Safeguarding Adults Procedures

February 2018: This chapter was significantly updated as a result of local review.

1. Definition of Self-Neglect

Self-neglect is the inability (intentional or non-intentional) to maintain a socially and culturally accepted standard of self-care with potential for serious consequences to health and wellbeing of the individual and potentially their family / neighbours and / or people within the community.

It includes:

  • lack of self-care – lack of personal hygiene, nutrition, hydration and or health thereby endangering safety and well-being; and / or
  • lack of care of one’s environment – squalor and hoarding and / or refusal of services which would mitigate the risks of harm.

An individual may be considered as self-neglecting and therefore maybe at risk of harm where they are:

  • either unable, or unwilling to provide adequate care for themselves;
  • not engaging with a network of support;
  • unable to or unwilling to obtain necessary care to meet their needs;
  • unable to make reasonable, informed or mentally capacitated decisions due to mental disorder (including hoarding behaviours), illness or an acquired brain injury;
  • unable to protect themselves adequately against potential exploitation or abuse;
  • refusing essential support without which their health and safety needs cannot be met and the individual lacks the insight to recognise this.

2. Definition of Hoarding

Hoarding is excessive collection and retention of any material to the point that it impedes day to day functioning (Frost and Gross 1993). Pathological or compulsive hoarding is a specific type of behaviour and this is outlined in detail in the safeguarding adults policy re hoarding on the intranet.

3. Introduction

The Care Act 2014 identifies self-neglect as a category of abuse that falls within adult safeguarding. It defines self-neglect as covering a wide range of behaviours such as neglecting to care for one’s personal hygiene, health or surroundings. The fact that self-neglect is a distinct category of abuse in its own right under the Care Act 2014 means that all safeguarding adults duties and responsibilities apply.

Safeguarding duties apply to an adult who:

  • has needs for care and support (whether or not the local authority is meeting any of those needs) and;
  • is experiencing, or at risk of, abuse or neglect; and
  • as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect

Self-neglect covers a wide range of behaviour and will not in all cases result in a section 42 enquiry. An assessment should be made and cases will be viewed on a case by case basis. A decision regarding whether a response is required by the safeguarding unit would be based on meeting section 5 of the screening tool (see Appendix 2).

4. Aims and Objectives

This policy provides a framework for multi-agency working for adults who are at risk of harm or death as a result of self-neglect.

It describes how multi-agency working should be implemented to discuss, identify and document risk for cases of high concern, and formulate a risk management plan identifying appropriate agency responsibility for carrying out these actions. It also provides a mechanism for review and re-evaluation of the risk management plan.

The dilemma of managing the balance between the protection of adults at risk from self-neglect, our duty of care and an individual’s right to self-determination is a recognised challenge for all services.

Using this multi-agency working will help ensure all reasonable and appropriate actions are taken to ensure, as far as possible, the safety and welfare of individuals who are at risk of serious harm because of self-neglect.

This policy does not preclude or prevent agencies/services from undertaking or discharging their single agencies responsibilities including the disclosure or sharing of information.

A failure to engage with individuals who are not looking after themselves (whether they have mental capacity or not) may have serious implications for, and a profoundly detrimental effect on, an individual’s health and wellbeing. It can also impact on the individual’s family and the local community.

Public authorities, as defined in the Human Rights Act 1998, must act in accordance with the requirements of public law. In relation to adults perceived to be at risk because of self-neglect, public law does not impose specific obligations on public bodies to take particular action. Instead, authorities are expected to act within the powers granted to them. They must act fairly, proportionately, rationally and in line with the principles of the Care Act 2014, the Mental Capacity Act 2005 and consideration should be given to the application of the Mental Health Act (1983, amended 2007) where appropriate.

Prevention of serious injury or even death of individuals who appear to be self-neglecting may be achieved by ensuring that:

  • individuals are empowered as far as possible, to understand the implications of their actions there is a shared, multi-agency understanding and recognition of the issues involved in working with individuals who self-neglect;
  • there is effective multi-agency working and practice;
  • concerns receive appropriate prioritisation;
  • agencies and organisations uphold their duties of care;
  • there is a proportionate response to the level of risk to self and others.

Where staff from any organisation/service have identified a self-neglect situation they should take all reasonable steps available to their organisation to address this. Where it has been identified that the involvement of another single agency would assist, contact should be made with the service to jointly address the situation. All agencies should co-operate in partnership when receiving a referral from another.

Where self-neglect is identified as an issue and there are children [under 18 years of age] involved a child concern notice should be raised immediately with Children’s and Families Social Care.

Aims and objectives of this policy can be achieved through:

  • promoting a person-centred approach which supports the right of the individual to be treated with respect and dignity, and to be in control of, and as far as possible, to lead an independent life;
  • aiding recognition of situations of self-neglect;
  • increasing knowledge and awareness of the different powers and duties provided by legislation and their relevance to the particular situation and individuals’ needs, this includes the extent and limitations of the ‘duty of care’ of professionals;
  • promoting adherence to a standard of reasonable care whilst carrying out duties required within a professional role, in order to avoid foreseeable harm;
  • promoting a proportionate approach to risk assessment and management;
  • clarifying different agency and practitioner responsibilities and in so doing, promoting transparency, accountability, evidence of decision-making processes, actions taken; and
  • promoting an appropriate level of intervention through a multi-agency approach.

As with all safeguarding adults procedures the six principles of safeguarding must be adhered to.

  1. Empowerment – Presumption of person-led decisions and informed consent.
  2. Protection – Support and representation for those in greatest need.
  3. Prevention – It is better to take action before harm occurs.
  4. Proportionality – Proportionate and least intrusive response appropriate to the risk presented.
  5. Partnership – Local solutions through agencies working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse.
  6. Accountability – Accountability and transparency in delivering safeguarding

5. Mental Capacity

See also Mental Capacity

The MCA provides a statutory framework for people who lack capacity to make decisions for themselves. The act has five statutory principles and these are the values which underpin the legal framework of the act.

The five principles:

  1. A person must be assumed to have capacity unless it is established that they lack capacity
  2. A person is not to be treated as unable to make a decision unless all practicable steps have been taken without success
  3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision
  4. An act done, or decision made under this act or on behalf of a person who lacks capacity must be done or made in his / her best interests
  5. Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action

When a person’s self-neglect poses a serious risk to their health and safety, intervention will be required. Prior presumption of mental capacity may be revisited in self-neglect cases. There may be cause for concern if a person repeatedly makes unwise decisions that put them at risk of harm or exploitation. Or makes a decision that is obviously irrational or out of character. Further exploration of past decisions and choices would need to be undertaken at this time. 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 “the persons’ behaviour or circumstances cause doubt as to whether they have capacity to make a decision”.

Any capacity assessment carried out in relation to self-neglect 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.

If the person lacks capacity to consent to the specific intervention then the decision maker must demonstrate that they have met the requirements of the Best Interest’s “checklist”. Due to the complexities there should be a best interests meeting.

In particularly complex cases the local authority may refer to the court of protection to make a best interests decision. Any referral to the court of protection should be discussed with legal services and the relevant service manager.

6. Information Sharing

The Care Act 2014 states that information sharing should be consistent with the principles set out in the Caldicott Review published in 2013 ensuring that:

  • Information is only shared on a ‘need to know’ basis and when it is in the interests of the adult.

Key points to note are:

  • confidentiality must not be confused with secrecy;
  • informed consent should be obtained but, if this is not possible and other adults are at risk of abuse or neglect, it may be necessary to override this requirement;
  • it is inappropriate for agencies to give assurances of absolute confidentiality in cases where there are concerns about abuse, particularly in those situations when other adults may be at risk;
  • where an adult has refused to consent to information being disclosed for these purposes, then practitioners must consider whether there is an overriding public interest that would justify information sharing and wherever possible the Caldicott Guardian should be involved;
  • decisions about who needs to know and what needs to be known should be taken on a case by case basis, within agency policies and the constraints of the legal framework;
  • principles of confidentiality designed to safeguard and promote the interests of an adult should not be confused with those designed to protect the management interests of an organisation. These have a legitimate role but must never be allowed to conflict with the welfare of an adult. If it appears to an employee or person in a similar role that such confidentiality rules may be operating against the interests of the adult then a duty arises to make full disclosure in the public interest.

Decisions about what information is shared and with whom will be taken on a case by case basis. Whether information is shared, with or without the adult at risk’s consent, the information should be:

  • necessary for the purpose for which it is being shared;
  • shared only with those who have a need for it;
  • accurate and up to date;
  • shared in a timely fashion;
  • shared accurately;
  • recorded proportionately demonstrating why a course of action was chosen – I did this because…….. I ruled this out because……. I chose this because………;
  • shared securely.

7. Criteria for Referral to Self-Neglect Multi-Agency Complex Panel Meeting

Concerns regarding self-neglect should be routinely managed within the care management process. The consent of the individual should be sought and all relevant engagement or lack thereof should be documented. All relevant attempts to reduce the risk and or manage the risk should be clearly recorded as should partner agency engagement.

In order to consider a person for a self-neglect multi agency complex panel meeting all the following criteria should apply:

  • there is a risk of serious harm or death by self-neglect, fire, deteriorating health condition, non-engagement with services;
  • there is a high level of concerns from a partner agency;
  • there is a public safety interest.

Serious harm means potential death or serious injury (either physical or psychological) which is life threatening and/or traumatic and which is viewed to be imminent or very likely to occur.

Public safety interest means there is, or is a risk of the health and wellbeing of the public by such as, the attraction of vermin, the attraction of infestations, the risk of fire and fire spread, caused by the build of clutter etc., unsafe buildings/structures perhaps due to disrepair. It would also include considerations of risk of harm/impairment to others including children and young people, or if a crime may have been committed or to prevent crime.

Where a practitioner thinks that this might apply they must consult with their manager and / or designated safeguarding team / Let’s Talk Team.

8. Roles and Responsibilities

8.1 Role of the Let’s Talk Team

The local authority’s Let’s Talk Team (see Local Contacts) are the lead coordinating agency for all complex multi-agency safeguarding adults processes. Their role is to:

  • co-ordinate and chair the Self-Neglect Multi Agency Complex Panel Meetings (including review meetings);
  • identify agencies to be invited in consultation with the referring agency;
  • ensure the timely distribution of minutes and Risk Management Plan;
  • provide support, advice and guidance to the Lead Worker and other members of the multi-agency team around the adult;
  • ensure the rights and responsibilities of the person remain central to the process;
  • ensure appropriate escalation of the situation in line with this guidance;
  • share relevant and proportionate information with all those engaged in supporting the person and who are part of the plan.

8.2 Role of the lead worker

The lead worker can be from any agency that has a role in working to support the person. Their role is to:

  • ensure the person is aware of the process and the risk management plan;
  • try to build effective relationship with the person with the support, advice and guidance of the Let’s Talk Team and relevant others in the team supporting the person e.g. substance misuse worker;
  • share relevant and proportionate information with all those engaged in supporting the person and who are part of the risk management plan.

8.3 Role of all members of the multi-agency team supporting the adult who self neglects

  • all those engaged in trying to reduce and mitigate risk to the person should support the process by providing relevant advice, information and guidance;
  • all should actively contribute to problem solving and resolving issues as part of the Risk Management Plan;
  • all are collectively responsible for developing the Risk Management Plan and remain accountable to their agencies for the actions they have agreed to deliver;
  • all will share relevant and proportionate information with all those engaged in supporting the person and who are part of the plan.

9. Self-Neglect Multi Agency Complex Panel Meeting

  • If the criteria are met the Let’s Talk Team will coordinate attendance at any meetings. They will help identify which other agencies/services will be invited to the meeting. This will be done in consultation with the referring agency.
  • Consideration should be given to inviting appropriate agencies including non-statutory, voluntary sector and local community groups to facilitate the best opportunity to encourage positive engagement with the person.
  • The Let’s Talk Team can request the attendance of another agency even if the person may be currently unknown to that agency.
  • All partner agencies should ensure appropriate staff attend who have the required seniority to make decisions on behalf of their organisation.
  • The purpose of this multi-agency meeting is to formulate a multi-agency risk assessment and identify actions to reduce risk to the person.
  • Consideration must be given as to how the views of the person can be included. The person and/or an appropriate representative are encouraged to attend.

The following agenda should be followed when chairing a meeting:

  • introductions;
  • background to the circumstances of the concerns by the referring agency (as outlined in the assessment);
  • consent and mental capacity Issues;
  • identify risks;
  • a detailed social and medical history;
  • essential information regarding activities of daily living;
  • environmental assessment;
  • a historical perspective of the situation;
  • the individual’s own narrative on the situation and their needs;
  • the willingness of the individual to accept support;
  • view of family / professionals and people in the individual’s network;
  • identify actions and timescales;
  • identify a lead worker to maintain/support contact the person;
  • organise review date or exit strategy.

In line with making safeguarding personal it is important to ensure the views, wishes and feelings of the individual are recorded and reviewed periodically throughout the entire working relationship with the individual. The section 42 enquiry should encompasses this information.

10. Recording the Risk Management Process

It is an expectation that any actions will be completed fully and will be circulated within two working days through the Let’s Talk Team.

Actions agreed at the meeting need to be initiated immediately by partner agencies and attendees must not rely on the minutes being distributed.

The minutes will be agreed by the Chair prior to distribution to attendees and the adult. This should happen within 10 working days of the meeting. This will include consideration of whether the adult at risk can receive the minutes in part or in full (if third party/other sensitive/confidential information is contained within, considering the requirements of the data protection law) and this should be determined by the Chair in consultation with other key professionals where appropriate.

Each agency, when sharing information within the meeting or when collectively considering the need to share/disclose information to others who may be at risk by the person’s behaviour / activity, must have regard to the principles of information sharing.

The first review of any service user being managed through the self-neglect safeguarding adult’s policies and procedures should be within 28 days of the initial meeting. The next subsequent meeting should be within 3 months at which point a decision would be made regarding whether the individual remains in safeguarding or reverts to care management.

Appendix 1: Self-Neglect Threshold Tool

Click here to access the Self-Neglect Threshold Tool

Appendix 2: Self-Neglect Screening Tool

Click here to access the Self-Neglect Screening Tool

Appendix 3: How to Use the Self-Neglect Screening Tool

  1. Any person who falls into column 1 – Optimum Care is deemed to be functioning well and does not fit the criteria for referral for self- neglect.
  2. Any person in falls into column 2 – Person uses universal services is deemed to be function well with support from immediate family / friends and does not require onward referral re concerns for self-neglect.
  3. Staff working with any person who falls into column 3 – Vulnerability forum criteria met should seek consent to refer to relevant service who can offer support / sign post to relevant agencies that could help.
  4. Staff working with a person who falls into column 4 Person in need of support from services – should with the consent of the individual consider making a referral to statutory services for an assessment of need.
  5. Staff working with any person who falls into column 5 Person to be referred for section 42 enquiry – discussion should be had with adult safeguarding unit who will make a decision regarding requirement for multi-agency complex panel meeting.

For those individuals who fall into column 5 staff presenting the case to the safeguarding unit should have the relevant information to allow a decision to be made. This would consist of:

  • background information;
  • what risks are apparent and what has been done to try and mitigate these;
  • relevant assessments that have been undertaken;
  • level of engagement of the individual;
  • support networks;
  • relevant medical history both physical and psychological.

Appendix 4: List of Multi-Agency Groups

Below is a list of agencies to be considered when multi agency working:

  • Health;
  • NTW;
  • Fire brigade;
  • Northumbria police;
  • South Tyneside Council;
  • Housing;
  • NEAS;
  • Voluntary sector;
  • Substance misuse services;
  • Benefits agency;
  • Environmental health;
  • Legal services;
  • Anti social behaviour team;
  • Commissioning;
  • CCG;
  • CQC.