Self-Neglect and Hoarding

1. Local Guidance

The Safeguarding Adults Board has developed local guidance to support safeguarding where self-neglect and/or hoarding is a factor. It should be read alongside this section of the procedure.

See: North of Tyne Self-Neglect Guidance.

2. What is Self-neglect?

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

Causes of self-neglect

Self-neglect may occur for many reasons:

1. A behavioural condition;
2. A mental health issue;
3. A cognitive impairment;
4. Changes in physical ability;
5. Triggered by trauma and significant life events;
6. Personal choice.

Periods of self-neglect can also be intentional, unintentional, brief, prolonged, repeated or single incidents.

3. What is Hoarding?

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.

Compulsive hoarding

Compulsive hoarding (more accurately described as 'hoarding disorder') is the excessive acquisition of and inability or unwillingness to discard large quantities of objects that cover the living areas of the home and cause significant distress.

Compulsive hoarders may be conscious of their irrational behaviour but the emotional attachment to the hoarded objects far exceeds the motivation to discard the items.

Compulsive hoarding behaviour has been associated with health risks, impaired functioning, economic burden, and adverse effects on friends and family members.

4. When is Self-neglect a Safeguarding Issue?

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."

5. Responding to Self-neglect and Hoarding

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.

As there are many causes of self-neglect, it is helpful to try and determine when the self-neglect began as this can help explain why it is happening.

Do not assume that self-neglect or hoarding is a lifestyle choice, or the way in which a person wants to live their life.

If a person self-neglects because they are unable to care for themselves due to, for example a physical disability, then 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.

Risk assessment

Crucial to all decision making is a robust risk assessment, preferably multi-agency that includes the views of the adult and their informal networks of support.

The risk assessment might cover:

1. Capacity and consent;
2. Indications of mental health issues;
3. The level of risk to the persons physical health;
4. The level of risk to their overall wellbeing;
5. Effects on other people's health and wellbeing;
6. Serious risk of fire;
7. Serious environmental risk e.g. destruction or partial destruction of accommodation.

The Clutter Image Ratings (CIR) may also be a helpful decision-making tool. It is a rising pictorial scale of nine photographs showing clutter in three rooms – living room, bedroom and kitchen.

Carers

If the adult has a carer, it is important to assess the ability of them to meet the needs of the adult and rule out any neglect or acts of omission. It could be that the carer has unintentionally neglected the caring role because they are no longer able to cope.

Carers can also neglect themselves due to the stresses and demands of their caring responsibilities.

6. Environment Health Service intervention

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.