied across services.