RBSAB
Rochdale Borough Safeguarding
Adults Board
Multi Agency
Practice Guide
Safeguarding and Self Neglect
Authors
Jane Timson: Head of Safeguarding, Adult Care.
Draft: Sept. 2012
Amended at RBSAB Operational Board 17.09.12
Approved at at RBSAB 28.01.2013
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Background to the Guidance
In 2012, the Safeguarding Adults Board conducted a Learning the Lessons
Inter Agency Review in respect of an adult who died having been admitted to
hospital in a concerning state of neglect. In response to the review
recommendations, this guidance has been produced to highlight good
practice for professionals when dealing with self-neglect and resistance to
engage with services.
It is intended to ensure that vulnerable adults are safeguarded, treated with
dignity and respect and that vulnerable adult decision making is recorded
appropriately within assessment documentation.
Purpose of the Guidance
Adults may make lifestyle choices which may be contrary to what is perceived
to be common sense, contrary to the advice or views of family friends and
professionals.
Such choices may well have an adverse effect on a person’s health, wellbeing
or safety.
Those involved in providing support, care or treatment needed to balance an
adults’ right to self determination, with duties to manage risk and safeguarding
those who are vulnerable. This is challenging.
Disengagement, non co-operation, mistrusts with services, poor lifestyle
choice and poor living conditions may be a feature of a person’s history.
Professionals need to judge when a cause for concern situation is becoming
more serious and reassess their power duties to intervene. Attempts to
intervene must be proportionate and reasonable.
Self neglect may in some circumstances impact on the safety and wellbeing of
others. Attempts to intervene must also take account of the rights and
wellbeing of others.
This guidance is intended as a framework to assist professionals in working
through their options when working with people whom there is a concern.
Definition of Self Neglect
A person is regarded as being significant risk because he/she:
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Is perceived to be unable or unwilling to care for themselves
Refuses or disengages from support, treatment or services which are
regarded as essential to safeguard their health, wellbeing or safety.
Is under duress to refuse, not engage with services, or is dependant on
someone who is unwilling/unable to engage with services.
Indicators of Self Neglect
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Any single indicator could be a significant risk to a person’s wellbeing
or safety.
Indicators are a cause for concern, which if not addresses could
escalate to a significant risk.
Multiple indicators are likely to raise the risk.
Some self neglect may additionally compromise the safety and
wellbeing of others e.g. neighbours or members of a household.
Health Indicators
These indicators apply when there is no reasonable explanation, e.g.
attributable to a person’s medical condition.
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Weight Loss
Incontinence
Infected Sores
Skin Integrity compromised
Missed health appointments, health professionals unable to gain
access,
Failure to follow treatment plans, medication regimes.
Repeated injuries as a result of falls, accidents in the kitchen etc.
Home Environments
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Fire Hazards, alerts raised by fire service, unsafe electrical appliances.
Alerts raised by police, ambulance, re concerns for safety.
Extreme clutter
Windows/Locks broken
No heating, water, electricity
Little or no sign of food in the home
Infestations
Legislative/Policy Framework
The key legislation which is helpful for when considering intervention in self
neglect cases
- The Human Rights Act 1998
Article 5, the Right to Liberty & Security
- National Assistance Act 1948
- Mental Health Act 1983
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Consideration should be given as to whether a person’s presentation would
warrant a Mental Health assessment. The Acts definition of Mental Disorder is
broad “any disorder or disability of the mind”.
- Mental Capacity Act 2005
Provides advice and guidance to anyone who makes decisions about:
provides care for or treatment to; conduct assessments for; adults who may
lack capacity to make decisions for themselves. The Mental Capacity Act
applies to relatives, friends, volunteers and professionals who provide care
and treatment. S5 of the Act has some powers for agencies to remove a
person to place where they can be cared for. The Deprivation of Liberty
Safeguards provides for people in hospital and Registered Homes who need
to stay there (again their will) to receive essential care and treatment.
Responses to Concerns about Self Neglect
In many cases self neglect will be dealt with under usual case management
arrangements and are regarded as safeguarding in its broadest sense. Where
the risk to the safety and wellbeing of a vulnerable adult and/or others are
becoming more critical a more formal Adult protection approach will be
required.
Engage the Adult
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Ensure they have necessary information in a format they can
understand
Check out that they do understand options and consequences of their
choices
Listen to their reasons for mistrust, disengagement, refusal and their
choice
The above three points may need to be a conversation over time i.e.
“not a one off”
Repeat all the above if risk to their health/safety increases
Consider who e.g. family member, advocate, other professional may
help the adult and you in these conversations and be relevant in
assisting with assessment and/or support
Always involve attorneys, receivers, person representatives if the adult
has one
Where an adult has fluctuating capacity it may be possible to establish
a plan when they are capacitated which determines what they want to
happen when they lack capacity
Check whether adult has made an Advance Directive when involved
with significant decisions, re. health
Involve adult in meetings where possible
Engage & Support the Person’s Family/Carers
Ensure the adult is aware and consenting to the proposed role of family/carer
in his/her care/treatment plan. If family are need/expected to provide care or
support:
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Involve them in the development of the care/treatment plan. They must
be invited to planning/discharge meetings
Ensure that the carers role, responsibilities are clearly recorded on
formal care or treatment plans
Check that they are willing and able to provide care/treatment
Provide them with necessary training, information to do what is
expected
Mentor/supervise, review to ensure they understand, have the skills
Carers Assessments must always be offered
This most obviously applies to family and friends but may equally apply to
professional carers- e.g. health professionals should not assume that a care
worker has the skills or capacity to undertake certain health related tasks.
Engage Other Professionals/Agencies
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Make referrals clear and timely – if others are regarded as essential to
a care/treatment plan
Consult, seek advice on areas which others may have more expertisethis does not always mean they should become actively involved in
cases
Where risk is complex and high risk ensure communication of essential
information is timely, accurate to other professionals involved. Consider
the need for a multi agency professionals meeting with/without the
adult and their representatives. This will aid co-ordination, and a
shared understanding of risk
Mental Capacity Considerations
The ability of an adult to make decisions is critical in determining whether their
right to self determination should be fully taken account of, when their
health/wellbeing or safety is likely to be significantly compromised as a result
of unwise decisions. The principles of The Mental Capacity Act 2005 must be
adhered to.
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Duress – is the adult being influenced by others who may not have
their best interests at heart? E.g. should financial gain, sexual
exploitation or other motives be considered? Safeguarding Meeting
should be convened
When concerns about risk are high it is recommended that the
professional considers the need for an assessment of capacity and
then records the outcome i.e. whether an assessment was clearly not
necessary or otherwise
Assessments of Capacity must also be considered and/or repeated as
risk increases
Assessments of capacity should be considered and/or repeated as risk
increases
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Assessment of capacity should be undertaken by the decision maker,
who may request assistance/opinion from other professionals and the
person’s family.
Where a person lacks capacity and the risks are high, multi agency,
best interest meetings must be held using the standard agenda.
Applications to Court of Protection may need to be considered
Where a person has no suitable family or friends and they lack capacity
an advocate must be considered
Always involve Attorneys, Receivers and Persons Representatives if
the adult has one and they lack capacity
Try to establish an advance plan with people whose engagements
fluctuates as their capacity fluctuates
Professionals should refer to Mental Capacity Act Codes of
Practice and Rochdale’s Practice Guide
Record Keeping
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Ensure personal details of the adult and significant others are correct
e.g. name, address, telephone etc. (Failed appointments could be due
to letters going to the wrong place)
Include all factual observations from visits and contracts which
describe risk factors, e.g. person’s appearance, comments, others
present, health symptoms, environment etc.
Self neglect situations are challenging and often those involved are involved
in judgements which are not clear cut and may need to stand scrutiny at a
future date, e.g. coroner’s court or other enquiry. It is therefore essential to
record:
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The decisions made
Who was involved in the discussion/meeting? How was the adult
included?
The rationale for decisions made i.e. what was weighed into the
decision making process, e.g. options considered, risks benefits of
options, least restrictive principles, adults wishes and view etc.
When were decisions made/reviewed, i.e. the dates of
meetings/discussions
In some cases these records ,ay be in the form of formal meetings minutes,
e.g. Discharge Planning, Case Review, Mental Capacity Best Interest
Meetings, Necessary when there is need to bring a number of people together
and the issues are complex/or concern significant risk. In less complex
scenarios it suffices for the above to be included in case notes.
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Mental capacity – was an assessment considered necessary? In high
risk situations it is advisable to record the decision to formally assess
or not.
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Mental Capacity – formal assessment should be recorded on the
recommended pro forma.
Pathways Adults Refusing Services & Self Neglect
Is this resulting in significant harm to a person’s health, safety or wellbeing?
Does the adult have capacity to make necessary decision(s) re, safety or wellbeing?
Yes
Maybe/Fluctuating
No
Provide adult with information
relevant to decision.
Mental Capacity Assessment
record outcome
Signpost to relevant services,
support as needed.
Re-package information, to
maximise adults capacity to
understand
Seek consent to share info
with other appropriate
agencies/family
Consider possibility of a plan
which takes account of
fluctuating capacity
Discuss options &
consequences of decisions
Re-negotiate options for
delivery of services/treatment
Record the fact that adult has
capacity
Share appropriate risk info
with other appropriate
agencies
Offer Carers Assessment if
appropriate
Need to advocate considered
Lead agency/professional
considers need for Best
Interest meeting, especially if
there is a disagreement
Involve an Advocate if the
person has no suitable
representation
DOLS Safeguards
considered if appropriate
Court of Protection
considered
Consider powers and duties
to get person to a place of
safety
Consider need for
Professional Meeting/
Case Conference/Protection
Planning Meeting
Monitor/Review
Always consult your manager/supervisor before closing a case if significant risk remains.
Record decision and rationale in case records.
If service refusal continues and/or risk becomes critical & there are concerns
re persons lack of capacity.
Lead professional alerts designated safeguarding officer in their agency who
will convene a Multi-Agency Professionals meeting to consider whether all
available powers and duties are exhausted, the need for Court of Protection
involvement considered.
Designated officer alerts Organisation’s Safeguarding Lead if exceptional
critical risk remains.
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