Makaton for Choice and Control in Learning Disability Services
Makaton can strengthen choice and control in learning disability services when it helps people understand options and communicate preference, refusal, uncertainty or readiness. Choice is not meaningful if people only receive verbal explanations they cannot process quickly enough. For some people, signs and symbols create a clearer route to influence daily life.
Strong providers use Makaton as part of wider communication and accessibility in learning disability support and connect it with learning disability service pathways and support models. This matters because choice happens across ordinary routines as well as formal reviews, including meals, clothes, activities, relationships, personal care, health appointments and time alone.
Concept explained clearly
Makaton uses signs, symbols and speech together to support understanding and expression. In choice-making, it can help people understand what is being offered, say yes or no, ask for more, indicate finished, request help or show that they need more time.
The purpose is not to make every decision formal. The purpose is to make everyday options clearer and to reduce reliance on staff guessing what the person wants.
Why it matters in real services
People may appear passive, compliant or resistant when the real issue is that choices are not being communicated clearly. A person may accept an option because it is the only one presented with confidence. Another person may reject everything because the choices are too fast, too verbal or too abstract.
Providers should be able to evidence that Makaton supports real choice, including the person’s right to refuse, change their mind or ask for help.
What good looks like
Good Makaton choice support uses a small, relevant set of signs and symbols consistently. Staff present realistic options, allow processing time and record how the person responds across different situations.
Strong services demonstrate a clear line of sight from Makaton use to clearer preference, reduced frustration and more person-led daily support.
Operational Example 1: Supporting activity choice without staff assumption
Context: A person in supported living was recorded as preferring quiet indoor activities. A new staff member noticed that the person watched others leave for community activities but did not respond when asked verbally if they wanted to go.
Support approach: The provider introduced Makaton signs for go, stay, walk, café, music, finished, yes and no, alongside real activity photos.
Five practical steps:
- The team reviewed whether previous activity choices had been communicated accessibly.
- Staff selected a small number of signs linked to real weekly options.
- The person was shown two options at a time using signs, speech and photos.
- Workers recorded looking, signing, pointing, rejection and repeated choices.
- The weekly activity plan was updated based on consistent preference evidence.
Day-to-day delivery detail: Staff signed “go” and showed the café photo, then signed “stay” and showed the lounge photo. The person began touching the café photo and moving towards their coat. Staff stopped assuming indoor preference and built in short community visits.
How effectiveness was evidenced: The person attended short café visits with low anxiety. Records showed clearer choice evidence and a wider activity pattern shaped by the person’s communication rather than staff assumption.
Deepening choice through total communication
Makaton works best when it sits within total communication beyond spoken language. A person may combine signs with objects, photos, facial expression, movement, vocalisation or routine cues. Staff need to recognise the whole communication picture, not just whether the sign is produced perfectly.
This means a person’s version of a sign may look different from the taught version. Services should record how the person uses or understands signs in practice, so staff respond consistently.
Operational Example 2: Supporting refusal during personal care
Context: A person became distressed during evening personal care. Staff described this as refusal, but records showed little evidence that the person had a clear way to say stop, wait or finished before distress escalated.
Support approach: The provider introduced Makaton signs for wash, stop, wait, help and finished, supported by a short visual routine.
Five practical steps:
- Staff identified where distress usually started in the routine.
- The team agreed signs that protected control and dignity, not only task completion.
- Workers practised the signs during calm preparation, outside personal care.
- Staff paused immediately when the person used or approximated “stop”.
- Managers reviewed personal care records for distress, pauses and successful completion.
Day-to-day delivery detail: The person began raising their hand in a consistent way when staff signed “stop”. Staff treated this as a valid pause request, waited quietly and resumed only when the person looked back at the visual routine.
How effectiveness was evidenced: Personal care distress reduced, and the person used the pause signal earlier. Records showed that Makaton supported refusal, pacing and dignity rather than being used to push the routine through.
Systems, workforce and consistency
Choice and control depend on staff using Makaton consistently. Teams should agree person-specific signs, record the person’s own responses and avoid introducing too many signs at once.
Supervision should check whether staff respect refusal and uncertainty. Handovers should include signs recently used, whether the person responded and whether any new preference has emerged. This prevents one staff member’s interpretation becoming an unsupported assumption.
Operational Example 3: Supporting health choices and reasonable adjustments
Context: A person needed a routine dental appointment but became anxious when staff explained the visit verbally. The person used Makaton for daily choices but this was not included in health preparation.
Support approach: The provider prepared a Makaton-supported appointment plan, alongside accessible written information aligned with accessible information standards in learning disability services.
Five practical steps:
- Staff identified signs needed for the appointment, including dentist, chair, stop, help and finished.
- The person practised the signs with photos of the actual dental surgery.
- The support worker briefed the dental team on the person’s stop and help signs.
- During the appointment, staff modelled signs calmly and waited for response.
- The team reviewed whether the person had more control during the appointment.
Day-to-day delivery detail: The person signed “stop” when the chair moved back. The dentist paused, explained the next step using fewer words and waited until the person signed “finished” after the check.
How effectiveness was evidenced: The appointment was completed without escalation. The health action plan recorded the Makaton signs used and the reasonable adjustments that supported control and participation.
Governance and evidence
The audit trail may include communication profiles, person-specific Makaton sign lists, staff competency checks, daily records, health preparation notes, supervision records and outcome reviews.
Data may show increased choice-making, fewer distressed refusals, improved appointment tolerance, reduced repeated prompts or more varied activity participation. Qualitative evidence should explain how Makaton helped the person express preference, refusal or need for support.
Commissioner and CQC expectations
Commissioners expect providers to evidence person-centred support, involvement and rights-based practice. Makaton can help demonstrate that people are supported to influence real decisions, not simply offered choices verbally.
CQC expects effective communication, dignity, consent-aware care, person-centred support and good governance. Inspectors may look at whether staff understand how people communicate choice and whether refusal is respected.
Common pitfalls
- Using Makaton to prompt compliance rather than support choice.
- Focusing only on yes responses and not teaching stop, no or finished.
- Introducing signs without checking whether the person understands them.
- Recording choice without describing the communication evidence.
- Ignoring the person’s own adapted version of a sign.
- Failing to share person-specific signs with health, respite or agency staff.
Conclusion
Makaton can strengthen choice and control when it gives people clearer ways to understand options and communicate what they want. Strong providers demonstrate that signs and symbols are used consistently, respectfully and in real routines. When Makaton supports preference, refusal and participation, daily support becomes more person-led and easier to evidence.