1. Self-neglect Practice Guidance
This practice guidance is for all professionals working with adults with care and support needs, and their carers.
Self-neglect is an extreme lack of self-care, it is sometimes associated with hoarding and may be a result of other issues such as alcohol and substance use.
Engaging with the person is crucial and to offer support without causing distress, and to understand the limitations to interventions, if the person does not wish to engage.
1.1 What is self-neglect?
The Care Act statutory guidance (2024) places a duty on local authorities to protect people from abuse and neglect and this includes those who self-neglect.
These duties apply equally to those adults with care and support needs regardless of whether those needs are being met, and regardless of whether the adult lacks mental capacity or not.
1.2 Definition of self-neglect
There is no single operational definition of self-neglect, however the Social Care Institute for Excellence (SCIE) describes self-neglect as “an extreme lack of self-care” and specifies “that it… may be a result of other issues such as addictions”. Link here to SCIE Guide 69 Types and Indicators of abuse. https://www.scie.org.uk/safeguarding/adults/introduction/types-and-indicators-of-abuse/
Types of self-neglect may include the following.
- Lack of self-care to an extent that it threatens personal health and safety.
- Neglecting to care for one’s personal hygiene, health or surroundings.
- Inability to avoid harm as a result of self-neglect.
- Failure to seek help or access services to meet health and social care needs.
- Inability or unwillingness to manage one’s personal affairs.
1.3 What causes self-neglect?
It is not always possible to establish a root cause for self-neglecting behaviours. Self-neglect can be a result of:
- a person’s brain injury, dementia, or other mental disorder
- obsessive compulsive disorder or hoarding disorder
- physical illness which influences abilities, energy levels, attention span, organisational skills or motivation.
- reduced motivation as a side effect of medication
- addictions
- traumatic life change and adverse childhood experiences (ACE’s).
2. Trauma and Adverse Childhood Experiences (ACEs)
Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. Substance Abuse Mental Health Services Administration’s (2014, p.7) definition), link here https://www.samhsa.gov/mental-health/trauma-violence
“Trauma is not what happens to you. Trauma is what happens inside you as a result of what happens to you”. (Gabor Mate, 2021).
Adverse Childhood Experiences (ACEs) are challenging and traumatising events or situations that children may face during their upbringing. These experiences can have long-term impacts on physical and mental health, as well as an individual’s life opportunities. Studies have shown a strong link between exposure to ACEs and the development of chronic diseases, mental health issues like depression and anxiety, access to education and employment, and risky behaviours in adulthood (Nelson et al. 2020). Reference (Nelson, C.A., Bhutta, Z.A., Harris, N.B., Danese, A., and Samara, M., (2020) ‘Adversity in childhood is linked to mental and physical health throughout life’, BMJ (Clinical research ed.), 371(3048), doi:10.1136/bmj.m3048.)
Trauma Informed approaches have been defined as:
“An organisational change process focused on preventing (re) traumatisation within services. (Sweeney and Taggert, 2018: 385). Reference, Sweeney, A., and Taggert, D., (2018) (Mis) Understanding trauma-informed approaches in mental health. Journal of Mental Health 27, 383-397)
A primary aim of trauma informed is to increase an organisation’s awareness of how trauma can negatively impact on children and adults, so that they can adapt practices to avoid causing further trauma.
The principles of trauma informed are:
- Safety
- Trustworthiness
- Choice
- Collaboration
- Empowerment
- Cultural considerations
Working Definition of Trauma Informed practice, UK Gov, 2022)
3. Professional curiosity
Professional curiosity is a practice mindset and communication skill that involves exploring and understanding what is happening by asking questions and maintaining an open mind. It is about understanding one’s own responsibility in managing risk and safety and knowing when to act, rather than making assumptions and taking things at face value. Refer to North Yorkshire Safeguarding Adults Board Professional Curiosity Practice Guidance, link here: https://safeguardingadults.co.uk/working-with-adults/practice-guidance/professional-curiosity/
4. Self-neglect and Safeguarding Duties
The safeguarding duties will apply where the adult has care and support needs, and they are at risk of self-neglect, and they are unable to protect themselves from (due to their care and support needs). The nature of the potential harm is often a chronic risk that originates in quite deep-rooted psychological issues (e.g., unresolved grief).
Self-neglect covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. 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.
Self-neglect is included in the Care Act Statutory Guidance link here: https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance
In most cases, the intervention should seek to minimise the risk while respecting the individual’s choices. It is rare that a total transformation will take place and positive change should be seen as a long-term, incremental process.
The adult often does not recognise the risks they are living with, they may often decline help from others; in many cases they do not feel that they need it. They may lack mental capacity in relation to the care needs, but often very fine judgements are required to determine whether the adult has capacity but is making a choice about how they are living.
Assessment of the adult’s ‘executive functioning’ (the ability to set goals and carry them out) is a key component in the assessment of their mental capacity in relation to specific decisions.
The most effective approaches are ones which allow a worker to get alongside the adult and work with their wishes as far as possible, to build a relationship of trust.
A multi-agency approach to risk assessment and risk management in partnership with the adult is likely to be most effective, where it is possible.
5. To raise a safeguarding concern in a situation of self-neglect
To raise a safeguarding concern to either North Yorkshire Council or City of York Council select the relevant link below.
5.1 North Yorkshire Council’s website: https://www.northyorks.gov.uk/adult-care/safeguarding/safeguarding-adults
Refer to the Joint Multi-Agency Safeguarding Adults Policy and Procedures (West Yorkshire, North Yorkshire and York), link here: https://safeguardingadults.co.uk/working-with-adults/nysab-procedures/
5.2 City of York Safeguarding Adults Board website: https://www.safeguardingadultsyork.org.uk/homepage/6/raise-a-concern
Refer to the Joint Multi-Agency Safeguarding Adults Policy and Procedures (West Yorkshire, North Yorkshire, and York), link here:
https://wynyy-cityofyork.trixonline.co.uk
6. Relevant legislation
6.1 The Care Act (2014) statutory guidance: self-neglect is included as a category under adult safeguarding. Self-neglect and/or living with abuse and exploitation, should never be regarded as a ‘lifestyle choice’.
6.2 Article 8 of the Human Rights Act 1998: gives us a right to respect for private and family life. However, this is not an absolute right and there may be justification to override it, for example, protection of health, prevention of crime, protection of the rights and freedoms of others.
6.3 Mental Health Act (2007) s.135: if an adult is believed to have a mental disorder and they are living alone and unable to care for themselves, a magistrate’s court can authorise entry to remove them to a place of safety.
6.4 Mental Capacity Act (2005) s.16(2)(a): the Court of Protection has the power to make an order regarding a decision on behalf of an adult. The court’s decision about the welfare of an adult who is self-neglecting may include allowing access to assess capacity.
6.5 Mental Capacity Act (2007) Deprivation of Liberty Safeguards: If an adult in a hospital or care home is under continuous supervision and control and is not free to leave, and they lack mental capacity to consent to arrangements for their care and treatment, providers should apply for a Deprivation of Liberty with the local authority and notify the CQC, if it is authorised.
6.6 Public Health Act (1984) s.31-32: local authority environmental health could use powers to clean and disinfect premises but only for the prevention of infectious diseases.
6.7 The Housing Act 1988: a landlord may have grounds to evict a tenant due to breaches of the tenancy agreement.
7. Environmental health legislation
Environmental health legislation can be useful in managing self-neglect.
7.1 Public Health Act 1936. This contains the principle power to deal with filthy and verminous premises. Under sections 83/84, the local authority can require an owner or occupier to remedy the condition of premises that are filthy, verminous and unwholesome and are prejudicial to health. The powers include cleansing and disinfecting, and the destruction and removal of vermin, which the local authority may carry out and charge for. Section 85 allows cleansing to free a person and their clothing from vermin.
7.2 Prevention of Damage by Pests Act 1949. Local authorities have a duty to take action against occupiers of premises where there is evidence of rats or mice.
7.3 The Public Health Act 1961. Section 36 gives the power to require vacation of premises during fumigation.
7.4 The Public Health (Control of Disease) Act 1984. Provides powers to intervene in situations of disease or infection posing significant risk of harm.
7.5 The Building Act 1984 Section 76. The local authority has the power to deal with any premises which are in such a state as to be prejudicial to health where the owner or occupier refuses to take remedial action.
7.6 The Environmental Protection Act 1990. Sections 79/80 empower the local authority to issue an abatement notice with regard to any premises in such as state, including through “accumulation or deposit”, as to be prejudicial to health or a nuisance, thus requiring the home conditions to be improved. The Act provides a power of entry, and a notice can also apply to the area outside a property.
7.7 The Housing Act 2004. This allows the local authority to carry out a risk assessment of any residential premises to identify any hazards that would likely cause harm and to take enforcement action where necessary to reduce the risk of harm. If the hazard is a category 1, there is a duty on the local authority to take action. If the hazard is a category 2, then there is a power to take action. There is ultimate recourse to injunctions (Housing Act 1996) or possession proceedings (Housing Act 1985).
7.8 Fire and Rescue Services Act 2004. This defines the circumstances under which a fire officer can enter premises and the powers they have on entry.
8. Working with adults who self-neglect
The research on self-neglect suggests beneficial approaches and a range of options, levers and practical measures that could help engagement with adults.
In the past we may have intervened in ways that prioritised the views of others rather than trying to work from the perspective of the individual.
Research has shown that those who self-neglect may be deeply upset and even traumatised by interventions such as ‘blitz’ or ‘deep cleaning’. When developing an approach, it is important to try to understand the individual and what may be driving their behaviour. There are some general pointers for an effective approach below.
8.1 Multi-agency: work with partner organisations to ensure the right approach for each person.
8.2 Person centred: respect the views and the perspective of the person, listen to them and work towards the outcomes they want to achieve.
8.3 Acceptance: good risk management may be the best achievable outcome; it may not be possible to change the person’s lifestyle or behaviour.
8.4 Analytical: it may be possible to identify underlying causes that help to address the issue.
8.5 Non-judgemental: it isn’t helpful for practitioners to make judgements about cleanliness or lifestyle; everyone is different.
8.6 Empathy: it is difficult to empathise with behaviours we cannot understand, but it is helpful to try.
8.7 Patience and time: short interventions are unlikely to be successful, practitioners should be enabled to take a long-term approach.
8.8 Trust: try to build trust and agree small steps.
8.9 Reassurance: the person may fear losing control, it is important to allay such fears.
8.10 Bargaining: making agreements to achieve progress can be helpful but it is important that this approach remains respectful.
8.11 Exploring alternatives: fear of change may be an issue so explaining that there are alternative ways forward may encourage the person to engage.
8.12 Always go back: regular, encouraging engagement and gentle persistence may help with progress and risk management.
9. Practical Tasks
9.1 Care Assessment (under the Care Act 2014): assessment and eligibility process provide a framework to identify any level of need for care and support so that local authorities can consider how to provide a proportionate response at the right time, based on the individual’s needs.
9.2 Risk assessment: have effective, multi-agency approaches to assessing and monitoring risk.
9.3 Assess capacity: ensure staff are competent in applying the Mental Capacity Act in cases of self-neglect.
9.4 Mental health assessment: it may, in a minority of cases, be appropriate to refer an individual for Mental Health Assessment.
9.5 Signpost: with a multi-agency approach people can be signposted to effective sources of support.
9.6 Contact family: with the person’s consent, try to engage family or friends to provide additional support.
9.7 Decluttering and cleaning services: where a person cannot face the scale of the task but is willing to make progress, offer to provide practical help.
9.8 Utilise local partner organisations: those who may be able to help include the RSPCA, the fire service, environmental health, housing, voluntary organisations.
9.9 Occupational Therapy assessment: physical limitations that result in self-neglect can be addressed.
9.10 Help with property management and repairs: people may benefit from help to arrange much needed maintenance to their home.
9.11 Peer support: others who self-neglect may be able to assist with advice, understanding and insight.
9.12 Counselling and therapies: some people may be helped by counselling or other therapies. Cognitive behaviour therapy, for example, may help people with obsessive compulsive disorder, hoarding disorder, or addictions.
10. Tools to support practice.
Many assessment tools exist which can help professionals to decide whether to take action, under the legislation and which can evidence the case for action. Some of these are listed below:
10.1 Assessing cognitive function: This toolkit contains (and explains) a number of tools for assessing cognitive function. This includes tools such as the Addenbrooke’s Cognitive examination and the Montreal Cognitive Assessment which can also be accessed separately.
10.2 Foetal Alcohol Spectrum Disorder Screening tool: treatment Improvement Protocol 58 from the US Substance Abuse and Mental Health Services Administration covers FASD from prior to conception to adulthood. It contains (pp21-22) a screening framework for FASD in adults.
https://store.samhsa.gov/product/TIP-58-Addressing-Fetal-Alcohol-Spectrum-Disorders-FASD-/SMA13-4803
10.3 Generalised Anxiety Disorder Scale (GAS-7): The NICE guidance document identifying and assessing common mental health disorders contains details on a number of screening tools for anxiety and depression and includes a copy of the GAD-7 tool.
https://pathways.nice.org.uk/pathways/common-mental-health-disorders-in-primary-care
10.4 MUST Malnutrition Universal Screening Tool: MUST if a five-step screening tool to identify adults who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines which can be used to develop a care plan. https://www.bapen.org.uk/pdfs/must/must_full.pdf
10.5 Hoarding – clutter image ratings: this helps accurately describe a clutter problem, a series of pictures of rooms in various stages of clutter are provider and graded so that professionals can describe the degree of clutter on a standard scale.
https://hoardingdisordersuk.org/wp-content/uploads/2014/01/clutter-image-ratings.pdf
10.6 Severity of Alcohol Dependence Questionnaire (SADQ): this tool offers 20 questions to assess the degree of alcohol dependence.
https://www.smartcjs.org.uk/wp-content/uploads/2015/07/SADQ.pdf
10.7 Audit:10 question general alcohol screening tool which will give an indication of alcohol dependence but it not as accurate as SADQ.
https://www.gov.uk/government/publications/alcohol-use-screening-tests
10.8 Gambling: a nine-question online tool to assess the presence of gambling problems.
11. Working with other professionals’ checklist
Credit: Professor Micheal Preston-Shoot and Mike Ward (2021). “How to use legal powers to safeguarding highly vulnerable dependent drinkers”. Link here:
The following checklist is for professionals.
11.1 Is the support plan based on a multi-agency approach? Ensure Community Voluntary Services have been considered. It will ensure that consensus exists on the move towards and using legal frameworks.
11.2 Have I shared information as far as legal possible? Sharing chronologies and contextual information to help understand the person being supported and include information on faith, ethnicity, sexuality, gender, age, or other relevant matters.
11.3 Have I been persistent in arguing for a more robust response? Practitioners should expect other professionals to resist or question the need. Therefore, if it is justified, professionals will need to be persistent.
11.4 Am I prepared to challenge other professionals? When a more robust response is justified and legal, it may be necessary to challenge other professionals to overcome blockages. This will be much easier to do with support of managers or in a multi-agency setting with the support of other professionals. Refer to Managing different professional perspectives and mutual challenge including professionals resolution guide available on this link https://safeguardingadults.co.uk/working-with-adults/practice-guidance/professionals-resolution/
11.5 Is my agency prepared to escalate concerns? It is possible to escalate concerns. Seek advice from your Safeguarding Concerns Manager or Designated Safeguarding Lead. Refer to Managing different professional perspectives and mutual challenge including professionals resolution guide available on this link https://safeguardingadults.co.uk/working-with-adults/practice-guidance/professionals-resolution/
11.6 Do I have positive (but not cosy) relationships with the professionals who are the gate keepers of these powers? It will be much easier to argue for the use of these powers if practitioners have a positive and informed relationship with the people who administer the powers, for example adult social care/ mental health services.
11.7 Am I keeping good records? Recording needs to be explicit concerning which legal rules were considered and the reasons for decision making regarding their appropriateness to the circumstances of the case.
11.8 Am I recording any unmet need? Agencies need to record unmet need to be shared with commissioners to enable them to consider the need for change.