Key agencies and their roles in responding to self-neglect

Hospitals and Early Intervention Community Teams

Community based therapists and nursing staff are often the first people to observe hoarding and self-neglect related problems. These professionals can be key to identifying triggers and changes which are then fed into the multi-disciplinary team. Therapists who work in acute wards may identify self-neglect related behaviours when undertaking access visits or home visits to help inform the discharge planning process. Therapists can assess and report on how an adults’ self-neglect or environment impacts on their overall ability to be safe at home and help determine the level of risk posed to the individual and others (family members, neighbours etc).

Discharge planning should commence as soon as possible to support good communication and effective multi-agency working to reduce risks following discharge.

If a patient is refusing medical treatment for their own sound reasons, the health care practitioner must make every effort to ensure that the person fully understands the risks of the refusal and continue supportive efforts to engage the person if appropriate.

Adult Social Care

In most circumstances, the Care Act 2014 Assessment procedures will be the best route to provide an appropriate intervention. If assessed as having mental capacity to make informed decisions on the issues raised, the person has the right to make their own choices. However, the social care practitioner must ensure the person has fully understood the risk and likely consequences if they decline services.

Involvement with the person should not stop at this point and efforts should be made to engage the person in the management of risks and to form a relationship with them to do this.

If the person is assessed as not having the mental capacity to make the relevant decisions, care should be provided in line with “best interest” principles (S.4 MCA). If the Social Care Practitioner considers a proposed care package may lead to a Deprivation of Liberty (DoLS); consideration must also be given to whether it would be necessary to obtain authorisation under the Community DoLS procedure.

Assessment of self-neglect should include assessment of any health issues such as impaired sight and mobility, pain issues, or long-term conditions that may be contributing towards the self-neglect.

Northeast Ambulance Service (NEAS)

Ambulance staff are called to people’s properties in emergency situations and often access parts of the property that other professionals may not ordinarily see. They can assess an individual’s living environment and physical health and often raise concerns with Adult Social Care Services and general practices. By its very nature, this is a brief observational assessment and may not give a holistic view.

Domiciliary Care and Enablement

These services may be directly provided. Care agencies are commissioned by Adult Social Care Services, or self-funded by individuals to provide support to people in their own homes. Those providing the services have a role in both identifying people who self-neglect and hoard and in working with them.

Environmental Health Services

Environmental Health Services have a range of powers to intervene where a property is in a condition that is prejudicial to health, or where the premises is materially affecting neighbouring premises.

Environmental Health is a frontline agency in raising alerts and early identification of cases of self-neglect. Where properties are verminous or pose a statutory nuisance, Environmental Health will take a leading role in case managing the necessary investigations and determining the most effective means of intervention. Where the individual is residing in conditions that only pose a threat to their own welfare, the powers available to Environmental Health may have limited or no effect. In cases involving persistent hoarders, the powers may only temporarily address and/or contain the problem. Therefore, utilising powers under public health legislation in isolation is often inappropriate due to the complexities of self-neglect and it may not be the most effective use of resources, particularly where a coordinated approach could provide immediate protection of the individual and others or promote a long-term solution.

Housing

Under Part 1 of the Housing Act 2004, housing departments have powers to take enforcement action where there is any risk of harm to the health or safety of an actual or potential occupier of a dwelling or house of multiple occupation which arises from a deficiency in the dwelling or house of multiple occupation or in any building or land in the vicinity (whether the deficiency arises as a result of the construction of any building, an absence of maintenance or repair, or otherwise). The housing department can require access to residential premises in their district to assess if such a hazard exists. The duty to inspect the property is restricted to where there is an official complaint made either to the Justice of the Peace or local council. However, where there is evidence that there is imminent risk of serious harm to the health and safety of the occupier, the local authority has emergency power to serve a remedial action notice or emergency probation notice prohibiting the use of the property.

There are also powers to serve a deferred action notice and take emergency remedial action. There is no requirement that the property is owned by the local authority, nor is the capacity of the inhabitant relevant to the exercise of these powers. However, use of these powers in isolation will have limited effect on those who have persistent behaviours. The Housing Act powers cannot be used to remove hoarded items or address any health and safety problems that are the result of the owner’s actions.

Children’s Services

Safeguarding Children refers to protecting children from maltreatment, preventing the impairment of their health or development and ensuring that they are growing up in circumstances consistent with the provision of safe and effective care. In particular, growing up in a hoarded property can put a child at risk by affecting their development and in some cases, leading to the neglect of a child, which is a safeguarding issue.

The needs of the child at risk must come first and any actions taken must reflect this. Therefore, where children live in a property where there is an issue with safeguarding and/or hoarding, a referral should always be made to Children’s Services.

Mental Health Services

Mental health services have a crucial role as for many individuals, hoarding or self-neglect are often the manifestations of an underlying mental health condition. Mental Health professionals may offer key insight into how best to intervene where the adult is self-neglecting or has a diagnosed mental health condition. Where relevant, powers conferred by the Mental Health Act 1983 (MHA) to Approved Mental Health Professionals (AMHP) enable the mental health service to take such steps as they consider necessary and proportionate to protect a person from the immediate risk of significant harm.

The police have powers of entry and so may be pivotal in gaining access to conduct assessments if all else fails. Under section 17 (1) (a) of the Police and Criminal Evidence Act 1984, the police have the power to enter without a warrant if required to save life or limb; or prevent serious damage to property; or to recapture a person who is unlawfully at large whilst liable to be detained.

Primary Care

In some cases of chronic or persistent self-neglect, individuals who are reluctant to engage with Adult Social Care Services or other agencies may engage with primary health care services such as their GP, district nursing service etc. GPs and district nurses often carry out home visits to people with care and support needs and may be the first people to notice a change in the person’s home environment. Alternatively, failure to keep health appointments or to comply with medication may indicate self-neglect. As well as raising alerts and providing information, primary health services can be very effective in forming a relationship with the person and in addressing underlying concerns.

Primary health services should monitor those individuals who are engaged with their service and show signs of significant self-neglect. Monitoring might include a regular check in with, and offer of intervention to, someone who is reluctant to engage. If deterioration is such that risks to the person or to others are assessed as high by the health professional, a multi-agency response will be required.

Private de-cluttering companies

There are several private companies and other organisations that offer specialist deep cleaning, decluttering and garden clearance services. Their staff should be specially trained to understand the complexities of hoarding and how to respond appropriately in sensitive circumstances. This option should be considered as part of a co-ordinated multi-disciplinary response, in cases where hoarding is apparent.

Private landlords/housing associations/registered social landlords

Private landlords/housing associations and registered social landlords have an obligation to ensure that their properties are in a good state of repair and are fit for human habitation. Where the tenant is responsible for the disrepair the landlord has a right of action, including ultimately seeking possession of the premises. The role of the landlord/housing association and powers afforded to them means that they have a key role in alerting the statutory authorities to particular cases and that consideration should always be given to their inclusion within multi-agency discussions.

Royal Society for the Prevention of Cruelty to Animal (RSPCA)

Animal hoarders own a high number of animals for which they may be unable to provide adequate standards of nutrition, sanitation, shelter and veterinary care. Hoarders often care about their animals deeply but may not see or understand that the living conditions could result in animal neglect. This neglect can involve cramped, poor living conditions and in extreme cases, result in starvation, illness or death.

Animal hoarders are often in denial about their inability to provide appropriate care for their animals and typically believe that no-one else can care for their animals like they do. Sensitivity is vital as animal hoarders often hold the belief that if they seek help, or allow external intervention, their animals will be euthanised or taken away from them. Professionals can contact the RSPCA who can offer advice and assistance to improve animal welfare, including giving people time to make improvements to their standards of care. Where assistance is declined, or in extreme cases of neglect, the RSPCA can consider prosecution under laws such as the Animal Welfare Act 2006.

County Durham and Darlington Fire and Rescue Service (CDDFRS)

CDDFRS is best placed to work with individuals to assess and address fire risk and to develop strategies to minimise significant harm caused by potential fire risks in the home.

CDDFRS will also raise alerts when called to or visiting addresses where significant risk is identified or where homes have damage because of a fire and the individual continues to live at that address.

CDDFRS will carry out Safe and Well visits and offer advice to individuals assuring them of the necessity and principles of fire prevention in the home. The WMFS have on occasion managed to enter a home for a referral where home access is refused to other services due to the trusted nature of their work.

Durham Constabulary

Each agency has responsibility to complete a welfare check where they are the main agency involved. Where, however, a crime is suspected or the person is missing, despite attempts to find them/make contact, the concern about immediate risk to life should be raised with the police.

Should police have concerns about the safety or wellbeing of a vulnerable adult who may be self-neglecting or hoarding, the concerns should be shared with Adult Social Care via a Safeguarding Adult Report.

Utility companies/building and maintenance workers

Utility companies/building and maintenance workers have an important role in the identification of hoarding and self-neglect as they visit people’s homes to read meters, carry out inspections or carry out building/maintenance work. Engagement of utility companies and other companies/workers who enter peoples’ homes is therefore important so that reports of hoarding and self-neglect can be received, and appropriate action taken.

Support available in the Community

There is a wide range of support and guidance available in the community. One of the difficulties of providing a list of such services is that it would not be exhaustive and would need regular updates and amendments to remain accurate and of value to practitioners.