Self-Neglect (including Hoarding)

Self-neglect can broadly be defined as one or more of the following:

Hoarding involves the acquisition of items with an associated inability to discard things that have little or no value (in the opinions of others) to the point where it interferes with use of living space or activities of daily living.

When significant, hoarding can impair functioning by preventing normal uses of space. For example that limits activities such as cooking, cleaning, moving through the house and sleeping. It could also potentially put the adult and others at risk from fire.

Many hoarders may be well-presented to the outside world, appearing to cope with other aspects of their life quite well, giving no indication of what is going on behind closed doors.

Hoarding can be an aspect of self-neglect.

It can also be an indicator of scams.

For further information about scams see Scams Procedure

Nationally there has been much discussion and debate about when self-neglect should trigger a safeguarding adult concern.

An update to the Care Act statutory guidance in March 2016 gave detail as to when self-neglect should be considered safeguarding:

"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."

In Gateshead, safeguarding should be considered as an option where a person who is self-neglecting is refusing support that has been offered to them, and remains at high risk of harm to themselves or of presenting harm to others.

Given the complex and diverse nature of self-neglect and hoarding, responses by a range of organisations are likely to be more effective than a single agency response with particular reference to housing providers.

It is important to recognise that assessments of self-neglect and hoarding are grounded in, and influenced by, personal, social and cultural values and people working with the adult should always reflect on how their own values might affect their judgement.

Finding the right balance between respecting the adult's autonomy and meeting the duty to protect their wellbeing may involve building up a rapport with the adult to come to a better understanding about whether self-neglect or hoarding are matters for adult safeguarding or any other kind of intervention.

It is helpful to determine when the self-neglect began and why a person self-neglects. If a person self-neglects because they are unable to care for themselves due to, for example a physical disability, then an enquiry may not be required. The most appropriate course of action may be a full assessment of needs and a care and support plan.

Some people self-neglect as a result of trauma, loss or bereavement. A person may have been neglected or abused, may be experiencing domestic abuse, or may have had significant loss in their life. This trauma or loss may have affected their self-esteem, self-worth and ability to self-care. Support from a counsellor or a full needs assessment may be helpful to consider all aspects of the person's wellbeing.

When assessing someone who self-neglects (including hoarding) do not assume that this is a lifestyle choice, or the way in which a person wants to live their life. Ask the miracle question, “If a miracle occurred overnight and things were different, what would you see, hear, smell, feel, be doing?” Most people respond by describing feeling well, healthy, a clean and tidy environment. Often there are other factors that present barriers to the person engaging.

If the adult has a carer, it is important to assess the ability of any carers to meet the needs of the person apparently self-neglecting and rule out carer neglect. If a person lacks capacity to make decisions about their own care and support, or is intimidated or controlled in their decision making then we may be considering neglect and / or coercive and controlling behaviour, rather than self-neglect. A full carers assessment will be required in addition to the assessment of the person appearing to self-neglect. In some situations the capacity of the carer to provide specific aspects of care will need to be assessed.

The care and support plan should identify all the needs being met by the carer and the carers responsibility to share any changes, or concerns with the Local Authority should be explicitly discussed with that carer and the discussion recorded. If the carer does not report significant deterioration in a persons wellbeing and their own ability to meet those needs depletes, they have a duty to inform services otherwise they are being negligent in their caring responsibilities. Wilful neglect is a crime and must be reported to the Police where someone knowingly allows a person in their care to deteriorate without seeking appropriate help. Where someone living within the same household, a partner or family member is preventing access to services domestic abuse and coercive and controlling behaviour must be considered.

Carers can neglect themselves due to the stresses and demands of their caring responsibilities. In such cases it is important that there is a 'whole family approach' and the needs of both parties are adequately assessed and supported.

The Environmental Health Service (EHS) has a range of powers to intervene where a property is in a condition that is prejudicial to health, or where the premise is materially affecting neighbouring premises.

In addition, where properties are verminous or pose a statutory nuisance, the EHS will take a leading role in case managing the necessary investigations and determining the most effective means of intervention.

Where the adult is residing in conditions that pose a threat only to their own welfare the powers available to the EHS may have limited or no effect.

In cases involving persistent hoarders the powers may only temporarily address and/or contain the problem. It must therefore be recognised that utilising powers under public health legislation in isolation may not be the most effective use of resources.

The North-East Safeguarding Adult Review Champions have produced seven 7-minute guides on different aspects of self-neglect:

• Self-Neglect: An Overview;
• Self-Neglect and Engagement;
• Self-Neglect and Alcohol and Substance Misuse;
• Self-Neglect and Hoarding;
• Self-Neglect and Homelessness;
• Self-Neglect and Self Care;
• Self-Neglect and Trauma.

All of these guides can be found in the Practice Resources and Guidance (Local) section of the Contacts and Practice Resources area.