2.10 Self-Neglect (TSSP)

1. Purpose of the Policy

This policy outlines a multi-agency procedure which staff across the partnership should use when dealing with issues and concerns relating to self-neglect and hoarding behaviour. This policy should be read alongside your individual agencies guidance on self-neglect and hoarding.

This policy seeks to ensure that professionals involved in working with adults who may experience self-neglect and hoarding, can refer to up to date information, which is easily accessible, that promotes workable strategies to support positive outcomes for the individuals involved.

This policy is aimed at a wide range of professionals involved in working with people who may self-neglect and hoard. This includes first responders, whose role is to identify issues of self-neglect, respond appropriately in the moment, and refer on to other agencies as necessary.

This policy does not include issues of risk associated with deliberate self-harm. If self-harm appears to have occurred due to an act of neglect or inaction by another individual or service, consideration should be given to raising a safeguarding adults concern with Adult Social Care. If there is an immediate threat to life call 999.

2. Definition of Self-Neglect and Hoarding

2.1 Self-Neglect

The Care Act 2014 defines self-neglect as:

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

There are various reasons why people self-neglect. Some people have insight into their behaviour, whilst other do not; some may be experiencing an underlying condition, such as dementia. You should consider the following reasons:

• unmet care and support needs;
• inability to maintain own self-care and household chores;
• chronic use of substance/ alcohol impacting on executive functioning
  parents who hoard ( learnt behaviours);
• childhood neglect/ childhood trauma/ adverse childhood experiencing;
• the impact of abuse or neglect;
• the impact of experiencing / witnessing domestic abuse;
• life changing events for example loss of a job, bereavement, loss of social status, loss of accommodation etc;
• the loss of a strongly held value system;
• the loss of independence as a result of an accident, trauma, major ill health or frailty.

The following characteristics and behaviours are useful examples of potential self-neglect and consequent impairments to lifestyle:

• living in very unclean, sometimes verminous conditions such as living with a toilet completely blocked with faeces or not disposing of rubbish and food items;
• neglecting household maintenance, and therefore creating hazards / fire risks / fall risks;
• animal collecting with potential of unsanitary conditions and neglect of animals’ needs;
• failing to care for themselves, in such a way that his/her health or physical wellbeing may decline;
• poor diet, nutrition and evidenced weight loss or increased health needs;
• failure to maintain social contact;
• failure to manage finances;
• failure to maintain health and social care needs or attend medical appointments. This includes managing mental health symptoms;
• refusing to allow access to other organisations with an interest in the property, for example staff working for utility companies (water, gas and electricity).

2.2 Hoarding

Hoarding disorder is where someone acquires an excessive number of items and stores them in a chaotic manner, usually resulting in unmanageable amounts of clutter. Items can be of little or no value.

Hoarding is considered a significant problem if:

• the amount of clutter interferes with everyday living, for example, the person is unable to use their kitchen or bathroom and cannot access rooms within their property;
• the clutter is causing significant distress or negatively impacting the quality of life of the person or their family, for example, they become upset if someone tries to clear the clutter and their relationship suffers as a result.

3. The Care Act 2014

The Care Act 2014 places specific duties on the Local Authority in relation to self-neglect. These are:

• Section 9 (1) where it appears to a local authority that an adult may have needs for care and support, the authority must assess whether the adult does have needs for care and support, and if so, what those needs are;
• Section 11 (1) where an adult refuses a needs assessment, the local authority concerned is not required to carry out an assessment. However, an assessment must take place if the local authority has concerns that:
  a) the adult lacks capacity to refuse the assessment and it is satisfied that carrying out the assessment would be in the adult’s best interests; and
  b) if the adult is experiencing, or is at risk of, abuse or neglect;
• Section 42 (Safeguarding Enquiry) applies where a local authority has reasonable cause to suspect that an adult in its area (whether or not ordinarily resident there):
  a) has care and support needs (whether or not the authority is meeting any of those needs);
  b) is experiencing, or is at risk of, abuse or neglect; and
  c) as a result of those needs is unable to protect themselves against the abuse or neglect, or the risk of it.

Under Section 42, the local authority must make (or cause to be made) whatever enquiries it thinks is necessary to enable it to decide whether any action should be taken in the adult’s case (whether under this part or otherwise) and, if so, what and by whom.

4. The Human Rights Act 1998

The Human Rights Act 1998 specifies that the UK Government and local authorities have a duty to protect the rights of individuals. For the purpose of this policy, there is a specific focus upon articles 2, 5 and 8 of the Human Right Act.

Article 2: The right to life: protects your life, by law. The state is required to investigate suspicious deaths and deaths in custody.

Article 5: The right to freedom and liberty: you have the right to be free and the state can only imprison you with very good reason, for example, if you are convicted of a crime.

Article 8: Respect for privacy and family life and the right to marry: protects against unnecessary surveillance or intrusion into your life.

5. The Mental Capacity Act 2005

The Mental Capacity Act 2005 concerns the ability of adults aged 16 years and over to make specific decisions at a specific time.

Prior to any mental capacity assessments the relevant person must be supported to make a decision for themselves by taking all practical steps, for example:

• Could the decision be delayed?
• Have they been provided with enough information relating to the decision?

Has this been communicated in a way in which they understand?
would having someone with them who knows them well be helpful?
do they fluctuate in the presentation (more capable at differing times of the day for example)?

When a person has been assessed not to have capacity to understand and make specific choices and decisions, interventions and services can be provided in the person’s best interests.

Respect for the persons wishes and beliefs needs to be central to your approach. Professionals need to be creative in the way they approach situations where people self-neglect and hoard, whilst being sensitive, all the while understanding what the behaviour means for the individual and they themselves wish to address the issue.

Assessing mental capacity can be complex and may require ongoing assessment over a period of time. For example, an adult may present as having mental capacity to make a decision as to their living arrangements during a conversation, however they are unable to follow through on decision on a more functional level (see Mental Capacity chapter). Consider discussing complex capacity issues with line management for further advice and guidance.

Professionals must consider whether coercion is a factor – if you suspect an individual is behaving in a manner caused by undue influence or coercive behaviour, consider discussing these concerns in a multi-agency meeting. You may wish to consider whether the inherent jurisdiction of the High Court might apply. An example of the inherent jurisdiction of the High Court is that it may be able to afford protection to persons who are unable to take a decision for themselves, but who do not suffer from an impairment of or disturbance in the functioning of the mind such as to satisfy the diagnostic criteria set down in s2(1) MCA 2005.

The inherent jurisdiction of the High Court is not limited solely to affording an person at risk of abuse and neglect a temporary ‘safe space’ within which to make a decision free from any alleged source of undue influence. The High Court could impose long-term injunctive relief to protect the person at risk.

‘Duty of Care’ (established through common law) can be summarised as ‘the obligation to exercise a level of care towards an individual, as is reasonable in all circumstances, by taking into account the potential harm that may be reasonably caused to that individual or their property’.

6. The Mental Health Act 1983 (as amended 2007)

The Mental Health Act 1983: psychiatric assessment and treatment may be appropriate, and in certain circumstances compulsory admission to hospital may be necessary. Assessment by an Approved Mental Health Practitioner (AMHP) must identify whether the grounds for section 2 (admission for assessment) or section 3 (admission for treatment) are met.

Guardianship (section 7) may be an alternative to hospital admission, providing a relationship of authority to determine where someone should live, require attendance for treatment, occupation, education or training, or facilitate access by a doctor or AMHP.

Under Section 135 of The Mental Health Act 1983, an AMHP may require a magistrate’s warrant authorising a Police constable (accompanied by an AMHP and a Doctor) to enter a property if it is believed an adult is a danger to themselves or others as a result of mental disorder.

7. Children

Information should be ascertained as to whether an adult has any dependants or caring responsibilities for children, but also other adults.

If the adult has responsibility for others, it should be understood whether or not the people the adult is responsible for reside at the same address, or whether they reside elsewhere but frequent the property. In both instances, practitioners must always consider if they the dependent / person being cared for are being put at risk of harm as a result of the clutter / cleanliness of the premise, or the carers’ ability to safeguard that individual.

It may be the case that a child is caring for the adult, this should be established. If a child or young person has a caring role (whether for an adult or another child), a referral should be made for a young carer’s assessment to be completed. Contact Trafford Carer’s Centre about making a referral for a young carer (see Contact).

If there are any concerns for the welfare of children, these must be referred to children’s services as a matter of urgency. Referrals to children’s social care should be made to Trafford Council’s children’s ‘First Response Team (see Contact).

8. Advocacy

If the adult has ‘sustainable difficulty’ in understanding and engaging with any social care process, including a Safeguarding Enquiry, the local authority must ensure that there is an appropriate person to help them, and if there is not, arrangements and for an independent advocate should be made.

Advocacy referrals for adults residing in the Trafford Borough can be sent to Advocacy Focus (see Contact).

9. Assessing and Managing Risk

If a person has capacity, is refusing to engage and there remains ongoing significant harm to a person’s health, safety or wellbeing then consideration should be given to the benefits of convening a multi-disciplinary meeting to ensure all available powers and duties are considered. This needs to be balanced and proportionate and take into account a person’s right to self-determination.

If a person lacks capacity the need for Court of Protection involvement should be considered. In the event an application to the Court of Protection is required, the court will expect to see evidence of professional decision making and recording having already taken place. If you believe a court application is required, then consult your line manager and seek advice form legal services.

If any agency is considering legal action, then a multi-agency meeting should be convened in most cases to ensure that all other potential options have been fully considered.

There are a range of ways to manage / monitor self-neglect cases depending on the individuals involved, the issues, the level of risk and the agencies involved. TSSP have made a bank of resources available on their website, to enable practitioners to risk assess and plan, and also to understand each agencies capabilities and responsibilities.

TARGet (Trafford Adults At Risk Group) a multi-agency group, co-chaired by Greater Manchester Police and Trafford Adult Social Care and supported by all relevant partners, is a useful and recommended source of support and advice. At this meeting, cases where there is on-going high level risk of death or severe harm are discussed. Please note that cases must have been considered at one professionals meeting prior to referral to TARGet. A link to the referral form can be found at Appendix 1.

10. Self-Neglect and Hoarding Toolkit

The North West Association of Directors of Adult Social Services (NW-ADASS) have produced a comprehensive toolkit for professionals dealing with self neglect and hoarding. It contains a number of tools and guidance notes that you may find helpful. Please see Appendix 2.

11. Potential Legal Options

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 is employed. e.g. a move of the person permanently to smaller accommodation where they can cope better and retain their independence.

The following is a summary of the powers and duties that may be relevant and steps that can be taken in cases of dealing with persons who self-neglect and hoard. This is not an exhaustive list of all legislative powers that may be relevant in any particular case.

12. Environmental Health

Environmental Health Officers in the local authority have powers and duties to deal with waste and hazards. They will be key contributors to cross departmental meetings and planning, and in some cases e.g. where there are no mental health issues, no lack of capacity of the person concerned, and no other social care needs, then they may be the lead agency and act to address the physical environment.

Powers available under the Public Health Act 1936 and 1961 include:

• power of the Local Authority to remove accumulations of rubbish on land in the open air (section 34);
• power of entry / warrant to survey / examine (section 239 / 240);
• power of entry / warrant for examination / execution of necessary work (section 287);
• power to require vacation of premises during fumigation (section 36);
• power to disinfect / destroy verminous articles at the expense of the owner (section 37);

Powers 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 as state as to be prejudicial to health or a nuisance (section 79 / 80).

Other duties and powers that exist include:

• 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.

13. 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 utilised.

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 Ground 1, Schedule 2 of the Housing Act 1985 (secure tenancies) or Ground 12, Schedule 2 of the Housing Act 2988 (assured tenancies). The 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 behaviour 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 anti-social 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 behaviour.

Appendix 1: TARGet Protocol (Trafford Adults at Risk Group)

Click here to view TARGet on the TSSP website)

Appendix 2: ADASS Self-Neglect Toolkit

Click here to view ADASS Self-Neglect and Hoarding Toolkit