2.6 Self-neglect

2.6.1 Context and Definition

The Care Act 2014 brought self-neglect within the statutory definition of abuse or neglect and included it as a category to be considered within safeguarding frameworks.

Statutory guidance published by the Department of Health defines self-neglect as; “a wide range of behaviour – neglecting to care for one’s personal hygiene, health of surroundings and includes behaviour such as hoarding”.

The use of a ‘Social Psychological Model’ of working with self-neglect is recommended, recognising the interplay of a variety of physical, mental, social, personal and environmental factors both internally and externally and how these impact in and on the person’s circumstances.

Practitioners are encouraged to consider self-neglect in a broad context, not just in terms of obvious manifestations such as hoarding. Other areas to consider may include;

substance misuse,
individuals with diagnosis of high functioning Autism Spectrum Conditions with difficulties that bring them into frequent contact with services,
sexual exploitation where there may be issues of situational incapacity (where individuals have the capacity under the (Mental Capacity Act) MCA 2005 but due to their situation they are compromised e.g. they are coerced or constrained or under undue influence),
people subject to frequent ‘Missing Persons’ alerts wherein they may be putting themselves at risk of significant harm,
people with significant mobility issues who are not taking action to protect themselves from fire risk,
those whom are non-concordant with medication,
people who are considered gravely overweight or
those who as a result of vulnerabilities linked to their care and support needs are putting themselves at repeated risk of significant harm.

In 2018, ‘Hoarding Disorder’ was included in (International Classification of Diseases) ICD-11 as a recognised mental health disorder. It is estimated that around 2-5% of the population in the UK hoard and that around 1.2 million people in the UK have hoarding disorder. The diagnostic criteria for this condition are:

Persistent difficulty discarding or parting with possessions, regardless of monetary value
Perceived need to save the items and distress associated with discarding them
The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas
Hoarding causes clinically significant distress or impairment in social, occupational, or to other important areas of functioning
Symptoms are not restricted to the symptoms of other disorders (e.g. hoarding due to obsessions in (Obsessive Compulsive Disorder) OCD, or delusions in a psychotic disorder)

When working with hoarding, it is recommended that practitioners utilise the Clutter Index Rating, which can be located here: https://hoardingdisordersuk.org/wp-content/uploads/2014/01/clutter-image-ratings.pdf.

This enables the objective scaling of hoarded items. Android and Apple Apps also exist for download onto smart phones for ease of use if preferred.

It is important to recognise that work with self-neglect and hoarding, which is a complex area of practice; is often influenced by personal, social and cultural values and staff working with the adult at risk should always reflect on how their own values may affect their judgement. Self-neglect is a complex issue and it is understood from research that responses from a variety of organisations are likely to be more effective than a single agency response. Most effective intervention with self-neglect relies on building a trusting relationship and rapport with the adult at risk to offer support in a person-centred way, working at a pace they feel comfortable with and taking account of their relevant history, preferences and priorities. It is essential to find the right balance between respecting the adult’s right to autonomy and meeting the duty to protect their wellbeing and to apply proportionate thresholds for interventions under a safeguarding framework. Research has proven that using short-term, coercive interventions is less effective when working with people whom self-neglect – and use of coercive powers should therefore be limited to where it is necessary.

2.6.2 Recognising and Referring

Possible indicators of self-neglect may include:

Being unable or unwilling to provide adequate care for self
Malnutrition or dehydration; little or no fresh food in the fridge or food that is off or very out of date
Living in ‘squalid’ or insanitary conditions for example; infested property or lack of functioning utilities
Neglecting household maintenance creating hazards and/or fire risk such as overloading of plug sockets and not maintaining clear escape routes
Unsafe smoking within a property, not discarding of cigarettes safely and any evidence of burn marks
Hoarding
Untreated or improperly attended medical condition, non-compliance with required health or care services, inability or unwillingness to take mediation or treat illness or injury
Coming into repeated contact with services as a result of seemingly capacitated but high risk decision making and risk taking

Threshold toolkits can be used to support decisions around when a situation of self-neglect or hoarding meets the threshold for referral under safeguarding. Toolkits can be used by any agency and supports practitioners to be objective both in terms of language used and in identifying risk. Toolkits also supports practitioners to consider capacity and consent around referral and prompts them to consider public interest (risk to others) and vital interest (risk of serious harm or distress or risk to life) issues. If a practitioner is in any doubt about what a tool is telling them, they can consult with the relevant Safeguarding Adults Team for advice. Links to local toolkits can be found in section 2.6.9.

2.6.3 Assessment

Crucial to assessment and intervention under safeguarding, is robust multiagency risk assessment that includes the views of the adult and those in their personal network. This may include matters such as; relevant history, capacity and consent, indications of mental or physical health issues, risk to overall wellbeing, effects on other people’s health and wellbeing, serious risk of fire or serious environmental risk.

A significant element of working with self-neglect and hoarding is also considering the risk presented to others, which may include family members, members of the public or professionals.

The ‘Social Psychological Model’ of assessment in self-neglect highlights a variety of important factors for consideration:

Underlying mental disorder, trauma response and/or neuropsychological impairment
Diminishing social networks and/or economic resource
Physical and nutritional deterioration
Personal philosophy and identity

In order to support practitioners from statutory agencies in working with this complex area of practice, the use of a comprehensive assessment toolkit is recommended. Use of this tool can be adapted to the circumstances of the adult concerned but acts as a useful prompt to consider the person and their situation holistically and in depth.

Practitioners are expected to use professional curiosity at all times.

2.6.4 Mental Capacity

When working with adults whom self-neglect, the starting point is always to consider whether the individual concerned has mental capacity to make decisions about their own wellbeing, and whether or not they are willing and able to care for themselves (in accordance with the principles of ‘Making Safeguarding Personal’). It is vital to be precise about the decision or decisions being considered, to avoid consideration of capacity will become bland and outcomes unlawful.

The Mental Capacity Act 2005 is clear the law allows capacitated adults to make ‘unwise decisions’. However, it is vital that practitioners also understand the implications of executive functioning (on the ability to use and weigh information), and that they are aware of situational incapacity and the inherent jurisdiction of the courts.

Executive functioning refers to the interplay between making a decision and being capable of acting upon it; weighing up the information and being able to understand the consequences of decisions and actions but also having the ability to implement those actions. Research therefore recommends that assessors ‘articulate and demonstrate’ models of assessment. Useful updated information on applying the Mental Capacity Act, including reference to these issues can be found here:

https://www.39essex.com/information-hub/mental-capacity-resource-centre/mental-capacity-resources/mental-capacity-guidance?page=1

There is also useful information concerning the Frontal Lobe Paradox to be found here: https://www.researchgate.net/publication/324899681_Mental_Capacity_Act_2005_assessments_why_everyone_needs_to_know_about_the_frontal_lobe_paradox

If an adult whom is capacitated does not want any intervention or safeguarding action to be taken, it may be appropriate not to intervene any further at that point. In making this decision, it is essential to:

Consider whether anyone else is at risk (public interest)
Consider whether the person’s ‘vital interests’ are compromised or not (risk of serious harm or distress or risk to life)
Ensure all decisions have been fully explained and recorded in a shared risk assessment
Ensure other agencies have been involved as necessary and informed of decisions
Ensure there is a route back to re-referral or accessing support should the person change their mind

Practitioners should always consider use of a multiagency risk panel / meeting / framework if the level of risk requires it. Details of local risk management frameworks can be found in section 2.6.8.

2.6.5 Relevant Legislation and legal Processes

There is a wide range of legislation that can be applicable to situations of self-neglect. As a reminder, it is important to reserve use of coercive powers for those situations wherein they are proportionate and essential. Involving an appropriate multiagency team in cases of self-neglect can support best outcomes.

Care Act 2014

Mental Capacity Act 2005

Mental Health Act (2007) s.135

A magistrate’s court can authorise entry to remove people to a place of safety if a person has a mental disorder and is unable to take care of themselves.

Article 8 of the Human Rights Act 1998

Applies to self-neglect when others are at risk from the behaviour.

Housing Act 2004

Part 1 assessment of hazards in the home, and powers including improvement and prohibition notices and emergency actions for urgent works.

Part 4 concerns Empty Dwelling Management Orders (see Secondary Powers)

Building Act 1984

Several powers to require property owners to address problems of ruinous, dangerous or dilapidated properties. Drains.

Local Government (Miscellaneous Provisions) Act 1982

S29 “Boarding Up Notice” to prevent unauthorised entry to or to prevent a home from becoming a danger to public health.

Environmental Protection Act 1990

Sections 79-82 abatement of statutory nuisance, including accumulations of rubbish or dampness affecting neighbouring properties.

Town and Country Planning Act 1990

s215 “Tidy Up Notice” requires owners to deal with unsightly land or the external appearance of a property.

Also includes powers relating to compulsory purchase.

Planning (Listed Building and Conservation Areas) Act 1990

To require urgent works to be carried out to unoccupied buildings to prevent deterioration, and compulsory acquisition of listed buildings in need of repair.

Public Health Act 1936.

Clearing and cleansing of ‘Filthy & Verminous’ property

Prevention of Damage by Pests Act 1949.

Require owners to eradicate vermin or take steps to prevent vermin infestations.

Anti-Social Behaviour Act 2003

Parts I&II – Closure Orders for crack-dens, illegal brothels and premises with persistent disorder or nuisance. Generally Police-led.

Anti-Social Behaviour, Crime & Policing Act 2014.

Community Protection Notices. Person’s conduct is having a detrimental effect, of a persistent or continuing nature, on the quality of life of those in the locality and the conduct is unreasonable.

Inherent Jurisdiction within the Court of Protection

For situations where an agency is concerned about the person’s ability to keep themselves safe to the extent that action needs to be taken under a lawful process. This is usually a last resort action. Access to this process is via the agencies legal team.

2.6.6 FURTHER CONSIDERATIONS

Immediate actions
- is there a risk to life
- Is there a risk of accidents

Take a creative and flexible approach
Be patient
Take a making safeguarding personal approach
Consider raising a safeguarding concern to the Local Authority
Work on a multi-agency basis
Consider use of multi-agency risk frameworks
Make thorough and accurate recordings
Taking a proportionate approach
Refer to Fire and Rescue Service for a Safe and Well visit
Remember that relationships change lives not resources
If nothing has changed after 3 months of active face to face practitioner involvement, review the case with relevant colleagues and agencies with particular reference to these legal frameworks:
- Mental Capacity Act 2005 for each decision specific.
- Mental Health Act-2007 amendment to Mental Heath Act 1983 Hoarding is a mental disorder

2.6.7 KEY MESSAGES RELATING TO PEOPLE WHO SELF-NEGLECT

The following key messages are drawn from research, practitioners’ experience and lessons learned from Safeguarding Adults Reviews (SARs)

All agencies have a role in supporting people who self-neglect, so please ensure you and your agency are fully committed to playing your part
Try to find out why the person is self-neglecting – this may be connected with trauma, grief, mental health episodes or other experiences (relevant history)
Try to really get to know the person, build a rapport, and ‘get alongside’ them
Don’t just look at the current picture, but try to piece together the person’s life story and find out what is important to them
Put yourself in their shoes to appreciate how they might be feeling or going through but refrain from laying over your values/views/beliefs with theirs.
Be prepared for long-term involvement – self-neglect situations are rarely resolved quickly
Look at the person’s family network and any community networks and think about how these might help support the person (consider whether a Carer’s assessment is needed)
Communicate clearly and regularly with all those involved with the person
Be clear about your role and responsibilities and those of others
Maintain clear records of interventions, decisions and rationale
Provide training, supervision and support for workers supporting people who self-neglect
Undertake a thorough risk assessment and explain your concerns openly to the person who is self-neglecting
Consider mental capacity in relation to the decisions which need to be made – is the person able to understand information / retain it / weigh it / communicate their decision?
Also consider the person’s ‘executive functioning’ – they may appear to understand but can they / will they see the decision through in practice?
Consider whether advocacy is needed
Remember that ‘self-funders’ are just as entitled to a care and support assessment as others whose care is funded by the Council
Be prepared to challenge decisions if you don’t agree with them, and escalate them if necessary
Don’t dismiss self-neglect as a ‘lifestyle choice’ or take an initial rejection of support as final
Don’t close a case simply because the person refuses an assessment or won’t accept a plan
Self-neglect can be found in all areas of society, but those who are homeless or living in temporary accommodation may be at greater risk
Always remember to ‘Think Family’ and consider any risks to those living with or closely related to the person who is self-neglecting

2.6.8 Local Risk Management Frameworks

Each Safeguarding Adult Board has a localised risk management framework which may be appropriate in cases where self-neglect is known or suspected. The risk frameworks can be found here: