MANCHESTER SPECIFIC INFORMATION
Self-neglect differs from the other forms of abuse because it does not involve a perpetrator. This has previously caused it to be viewed differently from other types of abuse, neglect or exploitation and was often not included by Safeguarding Adult Boards (SABs) as a type of abuse. It is a form of abuse of which there is considerable debate. Chapter 14 of the Care and Support Statutory Guidance (Department of Health, 2016), issued under the Care Act 2014, includes self-neglect as a category under different types of abuse and neglect, but notes it may not always result in a safeguarding enquiry:
‘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. It should be noted that self-neglect may not prompt a section 42 enquiry’ (14.17).
Cases of self-neglect should be considered on a case by case basis and while these cases may not prompt a s42 safeguarding enquiry, it should be remembered that there may come a time where the person who is self-neglecting may no longer be able to protect themselves (also see Section 3, Thresholds).
Whilst each of these cases may prompt a professional discussion of whether it is a matter of personal choice and autonomy or an inability of the person to protect themselves, the Local Government Ombudsman and the Health Ombudsman have stated that a local authority will have failed in its duty to investigate in cases of self-neglect where there is a risk of serious harm
s42 of the Care Act places a duty on the local authority to make enquiries where abuse is suspected and the Care and Support Statutory Guidance (2016) states that the local authority should decide what should be done i.e. whether the provider should investigate in the first instance.
The issue of whether an adult is self-neglecting should always be considered in relation to their mental capacity (see Section 6.2, Adults who have Mental Capacity). For those who have mental capacity the degree of which they have personal choice is a key consideration. The difference between being unable to care for themselves or whether they are unwilling to self-care should be the main basis for discussion.
The Mental Capacity Act 2005 (MCA) is clear that a person must be assumed to have capacity unless there is evidence to the contrary and that a person can make a seemingly bad or unwise decision in the event that they have the capacity to do so.
Self-neglect covers a wide range of behaviour including, hoarding, animal collecting, non-compliance, risky behaviour, failure to eat, drink, maintain home environment, personal hygiene, financial viability, social contact, comply with treatment, and protect oneself from abuse.
The causes of self-neglect may include poor physical health, mental health, impaired physical function, poor access to support, poor financial support, pain, nutritional deficiency, past trauma including wartime experiences, loss and cumulative loss, physical / sexual abuse or drug or alcohol misuse. Older people who are identified as suffering from self-neglect are more likely to have cluttered homes and poor personal appearance and hygiene.
The diagnosis of Diogenges Syndrome was first established in 1975 and applies to people who have unkempt personal appearance, live in dirty insanitary environments, who hoard items and refuse help.
There are a wide range of experiences that may lead to self-neglect and it is therefore crucial to look beyond the immediately obvious issues of mental and physical health issues. See Section 6, Self-Neglect and Mental Capacity: Practice Guidance.
Contributory factors may include the individual’s cultural / life view. For older people this may include not wanting to complain, fear of professional intervention, fear of losing their home, pets and possessions. In addition to this self-neglect may occur due to the person’s inability or unwillingness to take care of themselves, or lack of care from informal or formal carers.
The Care Act 2014 includes the definition of self-neglect within types of abuse. However, as noted in Section 1, Definition, the Care and Support Statutory Guidance states: ‘It should be noted that self-neglect may not prompt a section 42 enquiry. An assessment should be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support.’
It is important that any professional who receives an enquiry, concern or referral that might indicate self-neglect, including staff in adult social care who are implementing eligibility criteria, should discuss the adult with their line manager / designated adult safeguarding lead. A referral to the adult safeguarding team should be made if it is decided that such action is appropriate (see Safeguarding Procedures for Responding in Individual Cases).
Self-neglect is mostly an issue for older people. As people are living longer there will therefore be an increased incidence of mental health, chronic and degenerative physical illness, isolation and depression. It is therefore likely that the incidence of self-neglect will also increase.
It does, however, also affect younger people. There is usually no incidence of hoarding but indicators for younger people may include; squalled living conditions, mental health problems, drug or alcohol misuse, chaotic lifestyles, attempts at reform, or spirals of dependency. Younger people often maintain social contact – although this may be difficult – with family, friends and statutory services though they may feel that they have been failed by services and professionals.
Self-neglect is therefore dependent on complex health and social circumstances and an individual’s ability and willingness to deal with these issues.
Cases of actual or suspected self-neglect often present and a complex situation in which personal autonomy has to be balanced against protection of the individual and others.
It is therefore crucial to assess capacity prior to considering any legal interventions (see Section 6, Self-Neglect and Mental Capacity: Practice Guidance). Relevant legal statutes include:
The starting point for working with clients at risk of or suffering from self-neglect should be negotiation and relationship building. Following this consideration should be given to a mental capacity assessment. If agreement cannot be reached with the adult, and the mental capacity assessment has shown they have capacity, legal intervention may be indicated.
There are a number of areas of the law available that can assist in cases of self-neglect including:
*In relation to the MCA, a local authority could apply to the Court of Protection for an order to enter the premises and potentially remove a person who is lacking capacity and suffering from self-neglect, in their best interests. This is a common approach for local authorities as a way of safeguarding a person who is suffering from self-neglect and who lacks capacity to decide on their place of care and residence. They are often placed in a care or nursing home where they may be the subject of Deprivation of Liberty Safeguards (see Deprivation of Liberty Safeguards). The crucial elements in the Court of Protection’s decision are the person’s capacity and best interests.
Whether or not an adult who is self-neglecting has mental capacity, is a key consideration in the discussion as to whether or not a safeguarding referral should be made (see Safeguarding Procedures for Responding in Individual Cases).
Cases of adults who self-neglect pose specific management challenges in balancing the needs and rights of the individual and the duty of the authority to protect the individual and others from harm. They often pose professional, ethical and practical challenges that need to be considered by staff on a case by case.
It should be noted that the perception of the professional and the individual, public and family may be at odds. There may also be differences of opinion between professionals.
Where it is considered an adult who is self-neglecting may not have mental capacity, an assessment of their capacity should be undertaken. The assessment must consider fluctuating capacity and the difference between decisional capacity (ability to make decisions) and executive capacity (ability to implement decisions), as these issues are key in cases of self-neglect. If the assessment concludes the adult does not have capacity, an Independent Mental Capacity Advocate (IMCA) should be appointed, a care and support plan agreed between all parties, including the adult where possible, and regularly reviewed. Whether the care and support plan will enable the adult to remain in their own home will depend on the individual case, the results of conducting a risk assessment and the support networks available.
In addition to best interest assessments under the Mental Capacity Act 2005, screening for dementia, depression and cognitive impairment should be central to assessments, in order to help clarify the balance between preserving the adult’s autonomy and protecting them.
Even where capacity is assessed to be lacking, there is still an obligation and a duty to apply the least restrictive measures of intervention. However, there are limits to an individual’s autonomy; family, professionals and the wider community should not be exposed to unacceptable risks. In order to ensure that action taken to preserve autonomy and protect from harm, many aspects of the situation and the individual’s circumstances must be taken into account.
Self-neglect is a complex phenomenon and great emphasis needs to be given to eliciting the adult’s unique circumstances and their perception of the situation as part of the assessment intervention. There are many grey areas in cases of self-neglect, where careful assessment is needed in order to avoid ambiguity or value judgements.
For people who have been assessed to have mental capacity to make decisions but who are at risk of or are suffering self-neglect, complex case management / social work may be needed as an intervention in its own right. Due to the complexity of the situation it may be necessary to take time to build a relationship of trust with the person and be creative in providing support.
There are a number of initial steps that professionals should take with adults with mental capacity who self-neglect.
Given that resistance to support is a central element of self-neglect, simple and small initial interventions can be of great significance and should not be overlooked or undervalued. Simple support in the form of shopping, cooking or companionship may produce improvements and create an environment for the development of more extensive support. Building good relationships and maintaining contact can enable interventions to be accepted and situations to be monitored.
Risk assessment is key to the management of self-neglect and can be assisted by suitable tools. However these may not always be able to cover the wide variety of situations of self-neglect, so care should be taken to use these in addition to risk assessment and not as a replacement.
Risk management is crucial to support work in such complex situations. Assessment tools may be of help in addition to interviewing skills that allow the worker to draw out individual views and ways of coping and assess how far these would be amenable to change and how this might take place. Such assessment needs to have a focus on future change as well as current risk.
For people who do not wish to move into long term care, consideration should be given to the use of day hospital support.
Sensitive and comprehensive assessment with accurate non-value laden information is essential and should include the following areas:
Case management should be outcome focused and reviewed on a regular basis. A degree of curiosity, imagination and creativity coupled with an ability to appropriately challenge current coping mechanisms and to record findings and thinking are important skills in assessment (see 6.2.3, Recording).
If the adult is willing, a care and support plan should be drawn up and regularly reviewed with them and other involved professionals. This will include interventions that will reduce or eliminate the self-neglect to the adult and those who may also be at risk such as neighbours. If this is not successful a safeguarding referral may have to be made (see Raising Concerns about Abuse or Neglect).
The Care and Support Statutory Guidance states ‘that if a significant safeguarding issue can be resolved by the provision of care and support – then a duty exists to ensure that provision is made available’. For example, paragraph 6.54 refers to the obligation on an authority (where a person is ‘experiencing, or at risk of, abuse or neglect’) … to ‘decide … what action, if any, is necessary and by whom’; then at paragraph 6.56 that where action is ‘required to protect the adult … authorities … should take appropriate action. In some cases, safeguarding enquiries may result in the provision of care and support’. At paragraph 7.26 the revised statutory guidance advises that ‘effective safeguarding is about seeking to promote an adult’s rights as well as about protecting their physical safety and taking action to prevent the occurrence or reoccurrence of abuse or neglect’; and at paragraph 10.39 that where an enquiry ‘leads to further specific interventions being put in place to address a safeguarding issue, this may be included in the care and support plan’.
Safeguarding is a multi-agency responsibility. Decisions about intervention in cases of suspected or actual self-neglect can be complicated and will therefore be assisted by a structure of inter-agency communication and sharing of risk.
Under the Care Act 2014 the local authority has a duty to make enquiries where abuse is suspected. The Care and Support Statutory Guidance (2016) requires the authority to decide what should then be done – i.e. which agency is to lead the investigation.
The sheer complexity of the multitude of causes that may be involved in any case indicates that a multi-agency strategy is vital.
In such a potentially confusing and complicated picture multi-dimensional, multi-agency approach to assessment of medical, psychological and social needs is crucial. This is best done in a formal multi-agency framework.
Other key assessments may include:
See Case Recording.
Recording in these complex cases is a crucial element in managing the risk for the individual. It is also essential for the local authority to be able to demonstrate proper process has been followed and that action taken has been reasonable and proportionate. It provides an audit trail for the options and actions considered.
Recording should include:
It is common in cases of self-neglect for the adult to refuse all interventions and support, in which case the level of risk cannot be reduced. In this case records which demonstrate how risks have been evaluated and weighed against issues of the individual’s autonomy and their protection will be vital.
Although this is a complex area of work, proper recording and information sharing supports defensible decision making. It also captures the decision making process and demonstrates how interventions were planned, why, with what purpose and by whom.
Sharing of information as appropriate, with managers, colleagues and multi-agency partners, is crucial to ensure that a full picture of the situation is available to all involved. This is pertinent at all stages of involvement with the adult, from initial contact to review of any safeguarding plan that is put in place. As issues of professional trust are often key for adults who self-neglect, it is vital that where professionals share information with colleagues they first inform the adult wherever possible. See also Information Sharing and Confidentiality.
Some Safeguarding Adult Reviews (SARs) have had self-neglect as a central issue, often in conjunction with other complex issues (for example A Serious Case Review in Respect of A2 Birmingham Safeguarding Adults Board, 2012)
Such SARs have found:
Raising public awareness is important both to help identify and respond appropriately to adults who self-neglect and increase understanding of the role of statutory and partner agencies. The public are generally less likely to understand the role of these agencies, and the issues of individual autonomy and adult safeguarding.
Professionals should also be mindful of potential discrimination that adults who evidently self-neglect may be subjected to by some members of the public. Such action may also warrant an adult safeguarding referral.
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