Mental Capacity in Adult Social Care: Moving Beyond Tick-Box Assessments
Mental capacity is one of the most misunderstood and poorly applied areas of adult social care practice. Despite widespread familiarity with the Mental Capacity Act (MCA), capacity assessments are still too often treated as static documents rather than live, decision-specific processes embedded in day-to-day support. This creates risk for people using services, families, providers and commissioners alike. Within mental capacity, consent and best interests decision-making, poor practice rarely fails because staff are unaware of the law; it fails because systems, culture and governance reduce capacity to a tick-box exercise rather than a core safeguarding and human rights function. This issue cannot be separated from wider core principles and values, including autonomy, dignity and least restrictive practice.
This article explores how services can move beyond superficial compliance and embed capacity practice that is lawful, proportionate and operationally realistic.
Why Tick-Box Capacity Assessments Persist
Tick-box capacity assessments persist because they appear administratively efficient. Templates are completed at admission, stored on the system and rarely revisited unless a crisis occurs. In pressured environments, this can feel pragmatic. However, the MCA is explicit that capacity is decision-specific and time-specific. A person may lack capacity for one decision today and have capacity for another decision tomorrow.
Common drivers of poor practice include:
- Over-reliance on generic capacity forms rather than decision-led assessments
- Insufficient training on applying the two-stage test in real situations
- Fear of challenge leading to defensive rather than person-centred recording
- Weak management oversight of assessment quality
Operational Example 1: Admission Assessments That Never Change
Context: An older person enters a supported living service following hospital discharge. A capacity assessment completed on day one states that the person lacks capacity “for care decisions”.
Support approach: Staff rely on this single assessment to justify ongoing decision-making on behalf of the person, including daily routines, finances and social contact.
Day-to-day delivery: No further capacity assessments are completed, even when the person clearly expresses preferences and demonstrates understanding in specific areas.
How effectiveness is evidenced: Following a safeguarding concern raised by a family member, the service is unable to demonstrate decision-specific assessments. This results in remedial action, staff retraining and increased scrutiny.
Decision-Specific Capacity: What Good Looks Like
Good capacity practice starts with clarity about the specific decision in question. This may relate to residence, care, finances, medical treatment, relationships or risk-taking. Staff must then evidence both stages of the MCA test:
- Is there an impairment of, or disturbance in, the functioning of the mind or brain?
- Does this impairment mean the person cannot understand, retain, weigh or communicate the relevant information?
Crucially, support to enable decision-making must be documented before concluding that capacity is lacking.
Operational Example 2: Supporting Capacity Through Adjustments
Context: A person with a learning disability is assessed as lacking capacity to consent to medication changes.
Support approach: The service introduces easy-read materials, repeat discussions and familiar staff involvement.
Day-to-day delivery: Discussions are broken into short sessions over several days rather than a single meeting.
How effectiveness is evidenced: The person demonstrates understanding and communicates consent, with clear records showing how support enabled capacity.
Commissioner Expectation
Commissioners expect capacity assessments to be decision-specific, proportionate and demonstrably reviewed. They will look for evidence that services are not using blanket capacity statements to manage risk or workload, and that reassessments occur as circumstances change.
Regulator / Inspector Expectation (CQC)
CQC expects providers to apply the MCA in practice, not just policy. Inspectors routinely test whether staff can explain how they assessed capacity for a real decision, how they supported the person, and how they recorded the outcome. Generic or outdated assessments are a red flag.
Operational Example 3: Quality Assurance as a Safeguard
Context: A provider identifies inconsistent capacity assessments across services.
Support approach: Managers introduce monthly audits of capacity decisions linked to supervision.
Day-to-day delivery: Staff receive feedback on assessment quality and decision framing.
How effectiveness is evidenced: Audit outcomes improve, safeguarding concerns reduce and inspection feedback highlights stronger MCA practice.
Embedding Capacity as Core Practice
Moving beyond tick-box assessments requires leadership, training and governance. Capacity must be treated as a living process, central to safeguarding, risk management and person-centred support, rather than a document completed once and forgotten.