Key Agencies and their roles in responding to self-neglect
A number of key agencies may be involved in Multi-Agency Risk Management (MARM).
This may involve initial referral for a MARM, being the lead agency or being part of the MARM meeting.
- Hospitals and Early Intervention Community Teams
- Yorkshire Ambulance Service
- Housing
- Children’s Services
- Adult Social Care
- Mental Health Services
- Primary Care
- Private de-cluttering companies
- Private landlords, housing associations and registered social landlords
- Royal Society for the Prevention of Cruelty to Animals
- North Yorkshire Fire and Rescue Service
- North Yorkshire Police
- Utility companies, building and maintenance workers
- Further support available in the community
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 (such as family members, neighbours).
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.
Yorkshire Ambulance Service
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 Practitioners. By its very nature, this is a brief observational assessment and may not give a holistic view. North Yorkshire Fire and Rescue Service.
Housing
Under the Housing Act 2004 local housing authorities are responsible for regulating housing conditions in the private sector, particularly in privately rented properties and housing of multiple occupations (HMOs) but also in privately owned properties on occasion.
Local housing authorities can take enforcement action where there is a risk of harm to the health or safety of an occupier of the dwelling or house of multiple occupation which arises from a deficiency in the property, and where a complaint has been received.
When a complaint is received the local housing authority can require access to the residential premises in their district to assess if any hazard exists and require the landlord or owner to take action to resolve any issue identified.
A range of enforcement options can be used by the local housing authority, depending on the level of risk and hazards identified, ranging from Hazard Awareness Notices to advise landlords or owners of an identified hazard, to Improvement Notices requiring the landlord or owner to carry out repair or improvement works, and to prohibition orders to restrict the use of all or parts of a dwelling
Where there is evidence that there is an imminent risk of serious harm to the health and safety of the occupier, the local housing authority can also use emergency powers to take quicker action. This can include the use of an emergency remedial action notice where the local authority carry out works to remove the imminent risk or use of an emergency prohibition notices to immediately prohibit the use of the all or parts of a property.
Failure to comply with any notice served is an offence and can result in service of a Civil Penalty Notice with a fine of up to £40,000, or prosecution by the Local Housing Authority.
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.
Registered Providers of Housing such as Housing Associations or Local Authority Housing providers are regulated. The Regulator of Social Housing requires minimum standards known as consumer standards requiring that properties are kept well maintained and safe along with other requirements. Housing Officers will work with tenants and communities and will often find people in situations where safeguarding referrals are needed including self-neglect, hoarding and exploitation. These Landlords require court orders to gain entry to homes unless invited or there is a dire emergency that justifies gaining entry. This is normally done by liaising with the police.
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.
Adult Social Care
Where the adult has care and support needs, the Care Act 2014 Assessment procedures may 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 (DoL); consideration must also be given to whether it would be necessary to obtain authorisation under the Community DoL 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 of the individual.
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.
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 or district nursing service. 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 and 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 or 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 Animals
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 Royal Society for the Prevention of Cruelty to Animals (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.
North Yorkshire Fire and Rescue Service
Fire and rescue services are 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.
They 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.
North Yorkshire Fire and Rescue will carry out Home Fire Safety visits and offer advice to individuals assuring them of the necessity and principles of fire prevention in the home.
North Yorkshire Police
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.
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.
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.
Further 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, but here are some useful links:
- Live Well York
- Local Area Coordinators (City of York Council)
- Social Prescribing (York CVS)
- Self Neglect Practice Guidance (City of York and North Yorkshire Safeguarding Adults Boards)