SELF- NEGLECT & HOARDING POLICY & PROTOCOL

Transcription

1 NORTH EAST LINCOLNSHIRE SAFEGUARDING ADULT BOARD SELF- NEGLECT & HOARDING POLICY & PROTOCOL 1. Introduction When providing care and support or acting to safeguarding adults there is a balance to be struck between care and treatment being provided and an adult s right to self-determination. This guidance provides a pathway for dealing with adults who may be vulnerable and for whom self-neglect is an issue. Adults sometimes make decisions and lifestyle choices that others may perceive to be either unwise or not in their best interest and adults do have the right to live as they choose without undue or disproportionate interference. On occasions however, external intervention will be both legitimate and necessary to address the safety and wellbeing of the adult or that of others and sometimes to safeguard an adult who lacks the mental capacity to make his or her own best interest decisions. This guidance does not provide exhaustive information on self-neglect and hoarding but indicates further guidance in Chapter 14 of Care Act guidance and via references to further reading. 1 P a g e

2 2. Care Act and Self-Neglect & Hoarding The Care Act and requirements within safeguarding processes for Making Safeguarding Personal prescribe some six guiding principles that should be applied when considering whether to act on concerns around self-neglect or hoarding: i. Empowerment: Starting from the assumption that individuals are best placed to judge their own wellbeing and giving consideration to the individual s view, wishes, feelings and belief ii. Prevention: Working to protect people from abuse and neglect and prevent escalation of risk by providing support that reduces the need for intervention iii. Proportionality: Working in the least intrusive way so that any restrictions placed on an individual s rights or freedom or any action taken that is against a person s will is kept to a minimum iv. Protection: Working to protect individuals from abuse and the impact and harm of neglect v. Partnership: Maximising the active participation of individuals in need, offering individual choice wherever possible and working with partner agencies to achieve the best outcomes vi. Accountability: Making sure that individuals are aware of what we are doing, who they are working with and what our responsibilities are Self-Neglect is defined by Department of Health as a wide range of behaviours neglecting to care for one s personal hygiene, health or surroundings, including behaviour such as hoarding (2014) Unlike other forms of harm, self-neglect has no perpetrator. Abuse cannot be excluded however as a possible cause of someone becoming self-neglecting, hence the Care Act 2014 and the Care Act guidance requiring that we have measures in place to address the causes of self-neglect or hoarding. Hoarding can be defined as collecting and failing to discard of excessive quantities of goods or objects. Hoarding is not uncommon and in most cases, not indicative of psychiatric illness. It can however become so severe as to cause psychological distress, physical impairment and a risk to health and safety. Although often covert, excessive hoarding can concern others, particularly when health & safety is compromised either because of the nature of materials hoarded or it spilling over and affecting the wider environment or becoming a fire risk. The reasons for hoarding and self-neglect are not fully understood but may be symptomatic of other conditions. For example, adults with mobility problems may be physically unable to clear large amounts of clutter or may start by leaving items close and within easy reach. People with learning disabilities or dementia may struggle to categorise or dispose of things and may unwittingly acquire duplicate items they already have. Mental health problems associated with hoarding include: Depression Psychotic disorders, such as schizophrenia Obsessive compulsive disorder (OCD) 2 P a g e

3 In some cases, hoarding is a condition in itself and often associated with self-neglect. 3. Principles of Practice The following principles should underpin practice when dealing with self-neglect: i. Adults have a right to make lifestyle choices that to others can defy common sense; so decisions and actions to intervene must always be justifiable, proportionate and reasonable ii. iii. iv. A measured partnership approach is always be preferable so that the skills, powers and resources of difference organisations can be utilized, shared and have optimum impact although emergency responses will still require immediate contact with fire, police or ambulance service Multi-agency meetings/panels to address concerns and include the adult at risk should be a starting point. Organisations need to take on roles to support adults at risk from self-neglect Doing nothing or closing cases before action has been taken to reduce risk to an acceptable level and minimize harm and/or the likelihood of repeat occurrences is not an option; to do so places adults at increased risk of harm and professionals will have failed in their duties. 4. Mental Capacity Unless known otherwise, adults are presumed to have capacity. Even with capacity however, adults can lack understanding or insight into the impact on themselves or others for their actions or omissions. When an individual s behaviours or observations raise doubt about capacity, then an assessment compliant with the Mental Capacity Act (MCA) 2005 must be undertaken. Where it is then found that a person lacks capacity, professionals must ensure that any action taken is in the person s best interests and takes account of the adult s perceived wishes and feelings. Self-Neglect and Adult Safeguarding: Findings from Research (Braye et al., 2011) notes the negative impact of Mental Capacity on perception of risk and action as the ability to process information and understand consequences of decisions becomes impaired. In self-neglect, where capacity for decision making is lacking, intervention should aim at reduction of risk via a Best Interest Decision. Capacity assessments for self-neglect or hoarding behavior must be time-specific relevant to the planned interventions or action. Assessments should be timely, accurately recorded and best interest decisions made formally with relevant professionals and relevant adults with an interest in the person s welfare. The MCA provides a lawful framework in which to eliminate risk, provided that actions do not deprive a person of his or her liberty. 3 P a g e

4 In complex cases, NEL has qualified best interest assessors who can advise and ultimately, a referral could be made to the Court of Protection for authorisation of a best interest decision. Referrals to the Court of Protection must be in consultation with safeguarding services, legal advice and the MCA Deprivation of Liberty (DOL) lead for North East Lincolnshire. 5. Responses to concerns about Self Neglect and Hoarding Most cases self-neglect and hoarding will be dealt with via the relevant single agency or via a multi-agency support plan. Where single agencies or non-statutory agencies providing services suspect there is a critical safeguarding issue, a referral should be made to focus safeguarding team for assessment via the Single Point of Access ( ) to ensure both risk and wellbeing are addressed. 5.1 Engaging the adult at risk Regardless of what process, organisation or pathway is followed for an adult at risk from self-neglecting or hoarding, the starting point must be engaging with the individual. Positive outcomes are best achieved through person-centered practice that takes into account the unique experience of each individual balanced with our ethical duties and safeguarding responsibilities. In engaging with the adult all professionals should consider whether: They have the necessary information in a format they can understand Check whether they understand options and consequences of their choices They understand their reasons for mistrust, disengagement, refusal and their choices There is time to build a rapport over a period and develop a trusting relationship There is family, advocate, other professional who can support engagement with the adult There are attorneys or legal representatives if the adult has one who should be consulted The plan for agreed actions or outcomes for a person who has fluctuating capacity was in place during a time when they had capacity for that decision The adult can be assisted to engage and to attend meetings wherever possible The family member or carer of an adult at risk should be engaged where the adult at risk has asked for that person or provided consent. Identifying who should be involved should be part of planning and decision making. Professionals should confirm who is willing and able to provide support and ensure that duties under the Care Act for carers assessments have been complied with. 5.2 Single Agency Management of Low-Risk outside of Safeguarding Case of self-neglect and hoarding can be, in some cases, managed without referral to safeguarding adults procedures. These could potentially be addressed via less formal routes such as engagement with the adult, supporting a person to address their personal concerns e.g. about letting go of treasured possessions or improving social skills and engagement with community activities, or access to health care and counselling. Professional judgement is key to deciding whether a case should be escalated and any factor or issue that changes 4 P a g e

5 can increase concerns and raise a low-risk case to a higher threshold. Professionals dealing with cases at a single agency level therefore need to continually review risk levels to determine what would warrant a referral into safeguarding adults. Professional judgement is needed to consider the level of risk, how this is being managed, the capacity of the adult at risk, and any other persons (including children) who may be affected. Please see self-neglect and hoarding threshold tool attached as appendix A. 6. Referrals via the SPA under safeguarding adults policy Safeguarding referrals should detail concerns regarding the vulnerability status and welfare of the person; the state of the property and the actual or likely effect on their health, their property, any children at the property and or concerns for animals or others at the property or in the vicinity. Concerns with respect to children, and the potential for harm or neglect, should be referred to children s services FFAP ( Option 2). Safeguarding enquiries once commenced should provide a forum for: Identifying the adult s wishes, views and beliefs and what outcome they want to achieve Discussing and where necessary, assessing the adult s capacity and best interest decisions Multi-agency information-sharing to address the risk assessment and risk management plan Establishing what may be contributing or causing the behaviours and ways to address them or look at preventative measures to reduce risk and reoccurrence Once self-neglect or hoarding is being managed within the safeguarding arena, decisions should be made as to who or which agency is best suited to undertake enquiries and/or engage with the adult at risk. The LA (via focus) will retain responsibility for coordinating the response and assuring itself that risk has been managed and reduced appropriately before any case closure. Risk assessment in cases of hoarding should take into account the Clutter Image Scale at the end of this document. 7. Adults Who Decline Intervention or Refuse Support If an adult at risk refuses or declines an assessment, services or support, a risk assessment must be carried out to determine the level of seriousness of each identified risk. Intervention must apply a Making Safeguarding Personal or person-centred/enabling approach that as far as possible promotes the adult s understanding of the risk and the options available for managing risk. Information should be shared on a needs to know basis with relevant professionals who have a role in contributing to the plan in managing or monitoring risks. Consideration must also be given to the mental capacity of the individual and whether they require support via appointment of an advocate to make decisions or express their views to inform best interests decision as appropriate. 5 P a g e

6 8. Proposal for a Community Multi Agency Risk Panel Model (CMRP) CMRP are multi-agency panels to discuss, identify and document serious current risks in complex cases (not subject to MARAC or MAPPA processes) and provide a framework for adults experiencing or at risk of abuse or neglect who have capacity to make unwise choices. Where an adult has mental capacity to understand the problem and the consequences of refusing help, a referral to a CMRP could be made to look at alternative potential solutions or jointly agree the risks. The panel s purpose is to evaluate risk, formulate plans, identify which agencies will be responsible for intervention and review action plans to evaluate effectiveness and monitor change and outcomes. CMPR should only be convened in circumstances whereby: An adult with care and support needs (whether or not the LA is meeting any of those needs) is experiencing, or is at risk of, abuse or neglect and as a result of those care and support needs, is unable to protect themselves from the risk or the experience of, abuse or neglect; The adult has mental capacity to make unwise decisions and choices about their life. The adult s decision-making leaves them unable to protect themselves from the risk of serious abuse or neglect from themselves or others. The adult is choosing not to engage with services to reduce the risk or work with alternative agencies to get support and continues to make an unwise decision of their own free will placing themselves or others at increased risk. The CMPR should be used only in exceptional circumstances, not as a regular alternative to replace existing processes or substitute for engagement and partnership working with the adult at risk. The CMPR process should be used only where there are significant concerns from partners or the community and there is evidence that all other attempts at safeguarding interventions have failed. Brief Interventions under Section 42 Enquiries Section 42 enquiries provide an opportunity to work with the adult at risk to obtain the outcome they have identified, while addressing areas of risk through the safeguarding plan. Section 42 enquiries in relation to self-neglect and hoarding can include, but is not limited to: Any enquiry into abuse and neglect that may have contributed to or precipitated the self-neglecting behavior or hoarding Therapeutic responses, e.g. access to mental health, drug & alcohol services, bereavement counselling and cognitive behaviour therapies services Brief interventions, particularly those that work to enable changes in attitude or behavior and to handle underlying issues Making Safeguarding Personal toolkit has a range of options available and details can be found at the end of this guidance. In addition, Braye et al. (2005) suggested the following intervention options can be applied: 6 P a g e

7 Theme Being there Practical input Risk limitation Health concerns Care and support Cleaning / clearing Networks Therapeutic input Change of environment Enforced action Examples Maintaining contact; monitoring risk/capacity, spotting motivation Household equipment, repairs, benefits, life management Safe drinking, fire safety, repairs Doctors appointments, hospital admissions Small beginnings to build trust Proportionate to risk, with agreement, being with, attention to what follows Family/ community, social connections, peer support Replacing what is relinquished; psychotherapy/mental health services Short term respite, a new start Setting boundaries on risk to self & others 9. Legal Options and Processes Legal processes can be implemented via single agencies or via safeguarding adults procedures. In cases where adults lack capacity to make decisions or, the adult has capacity but there is significant level of risk, legal measures can be considered under the safeguarding adults procedures. Legal steps can be used to compel an adult to remove risk, permit service access and in some instances to remove the adult from the risk. It should be remembered that legal intervention should be a last resort and a balance struck between an individual s rights and the rights of others who may be adversely affected by the adult s behaviour, particularly hoarding. In brief some of the legal options may include: i. Public Health Act 1936, Section 79: Power to require removal of noxious matter by occupier of premises ii. iii. iv. Public Health Act 1936, Section 83: Cleansing of filthy or verminous premises Public Health Act 1936, Section 84: Cleansing or destruction of filthy or verminous articles Prevention of Damage by Pests Act 1949, Section 4: Power of LA to require action to prevent or treat rats and mice v. Environmental Protection Act 1990, Section 80: Dealing with statutory nuisances vi. vii. Mental Health Act 1983, Section 2 & 3: for health and safety and protection of others Mental Health Act 1983, Section 135: removal of person to place of safety for assessment to take place There are additional powers through housing, such as the Town and Country Planning Act and the Housing Act 2004, in which orders for repairs or enforcement action for hazards exist in any building or land posing a risk. It is important to know when we can/may act (have the power to do so) and where we shall/must act (have a duty to do so). The first step will always be to try to gain the consent of the person being affected and to accept the necessary services to meet their needs. 7 P a g e

8 10. Responses to service refusal The most frequent concern raised by professionals when working with adults who may selfneglect or hoard is the challenge when adults refuse to engage or accept services. Self-neglect or hoarding needs to be understood from each individual s unique set of circumstances and experiences. There is no one model that explains self-neglect or hoarding and each case may be combination of physical, mental, social, personal and environmental factors. It is therefore always preferable to get to know the individual and their history in order to understand their behaviour and why they are unable or reluctant to address the problem or engage with and trust services and professionals. Actions that may promote engagement in self-neglect cases are suggested by Braye et al. (2015) as: Theme Building rapport Moving from rapport to relationship Finding the right tone Going at the individuals pace Agreeing a plan Finding something that motivates the individual Starting with practicalities Bartering Focusing on what can be agreed Keeping company Straight talking Finding the right person External levers Examples Taking the time to get to know the person, refusing to be shocked Avoiding kneejerk responses to self-neglect, talking through the interests, history and stories Being honest while also being non-judgmental, separating the person from the behaviour Moving slowly and not forcing things; continued involvement over time Making clear what is going to happen; a weekly visit might be the initial plan Linking to interests (e.g. hoarding for environmental reasons, link into recycling initiatives) Providing small practical help at the outset may help build trust Linking practical help to another element of agreement bargaining Finding something to be the basis of the initial agreement, that can be built on later Being available and spending time to build up trust Being honest about potential consequences Working with someone who is well placed to get engagement Recognizing and working with the possibility of enforcement action 8 P a g e

9 Appendix A: Self- Neglect and Hoarding Threshold Tool Factors 1. The vulnerability of the person 2. Types Self Neglect Hoarding Property Hoarding household functions Hoarding Health and safety Hoarding Safeguarding 3. Level of selfneglect / hoarding (See clutter rating scale for Hoarding) 4. Background to hoarding / selfneglect Guidance Low risk Low risk Low impact Self-Neglect and Hoarding Threshold Tool Level of Vulnerability Moderate Moderate risk High / Critical High risk Seriously affected Does the person have capacity to make decisions with regard to care provision / housing etc.? Does the person have a diagnosed mental illness? Does the person have support from family or friends? Does the person accept care and treatment? Does the person have insight into the problems they face? Refer to the table overleaf. Types and Seriousness of Hoarding and self-neglect. Look at the relevant categories of hoarding and self-neglect and use your knowledge of the case and your professional judgement to gauge the seriousness of concern. Incidents that might fall outside safeguarding adults procedures (Low Risk) could potentially be addressed via preventative measures such as engaging with the person, developing a rapport, supporting the person to address concerns, getting the person to engage with community activities and develop / repair relationships, access to health care and counselling If a Social Worker or nurse is involved in the care report concerns to them as part of preventative measures. This tool does not replace professional judgement and does not aim to set a rigid threshold for intervention. Note professional decision making reflects the fact that the type & seriousness of hoarding and self-neglect may fall within the low risk threshold, other factors may make the issue more serious and therefore warrant progression via safeguarding procedures. Determine if the hoarding / self-neglect is: A fire risk? Impacting on the person s wellbeing (Care Act 2014 definition)? Preventing access to emergency services? Affecting the person s ability to cook, clean and general hygiene? Creating limited access to main areas of the house? Is the person at increased risk of falls? Does the person have a disability that means that they cannot care for themselves? Does the person have mental health issues and to what extent? Has this been a long standing problem? Does the person engage with services, support and guidance offered? Are there social isolation issues? 9 P a g e

10 5. Impact on others 6. Reasonable suspicion of abuse No one else affected No suspicion Others indirectly affected Indicators present Others directly affected Reasonable suspicion Others may be affected by the self-neglect or hoarding. Determine if: Are there other vulnerable people (children or adults) within the house affected by the persons hoarding / self-neglect? Does the hoarding / self-neglect prevent the person from seeing family and friends? Are there animals within the property that are not being appropriately cared for? Determine if there is reason to suspect: That the hoarding self-neglect is an indicator that the person may be being abused The person may be targeted for abuse from local people That a crime may be taking place That the person is being neglected by someone else That safeguarding is required 7. Legal frameworks No current legal issues Some minor legal issues not currently impacting Serious legal issues Try to determine whether: The person is at risk of eviction, fines, non-payment issues There is an environmental risk that requires action Public health issues There are safeguarding and animal welfare issues Fire risks that are a danger to others 10 P a g e

11 Self-Neglect and Hoarding Threshold Tool Types and Seriousness Examples of concerns that do not require formal safeguarding procedures and can be dealt with by other systems e.g. Health / GP intervention, community engagement, counselling, developing a rapport. It is likely that only concerns in the second column need to be reported Use professional judgement The examples below are likely to indicate the need for a referral for formal procedures. If there is any immediate danger of a crime or abuse to an individual evident, call 999 straight away and make a safeguarding referral. Level of Risk Minimal Risk Moderate High / Critical Self-Neglect Person is accepting support and services Health care is being addressed Person is not losing weight Person accessing services to improve wellbeing There are no carer issues Person has access to social and community activities Person is able to contribute to daily living activities Personal hygiene is good Hoarding Property All entrances and exits, stairways, roof space and windows accessible. Smoke alarms fitted and functional or referrals made to fire brigade to Access to support services is limited Health care and attendance at appointments is sporadic Person is of low weight Persons wellbeing is partially affected Person has limited social interaction Carers are not present Person has limited access to social or community activities Persons ability to contribute toward daily living activities is affected Personal hygiene is becoming an issue Only major exit is blocked Only one of the services is not fully functional Concern that services are not well The person refuses to engage with necessary services Health care is poor and there is deterioration in health Weight is reducing Wellbeing is affected on a daily basis Person is isolated from family and friends Care is prevented or refused The person does not engage with social or community activities The person does not manage daily living activities Hygiene is poor and causing skin problems Aids and adaptations refused or not accessed Limited access to the property due to extreme clutter Evidence may be seen of extreme clutter seen at windows 11 P a g e

12 visit and install. All services functional and maintained in good working order. Garden is accessible, tidy and maintained maintained Smoke alarms are not installed or not functioning Garden is not accessible due to clutter, or is not maintained Evidence of indoor items stored outside Evidence of light structural damage including damp Interior doors missing or blocked open Evidence may be seen of extreme clutter outside the property Garden not accessible and extensively overgrown Services not connected or not functioning properly Smoke alarms not fitted or not functioning Property lacks ventilation due to clutter Evidence of structural damage or outstanding repairs including damp Interior doors missing or blocked open Evidence of indoor items stored outside Hoarding Household functions No excessive clutter, all rooms can be safely used for their intended purpose. All rooms are rated 0-3 on the Clutter Rating Scale No additional unused household appliances appear in unusual locations around the property Property is maintained within terms of any lease or tenancy agreements where appropriate. Property is not at risk of action by Environmental Health. Clutter is causing congestion in the living spaces and is impacting on the use of the rooms for their intended purpose. Clutter is causing congestion between the rooms and entrances. Room(s) scores 4-5 on the clutter scale. Inconsistent levels of housekeeping throughout the property Some household appliances are not functioning properly and there may be additional units in unusual places. Property is not maintained within terms of lease or tenancy agreement where applicable. Evidence of outdoor items being stored inside Clutter is obstructing the living spaces and is preventing the use of the rooms for their intended purpose. Room(s) scores 7-9 on the clutter image scale and not used for intended purpose Beds inaccessible or unusable due to clutter or infestation Entrances, hallways and stairs blocked or difficult to pass Toilets, sinks not functioning or not in use Resident at risk due to living environment Household appliances are not functioning or inaccessible and no safe cooking environment Resident is using candles Evidence of outdoor clutter being stored indoors. No evidence of housekeeping being undertaken Broken household items not discarded e.g. broken glass or plates Concern for declining mental health Property is not maintained within terms of lease or tenancy agreement where applicable and is at risk of notice being served by Environmental Health 12 P a g e

13 Hoarding Health and Safety Hoarding Safeguarding of Children, family members and / or animals Property is clean with no odours, (pet or other) No rotting food No concerning use of candles No concern over flies Residents managing personal care No writing on the walls Quantities of medication are within appropriate limits, in date and stored appropriately. Personal protective equipment is not required No Concerns for household members Kitchen and bathroom are not kept clean Offensive odour in the property Resident is not maintaining safe cooking environment Some concern with the quantity of medication, or its storage or expiry dates. No rotting food No concerning use of candles Resident trying to manage personal care but struggling No writing on the walls Light insect infestation (bed bugs, lice, fleas, cockroaches, ants, etc.) Latex Gloves, boots or needle stick safe shoes, face mask, hand sanitizer, insect repellent. Personal Protective Equipment required. Hoarding on clutter scale 4-7 doesn t automatically constitute a Safeguarding Alert. Please note all additional concerns for householders Properties with children or vulnerable residents with additional support needs may trigger a Safeguarding Alert Human urine and or excrement may be present Excessive odour in the property, may also be evident from the outside Rotting food may be present Evidence may be seen of unclean, unused and or buried plates & dishes. Broken household items not discarded e.g. broken glass or plates Inappropriate quantities or storage of medication. Pungent odour can be smelt inside the property and possibly from outside. Concern with the integrity of the electrics Inappropriate use of electrical extension cords or evidence of unqualified work to the electrics. Concern for declining mental health Heavy insect infestation (bed bugs, lice, fleas, cockroaches, ants, silverfish, etc.) Visible rodent infestation Hoarding on clutter scale 7-9 constitutes a Safeguarding Alert. Please note all additional concerns for householders RESPONSIBILITY All workers to engage with the person, develop a rapport, supporting the person to address concerns, getting the person to Consideration for referral into safeguarding Consideration for referral into safeguarding 13 P a g e

14 engage with community activities and develop / repair relationships, access to health care and counselling, improve wellbeing Preventative measures Appendix B: Clutter Image Scale Appendix C: Further Information Further suggested reading: Braye, S., Orr, D. and Preston-Shoot, M. (2014). Self-Neglect Policy & Practice: Building an Evidence Base for Adult Social Care. London: SCIE: Braye, S., Orr, D. and Preston-Shoot, M. (2015). Learning lessons about self-neglect? An analysis of serious case reviews. Journal of Adult Protection. 17, 1, Making Safeguarding Personal Toolkit on the Local Government Association (LGA) website 14 P a g e