Draft Policy: Self Neglect and Hoarding – April 2017 Sue Sheriden NEL Safeguarding Adult Board 1 | Page NORTH EAST LINCOLNSHIRE SAFEGUARDING ADULT BOARD SELF- NEGLECT & HOARDING POLICY & PROTOCOL 1. Introduction When providing care and support or acting to safeguarding adults there is a balance to be struck between care and treatment being provided and an adult’s right to self-determination. This guidance provides a pathway for dealing with adults who may be vulnerable and for whom self-neglect is an issue. Adults sometimes make decisions and lifestyle choices that others may perceive to be either unwise or not in their best interest and adults do have the right to live as they choose without undue or disproportionate interference. On occasions however, external intervention will be both legitimate and necessary to address the safety and wellbeing of the adult or that of others and sometimes to safeguard an adult who lacks the mental capacity to make his or her own best interest decisions. This guidance does not provide exhaustive information on self-neglect and hoarding but indicates further guidance in Chapter 14 of Care Act guidance and via references to further reading.
Transcript
Draft Policy: Self Neglect and Hoarding – April 2017 Sue Sheriden NEL Safeguarding Adult Board
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NORTH EAST LINCOLNSHIRE
SAFEGUARDING ADULT BOARD
SELF- NEGLECT &
HOARDING POLICY &
PROTOCOL 1. Introduction
When providing care and support or acting to safeguarding adults there is a balance to be
struck between care and treatment being provided and an adult’s right to self-determination.
This guidance provides a pathway for dealing with adults who may be vulnerable and for
whom self-neglect is an issue.
Adults sometimes make decisions and lifestyle choices that others may perceive to be either
unwise or not in their best interest and adults do have the right to live as they choose without
undue or disproportionate interference. On occasions however, external intervention will be
both legitimate and necessary to address the safety and wellbeing of the adult or that of
others and sometimes to safeguard an adult who lacks the mental capacity to make his or
her own best interest decisions.
This guidance does not provide exhaustive information on self-neglect and hoarding but
indicates further guidance in Chapter 14 of Care Act guidance and via references to further
reading.
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2. Care Act and Self-Neglect & Hoarding
The Care Act and requirements within safeguarding processes for Making Safeguarding Personal prescribe some six guiding principles that should be applied when considering whether to act on concerns around self-neglect or hoarding:
i. Empowerment: Starting from the assumption that individuals are best placed to
judge their own wellbeing and giving consideration to the individual’s view, wishes, feelings and belief
ii. Prevention: Working to protect people from abuse and neglect and prevent
escalation of risk by providing support that reduces the need for intervention
iii. Proportionality: Working in the least intrusive way so that any restrictions placed
on an individual’s rights or freedom or any action taken that is against a person’s will is kept to a minimum
iv. Protection: Working to protect individuals from abuse and the impact and harm of
neglect
v. Partnership: Maximising the active participation of individuals in need, offering
individual choice wherever possible and working with partner agencies to achieve the best outcomes
vi. Accountability: Making sure that individuals are aware of what we are doing, who
they are working with and what our responsibilities are
Self-Neglect is defined by Department of Health as “… a wide range of behaviours
neglecting to care for one’s personal hygiene, health or surroundings, including behaviour
such as hoarding” (2014)
Unlike other forms of harm, self-neglect has no ‘perpetrator’. Abuse cannot be excluded
however as a possible cause of someone becoming ‘self-neglecting’, hence the Care Act
2014 and the Care Act guidance requiring that we have measures in place to address the
causes of self-neglect or hoarding.
Hoarding can be defined as collecting and failing to discard of excessive quantities of
goods or objects. Hoarding is not uncommon and in most cases, not indicative of psychiatric
illness. It can however become so severe as to cause psychological distress, physical
impairment and a risk to health and safety. Although often covert, excessive hoarding can
concern others, particularly when health & safety is compromised either because of the
nature of materials hoarded or it ‘spilling over’ and affecting the wider environment or
becoming a fire risk.
The reasons for hoarding and self-neglect are not fully understood but may be symptomatic of other conditions. For example, adults with mobility problems may be physically unable to clear large amounts of clutter or may start by leaving items close and within easy reach. People with learning disabilities or dementia may struggle to categorise or dispose of things and may unwittingly acquire duplicate items they already have. Mental health problems associated with hoarding include:
Depression Psychotic disorders, such as schizophrenia Obsessive compulsive disorder (OCD)
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In some cases, hoarding is a condition in itself and often associated with self-neglect.
3. Principles of Practice
The following principles should underpin practice when dealing with self-neglect:
i. Adults have a right to make lifestyle choices that to others can defy common sense;
so decisions and actions to intervene must always be justifiable, proportionate and
reasonable
ii. A measured partnership approach is always be preferable so that the skills, powers
and resources of difference organisations can be utilized, shared and have optimum
impact although emergency responses will still require immediate contact with fire,
police or ambulance service
iii. Multi-agency meetings/panels to address concerns and include the adult at risk
should be a starting point. Organisations need to take on roles to support adults at
risk from self-neglect
iv. Doing nothing or closing cases before action has been taken to reduce risk to an
acceptable level and minimize harm and/or the likelihood of repeat occurrences is not
an option; to do so places adults at increased risk of harm and professionals will
have failed in their duties.
4. Mental Capacity
Unless known otherwise, adults are presumed to have capacity. Even with capacity
however, adults can lack understanding or insight into the impact on themselves or others
for their actions or omissions. When an individual’s behaviours or observations raise doubt
about capacity, then an assessment compliant with the Mental Capacity Act (MCA) 2005
must be undertaken. Where it is then found that a person lacks capacity, professionals must
ensure that any action taken is in the person’s best interests and takes account of the adult’s
perceived wishes and feelings.
‘Self-Neglect and Adult Safeguarding: Findings from Research’ (Braye et al., 2011) notes the
negative impact of Mental Capacity on perception of risk and action as the ability to process
information and understand consequences of decisions becomes impaired. In self-neglect,
where capacity for decision making is lacking, intervention should aim at reduction of risk via
a Best Interest Decision.
Capacity assessments for self-neglect or hoarding behavior must be time-specific relevant to
the planned interventions or action. Assessments should be timely, accurately recorded and
best interest decisions made formally with relevant professionals and relevant adults with an
interest in the person’s welfare. The MCA provides a lawful framework in which to eliminate
risk, provided that actions do not deprive a person of his or her liberty.
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In complex cases, NEL has qualified best interest assessors who can advise and ultimately,
a referral could be made to the Court of Protection for authorisation of a best interest
decision. Referrals to the Court of Protection must be in consultation with safeguarding
services, legal advice and the MCA Deprivation of Liberty (DOL) lead for North East
Lincolnshire.
5. Responses to concerns about Self Neglect and Hoarding
Most cases self-neglect and hoarding will be dealt with via the relevant single agency or via
a multi-agency support plan. Where single agencies or non-statutory agencies providing
services suspect there is a critical safeguarding issue, a referral should be made to focus
safeguarding team for assessment via the Single Point of Access (01472 256256) to
ensure both risk and wellbeing are addressed.
5.1 Engaging the adult at risk
Regardless of what process, organisation or pathway is followed for an adult at risk from
self-neglecting or hoarding, the starting point must be engaging with the individual. Positive
outcomes are best achieved through person-centered practice that takes into account the
unique experience of each individual balanced with our ethical duties and safeguarding
responsibilities.
In engaging with the adult all professionals should consider whether: They have the necessary information in a format they can understand Check whether they understand options and consequences of their choices They understand their reasons for mistrust, disengagement, refusal and their choices There is time to build a rapport over a period and develop a trusting relationship There is family, advocate, other professional who can support engagement with the
adult There are attorneys or legal representatives if the adult has one who should be
consulted The plan for agreed actions or outcomes for a person who has fluctuating capacity
was in place during a time when they had capacity for that decision The adult can be assisted to engage and to attend meetings wherever possible
The family member or carer of an adult at risk should be engaged where the adult at risk has
asked for that person or provided consent. Identifying who should be involved should be part
of planning and decision making. Professionals should confirm who is willing and able to
provide support and ensure that duties under the Care Act for carers’ assessments have
been complied with.
5.2 Single Agency Management of Low-Risk outside of Safeguarding
Case of self-neglect and hoarding can be, in some cases, managed without referral to
safeguarding adults procedures. These could potentially be addressed via less formal routes
such as engagement with the adult, supporting a person to address their personal concerns
e.g. about letting go of treasured possessions or improving social skills and engagement
with community activities, or access to health care and counselling. Professional judgement
is key to deciding whether a case should be escalated and any factor or issue that changes
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can increase concerns and raise a low-risk case to a higher threshold. Professionals dealing
with cases at a single agency level therefore need to continually review risk levels to
determine what would warrant a referral into safeguarding adults. Professional judgement is
needed to consider the level of risk, how this is being managed, the capacity of the adult at
risk, and any other persons (including children) who may be affected.
Please see self-neglect and hoarding threshold tool attached as appendix A.
6. Referrals via the SPA under safeguarding adults policy
Safeguarding referrals should detail concerns regarding the vulnerability status and welfare
of the person; the state of the property and the actual or likely effect on their health, their
property, any children at the property and or concerns for animals or others at the property
or in the vicinity.
Concerns with respect to children, and the potential for harm or neglect, should be referred
to children’s services FFAP (01472 326292 Option 2).
Safeguarding enquiries once commenced should provide a forum for: Identifying the adult’s wishes, views and beliefs and what outcome they want to
achieve Discussing and where necessary, assessing the adult’s capacity and best interest
decisions Multi-agency information-sharing to address the risk assessment and risk
management plan Establishing what may be contributing or causing the behaviours and ways to
address them or look at preventative measures to reduce risk and reoccurrence
Once self-neglect or hoarding is being managed within the safeguarding arena, decisions
should be made as to who or which agency is best suited to undertake enquiries and/or
engage with the adult at risk. The LA (via focus) will retain responsibility for coordinating the
response and assuring itself that risk has been managed and reduced appropriately before
any case closure.
Risk assessment in cases of hoarding should take into account the Clutter Image Scale at
the end of this document.
7. Adults Who Decline Intervention or Refuse Support If an adult at risk refuses or declines an assessment, services or support, a risk assessment must be carried out to determine the level of seriousness of each identified risk. Intervention must apply a ‘Making Safeguarding Personal’ or person-centred/enabling approach that as far as possible promotes the adult’s understanding of the risk and the options available for managing risk. Information should be shared on a ‘needs to know basis’ with relevant professionals who have a role in contributing to the plan in managing or monitoring risks. Consideration must also be given to the mental capacity of the individual and whether they require support via appointment of an advocate to make decisions or express their views to inform best interests decision as appropriate.
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8. Proposal for a Community Multi Agency Risk Panel Model (CMRP)
CMRP are multi-agency panels to discuss, identify and document serious current risks in complex cases (not subject to MARAC or MAPPA processes) and provide a framework for adults experiencing or at risk of abuse or neglect who have capacity to make unwise choices. Where an adult has mental capacity to understand the problem and the consequences of refusing help, a referral to a CMRP could be made to look at alternative potential solutions or jointly agree the risks. The panel’s purpose is to evaluate risk, formulate plans, identify which agencies will be responsible for intervention and review action plans to evaluate effectiveness and monitor change and outcomes. CMPR should only be convened in circumstances whereby:
An adult with care and support needs (whether or not the LA is meeting any of those needs) is experiencing, or is at risk of, abuse or neglect and as a result of those care and support needs, is unable to protect themselves from the risk or the experience of, abuse or neglect;
The adult has mental capacity to make unwise decisions and choices about their life.
The adult’s decision-making leaves them unable to protect themselves from the risk of serious abuse or neglect from themselves or others.
The adult is choosing not to engage with services to reduce the risk or work with alternative agencies to get support and continues to make an unwise decision of their own free will placing themselves or others at increased risk.
The CMPR should be used only in exceptional circumstances, not as a regular alternative to replace existing processes or substitute for engagement and partnership working with the adult at risk. The CMPR process should be used only where there are significant concerns from partners or the community and there is evidence that all other attempts at safeguarding interventions have failed.
Brief Interventions under Section 42 Enquiries
Section 42 enquiries provide an opportunity to work with the adult at risk to obtain the
outcome they have identified, while addressing areas of risk through the safeguarding plan.
Section 42 enquiries in relation to self-neglect and hoarding can include, but is not limited to:
Any enquiry into abuse and neglect that may have contributed to or precipitated the
self-neglecting behavior or hoarding
Therapeutic responses, e.g. access to mental health, drug & alcohol services,
bereavement counselling and cognitive behaviour therapies services
Brief interventions, particularly those that work to enable changes in attitude or
behavior and to handle underlying issues
Making Safeguarding Personal toolkit has a range of options available and details can be
found at the end of this guidance. In addition, Braye et al. (2005) suggested the following
intervention options can be applied:
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Theme Examples
Being there Maintaining contact; monitoring risk/capacity, spotting motivation
Risk limitation Safe drinking, fire safety, repairs
Health concerns Doctors’ appointments, hospital admissions
Care and support Small beginnings to build trust
Cleaning / clearing Proportionate to risk, with agreement, ‘being with’, attention to what follows
Networks Family/ community, social connections, peer support
Therapeutic input Replacing what is relinquished; psychotherapy/mental health services
Change of environment Short term respite, a new start
Enforced action Setting boundaries on risk to self & others
9. Legal Options and Processes
Legal processes can be implemented via single agencies or via safeguarding adults
procedures. In cases where adults lack capacity to make decisions or, the adult has capacity
but there is significant level of risk, legal measures can be considered under the
safeguarding adults procedures. Legal steps can be used to compel an adult to remove risk,
permit service access and in some instances to remove the adult from the risk. It should be
remembered that legal intervention should be a ‘last resort’ and a balance struck between an
individual’s rights and the rights of others who may be adversely affected by the adult’s
behaviour, particularly hoarding.
In brief some of the legal options may include:
i. Public Health Act 1936, Section 79: Power to require removal of noxious matter by occupier of premises
ii. Public Health Act 1936, Section 83: Cleansing of filthy or verminous premises
iii. Public Health Act 1936, Section 84: Cleansing or destruction of filthy or verminous articles
iv. Prevention of Damage by Pests Act 1949, Section 4: Power of LA to require action to prevent or treat rats and mice
v. Environmental Protection Act 1990, Section 80: Dealing with statutory nuisances
vi. Mental Health Act 1983, Section 2 & 3: for health and safety and protection of others
vii. Mental Health Act 1983, Section 135: removal of person to place of safety for assessment to take place
There are additional powers through housing, such as the Town and Country Planning Act
and the Housing Act 2004, in which orders for repairs or enforcement action for hazards
exist in any building or land posing a risk. It is important to know when we can/may act (have
the power to do so) and where we shall/must act (have a duty to do so). The first step will
always be to try to gain the consent of the person being affected and to accept the
necessary services to meet their needs.
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10. Responses to service refusal
The most frequent concern raised by professionals when working with adults who may self-
neglect or hoard is the challenge when adults refuse to engage or accept services.
Self-neglect or hoarding needs to be understood from each individual’s unique set of
circumstances and experiences. There is no one model that explains self-neglect or
hoarding and each case may be combination of physical, mental, social, personal and
environmental factors. It is therefore always preferable to get to know the individual and their
history in order to understand their behaviour and why they are unable or reluctant to
address the problem or engage with and trust services and professionals.
Actions that may promote engagement in self-neglect cases are suggested by Braye et al.
(2015) as:
Theme Examples
Building rapport
Taking the time to get to know the person, refusing to be shocked
Moving from rapport to relationship
Avoiding kneejerk responses to self-neglect, talking through the interests, history and stories
Finding the right tone Being honest while also being non-judgmental, separating the person from the behaviour
Going at the individuals pace
Moving slowly and not forcing things; continued involvement over time
Agreeing a plan Making clear what is going to happen; a weekly visit might be the initial plan
Finding something that motivates the individual
Linking to interests (e.g. hoarding for environmental reasons, link into recycling initiatives)
Starting with practicalities
Providing small practical help at the outset may help build trust
Bartering Linking practical help to another element of agreement – bargaining
Focusing on what can be agreed
Finding something to be the basis of the initial agreement, that can be built on later
Keeping company Being available and spending time to build up trust
Straight talking Being honest about potential consequences
Finding the right person Working with someone who is well placed to get engagement
External levers Recognizing and working with the possibility of enforcement action
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Appendix A: Self- Neglect and Hoarding Threshold Tool
Factors Guidance 1. The vulnerability
of the person Level of Vulnerability
Does the person have capacity to make decisions with regard to care provision / housing etc.?
Does the person have a diagnosed mental illness?
Does the person have support from family or friends?
Does the person accept care and treatment?
Does the person have insight into the problems they face?
2. Types Low risk Moderate
High / Critical
Refer to the table overleaf. Types and Seriousness of Hoarding and self-neglect. Look at the relevant categories of hoarding and self-neglect and use your knowledge of the case and your professional judgement to gauge the seriousness of concern.
Incidents that might fall outside safeguarding adults procedures (Low Risk) could potentially be addressed via preventative measures such as engaging with the person, developing a rapport, supporting the person to address concerns, getting the person to engage with community activities and develop / repair relationships, access to health care and counselling
If a Social Worker or nurse is involved in the care report concerns to them as part of preventative measures.
This tool does not replace professional judgement and does not aim to set a rigid threshold for intervention. Note professional decision making reflects the fact that the type & seriousness of hoarding and self-neglect may fall within the low risk threshold, other factors may make the issue more serious and therefore warrant progression via safeguarding procedures.
Self Neglect
Hoarding Property
Hoarding household functions
Hoarding Health and safety
Hoarding Safeguarding
3. Level of self-neglect / hoarding
(See clutter rating scale for Hoarding)
Low risk
Moderate risk High risk
Determine if the hoarding / self-neglect is:
A fire risk?
Impacting on the person’s wellbeing (Care Act 2014 definition)?
Preventing access to emergency services?
Affecting the person’s ability to cook, clean and general hygiene?
Creating limited access to main areas of the house?
Is the person at increased risk of falls?
4. Background to hoarding / self-neglect Low impact
Seriously affected
Does the person have a disability that means that they cannot care for themselves?
Does the person have mental health issues and to what extent?
Has this been a long standing problem?
Does the person engage with services, support and guidance offered?
Are there social isolation issues?
Self-Neglect and Hoarding Threshold Tool
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5. Impact on others
No one else affected
Others indirectly affected
Others directly affected
Others may be affected by the self-neglect or hoarding. Determine if:
Are there other vulnerable people (children or adults) within the house affected by the persons hoarding / self-neglect?
Does the hoarding / self-neglect prevent the person from seeing family and friends?
Are there animals within the property that are not being appropriately cared for?
6. Reasonable suspicion of abuse
No suspicion Indicators
present Reasonable
suspicion
Determine if there is reason to suspect:
That the hoarding self-neglect is an indicator that the person may be being abused
The person may be targeted for abuse from local people
That a crime may be taking place
That the person is being neglected by someone else
That safeguarding is required
7. Legal frameworks
No current legal issues
Some minor legal issues
not currently impacting
Serious legal issues
Try to determine whether:
The person is at risk of eviction, fines, non-payment issues
There is an environmental risk that requires action – Public health issues
There are safeguarding and animal welfare issues
Fire risks that are a danger to others
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Self-Neglect and Hoarding Threshold Tool
Types and
Seriousness
Examples of concerns that do not
require formal safeguarding procedures
and can be dealt with by other systems
e.g. Health / GP intervention,
community engagement, counselling,
developing a rapport. It is likely that
only concerns in the second column
need to be reported – Use professional
judgement
The examples below are likely to indicate the need for a referral for formal procedures. If there is any
immediate danger of a crime or abuse to an individual evident, call 999 straight away and make a
safeguarding referral.
Level of Risk Minimal Risk Moderate High / Critical
Self-Neglect Person is accepting support and services
Health care is being addressed
Person is not losing weight
Person accessing services to improve wellbeing
There are no carer issues
Person has access to social and community activities
Person is able to contribute to daily living activities
Personal hygiene is good
Access to support services is limited
Health care and attendance at appointments is sporadic
Person is of low weight
Persons wellbeing is partially affected
Person has limited social interaction
Carers are not present
Person has limited access to social or community activities
Persons ability to contribute toward daily living activities is affected
Personal hygiene is becoming an issue
The person refuses to engage with necessary services
Health care is poor and there is deterioration in health
Weight is reducing
Wellbeing is affected on a daily basis
Person is isolated from family and friends
Care is prevented or refused
The person does not engage with social or community activities
The person does not manage daily living activities
Hygiene is poor and causing skin problems
Aids and adaptations refused or not accessed
Hoarding Property All entrances and exits, stairways, roof space and windows accessible.
Smoke alarms fitted and functional or referrals made to fire brigade to
Only major exit is blocked
Only one of the services is not fully functional
Concern that services are not well
Limited access to the property due to extreme clutter
Evidence may be seen of extreme clutter seen at windows
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visit and install.
All services functional and maintained in good working order.
Garden is accessible, tidy and maintained
maintained
Smoke alarms are not installed or not functioning
Garden is not accessible due to clutter, or is not maintained
Evidence of indoor items stored outside
Evidence of light structural damage including damp
Interior doors missing or blocked open
Evidence may be seen of extreme clutter outside the property
Garden not accessible and extensively overgrown
Services not connected or not functioning properly
Smoke alarms not fitted or not functioning
Property lacks ventilation due to clutter
Evidence of structural damage or outstanding repairs including damp
Interior doors missing or blocked open
Evidence of indoor items stored outside
Hoarding –
Household functions
No excessive clutter, all rooms can be safely used for their intended purpose.
All rooms are rated 0-3 on the Clutter Rating Scale
No additional unused household appliances appear in unusual locations around the property
Property is maintained within terms of any lease or tenancy agreements where appropriate.
Property is not at risk of action by Environmental Health.
Clutter is causing congestion in the living spaces and is impacting on the use of the rooms for their intended purpose.
Clutter is causing congestion between the rooms and entrances.
Room(s) scores 4-5 on the clutter scale.
Inconsistent levels of housekeeping throughout the property
Some household appliances are not functioning properly and there may be additional units in unusual places.
Property is not maintained within terms of lease or tenancy agreement where applicable.
Evidence of outdoor items being stored inside
Clutter is obstructing the living spaces and is preventing the use of the rooms for their intended purpose.
Room(s) scores 7 - 9 on the clutter image scale and not used for intended purpose
Beds inaccessible or unusable due to clutter or infestation
Entrances, hallways and stairs blocked or difficult to pass
Toilets, sinks not functioning or not in use
Resident at risk due to living environment
Household appliances are not functioning or inaccessible and no safe cooking environment
Resident is using candles
Evidence of outdoor clutter being stored indoors.
No evidence of housekeeping being undertaken
Broken household items not discarded e.g. broken glass or plates
Concern for declining mental health
Property is not maintained within terms of lease or tenancy agreement where applicable and is at risk of notice being served by Environmental Health
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Hoarding – Health
and Safety
Property is clean with no odours, (pet or other)
No rotting food
No concerning use of candles
No concern over flies
Residents managing personal care
No writing on the walls
Quantities of medication are within appropriate limits, in date and stored appropriately.
Personal protective equipment is not required
Kitchen and bathroom are not kept clean
Offensive odour in the property
Resident is not maintaining safe cooking environment
Some concern with the quantity of medication, or its storage or expiry dates.
No rotting food
No concerning use of candles
Resident trying to manage personal care but struggling
Hoarding on clutter scale 4 -7 doesn’t automatically constitute a Safeguarding Alert.
Please note all additional concerns for householders
Properties with children or vulnerable residents with additional support needs may trigger a Safeguarding Alert
Hoarding on clutter scale 7-9 constitutes a Safeguarding Alert.
Please note all additional concerns for householders
RESPONSIBILITY
All workers to engage with the
person, develop a rapport,
supporting the person to address
concerns, getting the person to
Consideration for referral into
safeguarding
Consideration for referral into safeguarding
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engage with community activities
and develop / repair relationships,
access to health care and
counselling, improve wellbeing –
Preventative measures
Appendix B: Clutter Image Scale http://hoardingdisordersuk.org/wp-content/uploads/2014/01/clutter-image-ratings.pdf Appendix C: Further Information Further suggested reading: Braye, S., Orr, D. and Preston-Shoot, M. (2014). Self-Neglect Policy & Practice: Building an Evidence Base for Adult Social Care. London: SCIE: http://www.scie.org.uk/publications/reports/69-self-neglect-policy-practice-building-an-evidence-base-for-adult-socia-care/ Braye, S., Orr, D. and Preston-Shoot, M. (2015). ‘Learning lessons about self-neglect? An analysis of serious case reviews.’ Journal of Adult Protection. 17, 1, 3-18. Making Safeguarding Personal Toolkit on the Local Government Association (LGA) website http://www.local.gov.uk/adult-social-care/-/journal_content/56/10180/6074789/ARTICLE
