Self-Neglect and Hoarding Protocol 2015
Supporting Adults with self-neglect and hoarding behaviours
A co-ordinated approach
and
Step by step guide
In partnership with:
Newham Adult Social Care
Newham CCG
Newham Housing Department
Newham Homes
Barts NHS Foundation Trust
East London Foundation Trust
Environmental Health
London Fire Brigade
Newham Metropolitan Police
Contents / PageSection One: Policy
1. Introduction / 4
2. Aims and Objectives of the Protocol / 4
3. Complimentary Resources / 5
4. Legal Context / 5
5. Care Act Section 44 Safeguarding Adults Review / 6
6. Principles of Effective Working / 7
7. Definitions-what is self neglect and hoarding? / 8
8. Assessment of Hoarding / 11
9. Carers / 11
10. Children / 12
11. Balancing Rights and Risks and the Mental Capacity Act 2005 / 12
12. Information Sharing and consent / 12
13. Successful Engagement / 13
14. Resolution of Disagreements and Complaints / 13
Section Two: Procedures
1. Referral / 14
2. Adult Social Care Response / 14
3. Assessment, risk assessment and multi-agency strategy meetings / 15
4. The High Risk Panel / 16
Section Three: Appendices
Appendix 1 – Main Risk Assessment and matrix
Appendix 2 -Clutter Rating Guide
Appendix 3 - Powers available by various agencies
Appendix 4- Quick Tick box Risk Assessment – HOMES
Appendix 5- Useful Resources
Audit Trail
Listed below is a brief audit trail, detailing revisions made to this policy.
Version number / Revision made incl page and chapter number / Person / organisation / DateV1.3 / Sent out for consultation
V1.4 / Updates to draft protocol / Cathy Newcombe/Rhys Powell / Gill Williams / 22.06.15
Updates to appendices / Cathy Newcombe, Simon Brooks / 22.06.15
V1.5 / Autism update / Melissa McAuliffe / 30.09.15
V1.6 / Footnotes / M Oliver / 10.10.15
V1.7 / Children’s section updated / Alan Critchley / 01.11.15
V1.8 / Revision of Care Act guidance re definition / Mandy Oliver / 16.03.16
Protocol
1. Introduction
1.1 Adults who are reluctant or do not engage with services can have complex and diverse needs that often fall between different agencies. Self-neglect can cover a wide range of behaviours such as neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding The adults’ needs are generally long standing and recurring and may frequently put themselves and others a high risk [1]
1.2 The Care Act 2014 now includes Self Neglect as a type of abuse . The principles of this act fundamentally reforms how the law works, prioritising people’s wellbeing, needs and goals. Not all people who self-neglect or hoard meet the requirements for a safeguarding enquiry. Assessments should be made on a case by case basis and a decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behavior. There may come a point when they are no longer able to do this without external support and therefore a section 42 enquiry should be raised.
1.3 Managing the balance between protecting adults at risk from self-neglect or hoarding behaviours against their right to self-determination is a serious challenge for services. Working with people who are difficult to engage can be exceptionally time consuming and stressful for all concerned. A failure to engage with people who are not looking after themselves, whether they have mental capacity or not, can have serious implications for the health and well-being of the person concerned and risk of reputational damage to the local authority or health agencies involved.
1.4 Self-neglect and hoarding behaviours can put neighbours, family and animals at risk of harm with the risk of fires, gas and water leaks and infestations spreading.
1.5 This protocol offers guidance to operational staff and managers on how the needs or presenting problems of difficult to engage adults who hoard or self-neglect should be addressed. It suggests multi-agency partnership working to determine the most favourable approach for achieving engagement with the adult.
1.6 It highlights the importance of preventing and reducing needs, and putting people in the centre and control of their care and support needs. An assessment and enquiry must be person centred, involving the individual and any carer that the adult has, or any other person they might want involved. Looking forward this protocol has been developed with these principles in mind.
1.7 This guidance is written with the understanding that the professional will have had specific training and development in understanding self-neglect and hoarding behaviours and their effects and mental capacity act training.
2. Aims and Objectives of the Protocol
2.1 This protocol provides a framework of intervention drawing on best practice approaches with reference to the legal context to prevent adults who self-neglect or hoard coming to harm as a result. This includes an escalation procedure to the multi-agency High Risk Panel
2.2 Hoarding and self-neglect behaviours are not the same and do not always present together. However there are often similarities in terms of health and social issues e.g. isolation of the individual and lack of engagement with services that can present a real challenge to practitioners where there is ongoing and significant risk of harm. With this in mind this protocol has been developed to provide support to practitioners in the engagement of the customer and the management of risk.
2.3 Referrals into the HR Panel will apply where an adult has been identified as
· self-neglecting or where hoarding behaviours have put them or others at risk which could result in significant harm and
· the Safeguarding Enquiry has not been able to mitigate the risk of significant harm.
3. Complimentary Resources:
(see also Appendix 3)
3.1 There are a number of complimentary resources and policies to assist to reducing risks and aid learning and development which should be used in conjunction with this protocol
· Tenants who self-neglect; Guidance for frontline housing staff and contractors http://www.scie.org.uk/publications/guides/guide53/frontline-housing/self-neglect/
· SCIE REPORT 46- ‘Self-neglect and adult safeguarding: findings from research’ http://www.scie.org.uk/publications/reports/report46.asp
· LFB Hoarding Policy: http://www.london-fire.gov.uk/hoarding.asp
4. Legal Context
Care Act Statutory 42 Enquiries
4.1 When an adult who self neglects and/or hoards comes to notice, a Safeguarding Concern must be raised and sent to the Adults Social Care service to commence an enquiry. Local authorities have a duty to undertake a Statutory 42 Enquiry.
This enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect, and if so, by whom.
a. It needs to ensure that the safeguarding pathway is person centred
b. Ensure the engagement of all appropriate agencies in responding to the referral and the ongoing work.
c. Make a referral for an Advocate or Independent Mental Capacity Advocate if the person does not have a representative.
d. Refer onto the High Risk Panel.
4.2 It is likely that in the majority of cases, particularly where the person engages with the enquiry and effective interventions to reduce the risks are established, the safeguarding process can be concluded and transferred to case management or the care programme approach and review.
4.3 Risk assessment procedures are crucial in assessing the level of risk and provide an appropriate intervention in situations of self-neglect or hoarding.
4.4 Often, the cases that give rise to the most concern are those where an adult refuses help and services and is seen to be at grave risk as a result. If an agency is satisfied that the adult has the mental capacity to make an informed decision on the issues raised, then that person has the right to make their own choices. But, this should not be seen as ‘an all or nothing’ strategy. It is in these circumstances staff need to follow the principles and procedures in this protocol.
4.5 It is important to consider whether it is appropriate to intervene at all. If there is no evidence of treatable mental disorder or lack of capacity with regard to the hoarding, and if no danger to public health it is likely to be difficult to justify intervention under Article 8 European Convention on Human Rights - Right to respect for private and family life
5. Care Act Section 44 Safeguarding Adults Review.
5.1 If during the course of professional interventions an adult dies or suffers permanent or serious harm as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult, then a referral should be sent to the Safeguarding Adults Board for consideration to implement a safeguarding adults review.
6. Principles of Effective Working
6.1 Practitioners and people who use services shared a wide range of insights and advice
on what makes a positive difference with self-neglect in practice. But the five themes that featured most strongly in the interviews were:
· the importance of relationships
· ‘finding’ the person
· legal literacy
· creative interventions
· effective multi-agency working
www.scie.org.uk/publications/reports/69-self-neglect-policy-practice.
6.2 Within the context of the safeguarding duties set out in the Care Act, safeguarding partnerships can be a positive means of addressing issues of self-neglect. The SAB is a multi-agency group that is the appropriate forum where strategic discussions can take place on dealing with what are often complex and challenging situations for practitioners and managers as well as communities more broadly. (Care Act 2014 guidance p260)
6.3 Newham social care services have lead responsibility for coordinating the Safeguarding Concern. However, it is recognised that the sheer complexity of the multiple causes in any given case of hoarding or self-neglect renders a multi-agency strategy indispensable. East London Foundation Trust (ELFT) will usually be the lead coordinator for those customers with 100% mental health or learning disability funding.
6.4 There is an expectation that all professionals and agencies engage in full partnership working to achieve the best outcome for the adult who chooses to hoard or self-neglect whilst satisfying organisational responsibilities and duty of care. The focus should be on person centred engagement and risk management.
6.5 It is well documented that self neglect requires time and patience, with improvements frequently slow moving, often over weeks, sometimes months or longer. This does not necessarily fit into the current approach of short term case management, re-enablement and personalised budgets. Therefore managers and senior staff need to ensure that flexibility is required in these instances.
6.6 Risk assessment and risk management should be seen as an essential part of the process when there are concerns. Arrangements should be made for monitoring and where appropriate, making proactive contact to ensure that the adult’s needs and rights are fully considered in the event of any changed circumstances. There is a need to be mindful that organisational and professional risk aversion can hinder choice, control and independent living. This poses real challenges for practitioners/professionals in balancing risk enablement with their professional duty of care to keep people safe. Risk enablement therefore needs to become a core part of placing people at the centre of their own care and support.
6.7 It is important that all staff are familiar with, and are mindful of their ‘Duty of Care’ when dealing with cases of self-neglect or hoarding, even if the Adult has mental capacity to make decisions specifically related to their care.
6.8 ‘Duty of Care’ 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 reasonably be caused to that individual or his property’.
Any failure in the duty of care that results in harm could lead to a claim of negligence and consequent damages.
6.9 Staff also need to be aware of the adults rights in law and of the duties and responsibilities of the council. A summary of these can be found in Appendix 3
6.10 This guidance provides assistance for those customers who are assumed to have mental capacity (or when capacity is not yet assessed) who when presented with the risks or statutory actions that may be taken, refuses to engage in solutions to resolve the presenting problems. In these situations care must be taken to address these risks when assessing the individuals capacity to determine whether they do in fact have the ability to weigh up and make use of the relevant information In such cases, the individual chooses to live in a situation that places themselves and potentially others at risk of harm. This will often require a professional judgement. Such situations might include:
· Portraying eccentric behaviours/lifestyles, such as hoarding or antisocial behaviour causing social isolation. This can impact on the living environment causing health and safety concerns including risk of fire
§ Neglecting household maintenance, and therefore creating hazards and risking their tenancy.
§ Poor diet and nutrition, evidenced by low weight, poorly fitting clothes, little or no fresh food, or what there is being mouldy or unfit for consumption
§ Refusing to allow access to health and/or social care staff in relation to personal hygiene and care with evidence of faecal or urine contamination.
§ Lack of personal or domestic hygiene that exacerbates a medical condition that could lead to a serious health problem such as pressure ulcers, diabetes or malnutrition.
7. Definitions
7.1 Staff will have been made aware of the different aspects of these behaviours in previous training development. However it is important that staff be familiar with, and recognise the risk factors associated with self-neglect or hoarding. Often age related changes will result in functional decline; cognitive impairment; frailty or psychiatric illness will increase vulnerability for abuse, neglect and self-neglect as well as increase the potential for developing a number of underlying health conditions
7.2.What is Self-neglect?
7.2.1 The complexity and multi-dimensional nature of self-neglect means that it can often be difficult to support or protect the adult at risk.