Self neglect – advice for all

In April 2019 the MSB published its MSP Self-Neglect & Hoarding Strategy and Toolkit (update October 2019).

For easy reference, we have also extracted the:

• MSP Self Neglect Toolkit_Hoarding_Insight_Characteristics_Guide
• MSP Self Neglect Toolkit – Clutter_Image_Rating_Scale

In September 2019 the MSB held a conference to launch its Self-Neglect & Hoarding Strategy and Toolkit. The launch event included subject specialist speakers, an update on learning from self-neglect SARs, workshops and networking.

Copies of the materials from these sessions have been uploaded to support partners and practitioners to cascade learning back to their agencies, teams and services; develop awareness; and promote the use of the MSB Self-Neglect and Hoarding Strategy and Toolkit.

Conference presentations:

• 1- Self Neglect – the NHS perspective
• 2- Self-Neglect – summary of MSAB strategy
• 3- Self Neglect – Adult MASH
• 4- Self-Neglect and drugs alcohol and mental health
• 5- Self-Neglect – the evidence base
• 6- Self Neglect – Hoarding – Tidy Homes Tidy Minds
• 7- Self-Neglect and mental health
• 8- Self-Neglect – ACEs and Hoarding

Indicators include:

• neglecting personal hygiene impacting upon health (including skin damage/pressure ulcers)
• poor diet and nutrition leading to significant weight loss or other associated health issues (including skin damage/pressure ulcers).
• social withdrawal from their family, community or support networks
• malnutrition and/or dehydration
• neglecting the home environment, with an impact upon health and well-being and possible public health issues; may also lead to:
  • hazards in the home due to poor maintenance
  • not disposing of refuse leading to infestations
  • living in squalid or unsanitary conditions
• hoarding – excessive attachment to possessions, people who hoard may hold an inappropriate emotional attachment to items
• large number of pets in inappropriate conditions
• lack of engagement with health and other services
  • inability or unwillingness to take medication or treat an illness or injury
• inability to protect them self from harm or abuse
  • substance misuse.

Social isolation and self-neglect are a toxic mix and can result in increasing deterioration to a person’s physical and mental well-being. Other risks can include:

• likelihood of fire
• falls and trips
• poor housing structures and lack of repairs
• items falling from a height
• nutritional risks
• insanitary conditions
• infection or vermin
• risk to others, including visiting professionals and emergency services
• environmental risks to others
• losing accommodation and becoming homeless.

Many adults self-neglect and sadly some have died as a result of their choices, so it is important to be able to recognise the signs and know how to report concerns.

You may know an adult who lives in filthy or unsafe accommodation, doesn’t look after themselves by not eating, not looking after their health or not washing themselves or their clothes. There may also be evidence of hoarding, where nothing is thrown away, including stacks of papers and magazines or other things that seem worthless to others but that the person cannot bear to dispose of.

The person may have poor personal hygiene (dirty hair, nails and skin) and may smell of faeces or urine. They could be unclothed or improperly dressed for the weather; or might not have the things that they need such as dentures, glasses, hearing aids, walker, wheelchair, or a commode. They may be dehydrated or seem underweight or malnourished.

Many adults who make these ‘unwise’ choices may do so because they are physically or mentally unable to meet their own needs or they have suffered trauma or loss and don’t believe they deserve to be well and happy.

Some adults may not recognise that they are self-neglecting as they have dementia, brain damage, depression or psychotic disorders; or they may misuse substances including prescribed medications.

It can be difficult to know when or if you should get involved but it is wise to stay alert to any changes that might indicate a problem with a neighbour, friend or family member – for example newspapers piling up on the porch; a pet losing weight or being uncared for; any significant, negative change in the person’s routine.

If you are concerned contact with Adults Service – find out how on our concerned page.

Contributory factors may include:

• the perception that this is a person’s ‘lifestyle choice
• poor multi-agency working and lack of information sharing
• lack of engagement from the individual or family
• challenges presented by the individual or family making it difficult for professionals to work with them
• an individual in a household is identified as a carer without a clear understanding of what their role includes – this can lead to assumptions that support is being provided when it is not
• a desensitisation to/from well known cases, resulting in minimisation of need and risk
• an individual with mental capacity making unwise decisions or withdrawing from agencies but continuing to be at risk of significant or serious harm
• individuals with chaotic lifestyles and multiple or competing needs
• inconsistency in thresholds across agencies and teams – level of subjectivity in assessing risk.

Contributing factors which may lead to or escalate self-neglect:

• age related changes, in physical health or mental health
• alcohol or drug dependency/ misuse
• bereavement/ traumatic event
• chronic mental health difficulty
• fear and anxiety
• social isolation.

The Social Care Institute for Excellence (SCIE) have published an excellent range of resources and policy research about self-neglect for community practitioners, such as housing officers, social workers, police and health professionals. These include a general briefing on self-neglect, a manager’s briefing and a practitioner’s briefing.

The SCIE self-neglect resources can be found on their website at www.scie.org.uk/self-neglect

Community Care has some thought provoking articles on self-neglect; these include:

• ‘Hoarding and self-neglect – what social workers need to know’  which examines possible interventions available to practitioners in a challenging area of adult social care – read more at www.communitycare.co.uk/hoarding-self-neglect-social-workers-need-know
• ‘Self-neglect: the tension between human rights and duty of care’  which considers if self-neglect being written into safeguarding procedures under the Care Act 2014 has helped social workers – read more at www.communitycare.co.uk/self-neglect-tension-human-rights-duty-care/

Buckinghamshire Safeguarding Adults Board recognised that working with people who self neglect either themselves and/or their environment can be challenging. They developed a Self Neglect Tool Kit and a range of tools to assist practitioners in working in this area:

• one page profile – a tool to help you work with someone to identify their priorities.
• Clutter Scales – a range of pictures which will help you to identify with the person the level of neglect of the environment and for use when talking to other agencies
• practitioner’s checklist – for establishing if a concern meets the criteria of self-neglect
• seven step guide – a tool to give an overview of self-neglect
• self-neglect leaflet – to share with families and friends of people who are at risk of/are self neglecting.

Find these resources at www.buckinghamshirepartnership.gov.uk

Selfneglect.org is a US website dedicated to providing unbiased, evidence-based information about self-neglect in order to educate the families and friends of individuals with self-neglect. Access their useful resources via the website
selfneglect.org

Over the years various local authorities have examined findings from Safeguarding Adult Reviews; some of the findings include:

• the importance of:
  • early information sharing, in relation to previous or ongoing concerns
  • thorough and robust risk assessment and planning
  • face-to-face reviews
  • effective collaboration between agencies
  • clear interface with safeguarding adults procedures
• increased understanding of the legislative options available to intervene to safeguard a person who is self-neglecting
• application and understanding of the Mental Capacity Act
  • where an individual refuses services, it is important to consider mental capacity and ensure the individual understands the implications and that this is documented
• services/ support should be re-visited at regular intervals; it may take time for an individual to be ready to accept some support
• the need for practitioners and managers to challenge and reflect upon cases through the supervision process and training
• requirement for robust guidance to assist practitioners in working in this complex area
• assessment processes need to identify who carers are (and significant others i.e. the ‘whole family approach’) and how much care and/or support they are providing.

The Care Act (2014) was implemented in April 2015 and brought about a number of changes which impact upon how self-neglect cases are dealt with.

Within the accompanying statutory guidance for the Care Act (2014), new categories of abuse were added, with ‘self-neglect’ specifically mentioned. As a result, self-neglect is now incorporated as a form of abuse and neglect covered by multi-agency safeguarding adults policy and procedures. The statutory guidance’s definition of self-neglect is:

“self-neglect – this covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding”.

The statutory guidance identifies that it can be difficult to assess self-neglect. Specifically, that it may be difficult to distinguish between whether a person is making a capacitated choice to live in a particular way (which may be described as unwise) or whether the person lacks mental capacity to make the decision.

Other key changes (of relevance to how self-neglect is dealt with under the safeguarding adults framework) include the removal of a significant harm threshold and that the adult at risk does not need to be eligible for social care services for a safeguarding adults enquiry to commence.

Duty of cooperation
The Care Act (2014) now makes integration, cooperation and partnership a legal requirement on local authorities and on all agencies involved in public care, including the NHS, independent or private sector organisations, housing and the Police. Cooperation with partners should enable earlier intervention – the best way to prevent, reduce or delay needs for care and support and safeguard adults at risk from abuse or neglect.

Well-being principle
The Care Act (2014) places significant emphasis on the well-being principle with decisions being person-led and outcome-focused. Local authorities must promote well-being when carrying out any of their care and support functions in respect of an individual, including when carrying out safeguarding adults enquiries. The well-being
principle will be an important consideration in responding to self-neglect cases. The definition of well-being as defined in the Care Act relates to the following areas:

• personal dignity (including treatment of the individual with respect)
• physical and mental health and emotional well-being
• protection from abuse and neglect
• control by the individual over day to day life (including over care and support provided and the way it is provided)
• social and economic well-being
• domestic, family and personal relationships
• participation in work, education, training or recreation
• suitability of living accommodation
• the individual’s contribution to society.

The Mental Capacity Act (2005) (MCA) is crucial to determining what action may or may not be taken in self-neglect cases. All adults have a right to take risks and behave in a way that may be construed as self-neglectful, if they have the capacity to do so without interference from the state.

Mental capacity is a complex attribute, involving not only the ability to understand the consequences of a decision but also the ability to carry out the decision. Where decisional capacity is not accompanied by the ability to carry out the decision, overall capacity is impaired and ‘best interests’ intervention by professionals to safeguard well-being may be legitimate.

Mental capacity assessments must be time and decision-specific – apparent capacity to make simple decisions should not result in an assumption that the person is able to make more complex decisions. All practicable steps should be taken to ensure firstly that the person understands what they are being asked and also enable the person to  communicate their wishes.

Where it is felt intervention may be required due to a person’s self-neglect behaviour, any action proposed must be with the person’s consent where they are assessed as having mental capacity unless there are wider public interest concerns, for example,other people may be at risk of harm or a crime has or may be committed. Examples where other people may be at risk as a result of self-neglect include where there is a fire risk or where there are public health concerns (e.g. infestation affecting other properties).

Where there is a concern around significant self-neglect one of the first considerations should be whether the person has mental capacity to understand the risks associated with their actions/lack of action. As per the first principle of the MCA, a person must be presumed to have capacity to make their own decisions.

However, a prior presumption of mental capacity may be revisited in self-neglect cases. This is confirmed by the MCA code of practice which states that one of the reasons why people may question a person’s capacity to make a specific decision is ‘the person’s behaviour or circumstances cause doubt as to whether they have capacity to make a decision’ (4.35 MCA Code of Practice, p. 52).

Any capacity assessment carried out in relation to self-neglect behaviour must be time specific, and relate to a specific intervention or action. The professional responsible for undertaking the capacity assessment will be the person who is proposing the specific intervention or action, and is referred to as the ‘decision maker’. Anyone acting in a professional capacity for, or in relation to, a person who lacks capacity OR being paid for acts for or in relation to a person who lacks capacity, legally must have regard to the MCA. This covers a wide range of people including: healthcare staff; social care staff; paramedics; housing workers, or police officers (MCA Code of Practice, p. 1-2).
Although the decision-maker may need to seek support from other professionals in the multi-disciplinary team, they are responsible for making the final decision about a person’s capacity.

If the person lacks capacity to consent to the specific action or intervention, then the decision maker must demonstrate that they have met the requirements of the best interests ‘checklist’.

In self-neglect cases where there is a risk of significant harm (or higher), it is best practice to demonstrate your assessment (or presumption) of capacity using the MCA1 form and where a best interest decision is required using the MCA2 form. In particularly challenging and complex cases, it may be necessary for a referral to the Court of Protection to make the best interests decision. Any referral to the Court of Protection should be discussed with legal services and the relevant Safeguarding Adults Manager. Due to the complexity of such cases, there must be a safeguarding strategy meeting to oversee the process.

If a person is assessed as having mental capacity this does not negate the need for action under safeguarding adults procedures, particularly where the risk of harm is deemed to be serious or critical. Where professionals foresee serious or critical harm to a person and they have mental capacity, duty of care extends to gathering all the
necessary information to inform a thorough risk assessment and subsequent action seven without the consent of the individual. It may be determined that there are no legal powers to intervene, however it will be demonstrated that risks and possible actions have been fully considered on a multi-agency basis.

For more information visit our Mental Capacity resource.

There are many legislative responsibilities placed on agencies to intervene in or be involved in some way with the care and welfare of adults who are believed to be vulnerable.

It is important that everyone involved thinks pro-actively and explores all potential options and wherever possible, the least restrictive option e.g. a move of the person permanently to smaller accommodation where they can cope better and retain their independence.

The following summary of the powers and duties that may be relevant and applicable steps that can be taken in cases of dealing with persons who are self-neglecting and/or living in squalor is not necessarily an exhaustive list of all the legislative powers that may be relevant in any particular case. Cases may involve use of a combination legislative powers.

Environmental Health
Environmental Health Officers in a local authority have wide powers/duties to deal with waste and hazards. They may be key contributors to multi-agency solutions and in some cases, for example where there are no mental health issues, no lack of capacity of the person concerned, and no other social care needs, they may be the lead agency and act to address the physical environment.

Remedies available under the Public Health Acts 1936 and 1961 include:

• power of entry/warrant to survey/examine (sections 239/240)
• power of entry/warrant for examination/execution of necessary work (section 287)
• Enforcement Notices in relation to filthy/verminous premises (section 83) – applies to all tenure.

Remedies available under the Environmental Protection Act 1990 include:

• litter clearing notice where land open to air is defaced by refuse (section 92a)
• Abatement Notice where any premise is in such a state as to be prejudicial to health or a nuisance (sections 79/80).

Other duties and powers include:

• the Town and Country Planning Acts provide the power to seek orders for repairs to privately owned dwellings and where necessary compulsory purchase orders
• the Housing Act 2004 allows enforcement action where either a category 1 or category 2 hazard exists in any building or land posing a risk of harm to the health or safety of any actual or potential occupier or any dwelling or house in multiple occupation (HMO)
  • those powers range from serving an improvement notice, taking emergency remedial action, to the making of a demolition order
• local authorities have a duty to take action against occupiers of premises where there is evidence of rats or mice under the Prevention of Damage by Pests Act 1949
• the Public Health (Control of Disease) Act 1984 Section 46 sets out restrictions in order to control the spread of disease, including use of infected premises, articles and actions that can be taken regarding infectious persons.

Housing – landlord powers
These powers could apply in Extra Care Sheltered Schemes, Independent Supported Living, private-rented or supported housing tenancies. It is likely that the housing provider will need to prove the tenant has mental capacity in relation to understanding their actions before legal action will be possible. If the tenant lacks capacity, the Mental Capacity Act 2005 should be used.

In extreme cases, a landlord can take action for possession of the property for breach of a person’s tenancy agreement, where a tenant fails to comply with the obligation to maintain the property and its environment to a reasonable standard. This would be under either under Ground 1, Schedule 2 of the Housing Act 1985 (secure tenancies) or Ground 12, Schedule 2 of the Housing Act 1988 (assured tenancies).

A tenant is responsible for the behaviour of everyone who is authorised to enter the property. There may also be circumstances in which a person’s actions amount to anti-social behavior under the Anti-Social Behaviour, Crime and Policing Act 2014.   Section 2(1)(c) of the Act introduces the concept of ‘housing related nuisance’ so that a direct or indirect interference with housing management functions of a provider or local authority, such as preventing gas inspections, will be considered as anti-social behaviour. Injunctions, which compel someone to do or not do specific activities, may be obtained under Section 1 of the Act. They can be used to get the tenant to clear the property or provide access for contractors.

To gain an injunction, the landlord must show that, on the balance of probabilities, the person is engaged or threatens to engage in antisocial behaviour, and that it is just and convenient to grant the injunction for the purpose of preventing an engagement in such behaviour. There are also powers which can be used to require a tenant to cooperate with a support service to address the underlying issues related to their behavior.

Mental Health Act 1983 
Mental Health Act 1983 – Sections 2 and 3
Where a person is suffering from a mental disorder (as defined under the Act) of such a degree, and it is considered necessary for the patient’s health and safety or for the protection of others, they may be compulsorily admitted to hospital and detained there under Section 2 for assessment for 28 days. Section 3 enables such a patient to be compulsorily admitted for treatment for up to 6 months, this can then be renewed for a further 6 months and then yearly if necessary.

Mental Health Act 1983 – Section 7 Guardianship
A Guardianship Order may be applied for where a person suffers from a mental disorder, the nature or degree of which warrants their reception into Guardianship (and it is necessary in the interests of the welfare of the patient or for the protection of other persons.) The person named as the Guardian may be either a local social services authority or any applicant.

A Guardianship Order confers upon the named Guardian the power to require the patient to reside at a place specified by them; the power to require the patient to attend at places and times so specified for the purpose of medical treatment, occupation, education or training; and the power to require access to the patient to be given, at any place where the patient is residing, to any registered medical practitioner, approved mental health professional or other person so specified.

In all three cases outline above (i.e. Section 2, 3 and 7) there is a requirement that any application is made upon the recommendations of two registered medical practitioners.

Mental Health Act 1983 – Section 135 
Under Section 135, a Magistrate may issue a warrant where there may be reasonable cause to suspect that a person believed to be suffering from mental disorder, has or is being ill-treated, neglected or kept otherwise than under proper control; or is living alone unable to care for themselves. The warrant, if made, authorises any constable to enter, if need be by force, any premises specified in the warrant in which that person is believed to be, and, if thought fit, to remove them to a place of safety.

Section 135 lasts 72 hours and is for the purpose of removing a person to a place of safety with a view to the making of an assessment regarding whether or not Section 2 or 3, or 7 of the Mental Health Act should be applied.

Mental Health Act 1983 – Section 136 
Section 136 allows police officers to remove adults who are believed to be “suffering from mental disorder and in immediate need of care and control” from a public place to a place of safety for up to 72 hours for the specified purposes. The place of safety could be a police station or hospital.

Community Treatment Orders (CTOs)
If a person has been in hospital under the Mental Health Act, a responsible clinician (usually a psychiatrist) can arrange for a person to have a Community Treatment Order (CTO). This means the person will have supervised treatment when they leave hospital. The person will need to follow the conditions of a CTO. The conditions aim
to make sure the person gets the appropriate treatment and can also be used to try and protect the person from harming themselves or other people. Conditions can include where the person will live or where they will go to get treatment. A person can be brought back to hospital if they break the conditions of their CTO.

Mental Capacity Act 2005
The powers to provide care to those who lack capacity are contained in the Mental Capacity Act 2005. Professionals must act in accordance with guidance given under the Mental Capacity Act Code of Practice when dealing with those who lack capacity and the overriding principal is that every action must is carried out in the best interests of the person concerned.

Where a person who is self-neglecting and/or living in squalor does not have the capacity (and this has been assessed) to understand the likely consequences of refusing to cooperate with others and allow care to be given to them and/or clearing and cleaning of their property a best interest decision can be made to put in place arrangements for such matters to be addressed. A best interest decision should betaken formally with professionals involved and anyone with an interest in the person’s welfare, such as members of the family.

The Mental Capacity Act 2005 provides that the taking of those steps needed to remove the risks and provide care will not be unlawful, provided that the taking of them does not involve using any methods of restriction that would deprive that person of their liberty. However where the action requires the removal of the person from their home then care needs to be taken to ensure that all steps taken are compliant with the requirements of the Mental Capacity Act. Consideration needs to be given to whether or not any steps to be taken require a Deprivation of Liberty
Safeguards application.

Where an individual resolutely refuses to any intervention, will not accept any amount of persuasion, and the use of restrictive methods not permitted under the Act are anticipated, it will be necessary to apply to the Court of Protection for an order authorising such protective measures. Any such applications would be made by the
person’s care manager who would need to seek legal advice and representation to make the application.

Emergency applications to the Court of Protection 
Application to the Court of Protection to get an urgent or emergency court order can be made in certain circumstances, e.g. a very serious situation when someone’s life or welfare is at risk and a decision has to be made without delay. A court order will not be made unless the court decides it is a serious matter with an unavoidable time limit. Where an emergency application is considered to be required, relevant legal advice must be sought.

Power of entry
The Police can gain entry to a property if they have information that a person inside the property was ill or injured with the purpose of saving life and limb. This is a power under Section 17 of the Police and Criminal Evidence Act 1984.

Inherent Jurisdiction
There have been cases where the Courts have exercised what is called the ‘inherent jurisdiction’ to provide a remedy where it has been persuaded that it is necessary, just and proportionate to do so, even though the person concerned has mental capacity.

In some self-neglect cases, there may be evidence of some undue influence from others who are preventing public authorities and agencies from engaging with the person concerned and thus preventing the person from addressing issues around self-neglect and their environment in a positive way.

Where there is evidence that someone who has capacity is not necessarily in a position to exercise their free will due to undue influence then it may be possible to obtain orders by way of injunctive relief that can remove those barriers to effective working. Where the person concerned has permitted another reside with them and that person is causing or contributing to the failure of the person to care for themselves or their environment, it may be possible to obtain an Order for their removal or restriction of their behaviours towards the person concerned.

In all such cases legal advice should be sought.

Animal welfare
The Animal Welfare Act 2006 can be used in cases of animal mistreatment or neglect. The Act makes it against the law to be cruel to an animal and the owner must ensure the welfare needs of the animal are met. Powers range from providing education to the owner, improvement notices, and fines through to imprisonment. The powers are usually enforced by the RSPCA, Environmental Health or  Defra (Department for Environment Food & Rural Affairs).

Fire
The Fire & Rescue Service can serve a prohibition or restriction notice to an occupier or owner which will take immediate effect (under the Regulatory Reform (Fire Safety) Order 2005). This can apply to single private dwellings where the criteria of risk to relevant persons apply.

Hoarding
Hoarding Disorder used to be considered a form of obsessive compulsive disorder (OCD). It is now considered a standalone mental disorder and is included in the 5th edition of the Diagnostic and and Statistical Manual of Mental Health Disorders 2013.

Hoarding can also be a symptom of other mental disorders. Hoarding Disorder is distinct from the act of collecting, and is also different from people whose property is generally cluttered or messy. It is not simply a lifestyle choice. The main difference between a hoarder and a collector is that hoarders have strong emotional attachments to their objects which are well in excess of their real value.

Hoarding does not favour a particular gender, age, ethnicity, socio-economic status,educational/occupational history or tenure type. Anything can be hoarded, in various areas including the resident’s property, garden or communal areas.