LSAB Self-neglect policy, procedures, guidance

The following characteristics and behaviours are useful indicators of self-neglect: 

• Living in very unclean home environment e.g. rubbish or waste not disposed of
• Physical or health needs not adequately cared for, causing them to deteriorate 
• Inadequate diet and nutrition, which impact on the person’s health and wellbeing 
• Social contacts not being maintained
• Finances not being managed, or assistance being sought 
• Prescribed medication not being taken or being declined 
• Refusing to allow access to health and/or social care staff in relation to care needs, health needs or property maintenance, or, being unwilling to attend appointments with relevant staff.

Public authorities must not act in a way that is incompatible with Human Rights; and wherever possible, existing laws have to be interpreted and applied in a way that fits with these rights. 

A summary of key articles of the European Convention on Human Rights is included within the appendix, refer to Equality and Human Rights Commission www.equalityhumanrights.com for a full description and explanation of each article. 

Article 8 and First Protocol Article 1 however, are also highlighted here:

Article 8: Right to respect for a private and family life 

1. Everyone has the right for his private and family life, his home and his correspondence 

2. There shall be no interference by a public authority with the exercise of this right except such as in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others. 

The First Protocol Article 1 – Protection of Property 

1. Every natural or legal person is entitled to the peaceful enjoyment of his possessions. No one should be deprived of his possessions except in the public interest and subject to the conditions provided for by law and by the general principles of international law. 

2. This provision does not however impair the right of the State to enforce such laws as it deems necessary to control the use of property in accordance with the general interest or to secure payment of taxes or other contributions or penalties.

 For a public body to interfere with these rights, the actions would need to be lawful, necessary and proportionate. An action is ‘proportionate’ when it is appropriate and no more than necessary to address the problem concerned. Where a person lacks mental capacity, decisions should be made in accordance with the Mental Capacity Act 2005.

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The Care Act 2014 places specific duties on the Local Authority in relation to self-neglect: 

(i) Assessment (Care Act 2014, Section 9 and Section 11). The Local Authority must undertake a needs assessment where it appears that the adult may have needs for care and support. In the event of their refusal, the duty to assess still applies if they are experiencing, or at risk of, self-neglect or if they lack capacity to decide and the assessment is in their best interests. 

In the event that a person refuses an assessment of need in situations of selfneglect, this may indicate the need for a safeguarding enquiry alongside the Section 11(2) duty to carry out a needs assessment 

(ii) Carers’ Assessments (Care Act 2014, Section 10) Carers are entitled to an assessment of their need for support as set out in Section 10 of the Care Act 2014. This entitlement would apply even where the person selfneglecting, is declining an assessment or support from the local authority or other agencies. 

(iii) Safeguarding enquiry (Care Act 2014, Section 42) When a Local Authority has reasonable cause to suspect that an adult with care and support needs is experiencing, or is at risk of, self-neglect, and as a result of these needs, is unable to protect himself or herself against self-neglect, or the risk of it, the Local Authority must make, or cause to be made, whatever enquiries it thinks necessary to enable it to decide what action should be taken in an adult’s case, 

The Care and Support Statutory guidance further states: 

“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” 

iv) Duty to cooperate (Care Act 2014, Section 6 and Section 7) 

General Duty (Section 6) 

Local authority must co-operate with each of its relevant partners, and each relevant partner must co-operate with the authority, in the exercise of its respective functions relating to adults with needs for care and support and carers.

Section 6(3) sets out examples of persons with whom a local authority may consider it appropriate to co-operate: 

• a person who provides services to meet adults’ needs for care and support, services to meet carers’ needs for support or services, facilities or resources 
• a person who provides primary medical services, primary dental services, primary ophthalmic services, pharmaceutical services or local pharmaceutical services under the National Health Service Act 2006; 
• a person in whom a hospital in England is vested which is not a health service hospital as defined by that Act; a private registered provider of social housing. 

Co-operating in specific cases (Section 7) 

Where cooperation between parties set out in Section 6, is sought from the other in relation to an individual with needs for care and support or in the case of a carer, a carer of a child or a young carer, each party must comply with the request unless it considers that doing so— 

(a) would be incompatible with its own duties, or                                                                               (b) would otherwise have an adverse effect on the exercise of its functions. 

(v) Representation and advocacy (Care Act 2014, Section 67 and Section 68) 

If an adult has a substantial difficulty in understanding or engaging with an assessment or safeguarding enquiry, the local authority must ensure that there is a friend or family member to facilitate their involvement; and if there is not, must arrange for an independent advocate.

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The Mental Capacity Act (MCA) 2005 applies to everyone involved in the care, treatment and support of people aged 16 and over living in England and Wales who are unable to make all or some decisions for themselves. All professionals have an obligation and duty to comply with the law and the Code of Practice. 

Mental capacity considerations are a key aspect of practice around supporting people who self-neglect. The Mental Capacity Act principles, mental capacity assessments, best interests, court of protection, issues of fluctuating capacity and unwise decisions are outlined in Section 5.5.

There will be times when the self-neglect impacts on the person’s health and wellbeing, their home conditions or on others, to such a degree that practitioners may need to consider what wider legislative action can be used to assist in minimising risks. 

Possible legal powers of intervention are included as a separate webpage for information only. Any such actions need to be considered in consultation with legal advice and as part of a carefully considered multi-agency agency intervention plan. Enforcement approaches are often most likely to succeed where they form part of a plan of support.

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An approach based around understanding the person and the underlying reasons for their behaviour, is seen throughout the research to achieve better outcomes than solely focusing on a reduction of the presenting behaviours. 

In Leeds, ‘Talk to me, Hear my voice’ is the expression given to us by citizens – the message is to engage, to get alongside, and seek to understand their views and perspectives. This approach underpins good practice in supporting citizens living in circumstances of self-neglect. 

Wherever possible practitioners should: 

• Explore and understand the individual’s life history and circumstances, and their possible connections to current patterns of self-neglect.   Recognise that underlying reasons for someone’s self-neglect may be linked to earlier life  experiences or traumas, or be occurring within in the context of complex relationships
• Use this approach to form an accurate assessment of the issues and work out what kinds of intervention are most likely to enable the person to achieve change.                                           
• Recognise the emotional component of people’s current experience of their circumstances. Practitioners need to work with people who may be experiencing fear, anxiety, embarrassment and shame in relation to their circumstances; which may pose barriers to accepting support.                      
• Demonstrate calm and understanding reactions to self-neglect. The research identifies that where practitioners normalised the self-neglect, neither dismissing it nor treating it as exceptional, this was valued.     
• Adopt strength-based approaches. Learning from research identifies that people who used services emphasised their own resilience and determination in coping with the circumstances that had led to self-neglect. They felt that practitioners did not often recognise these qualities, focusing instead on the highly visible signs of neglect, and they valued practitioners who recognised and worked with the strengths they had. 

There is a clear evidence base that approaches based upon finding the person help, practitioners to devise individualised interventions that recognise the person’s personal life experience, networks, strengths, relationships and motivations.

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Working closely with family members/unpaid carers can be an important element of achieving effective engagement with the person at risk, and in providing support that reduces risks and improves personal circumstances. 

The family member / unpaid carers should be involved with their consent or in their best interests under the Mental Capacity Act 2005. There may also be occasions where involving a person’s family members / unpaid carers without consent is a proportionate act taking into account Article 8 of the Human Rights Act. 

Be aware that relatives and unpaid carers: 

• Have unique relationships with the person at risk that may support positive engagement with practitioners 
• Will be able to support assessments of need and risk 
• Will have a unique understanding of the person’s past history and motivation 
• May provide ongoing support, or be key to the provision of support in the future 

Practitioners should consider the following when working with relatives and unpaid carers: 

• Ensure the person at risk is aware and wherever possible consenting to the proposed role of the relative / unpaid carer in his/her care/treatment plan 
• Offer/carry out carers’ assessments if relatives are providing care or support 
• Involve the relative / unpaid carer in the development of any care and support plan. Consider if it is appropriate to invite relatives / unpaid carer to meetings or develop other ways of involving them in planning. 
• Ensure the carer’s role and responsibilities are clearly recorded on formal care and support plans 
• Check that they are willing and able to provide care and support 
• Provide them with necessary support, training, information to do what is expected 
• Mentor/supervise to ensure they understand and have the skills they need 
• Explore the dynamics between family members – these may underpin the person’s self-neglecting behaviours and influence their decision making. 
• Recognise that relatives/unpaid carers may have shared life experiences with the person who is self-neglecting 
• Adopt Think family, Work family approaches to understanding the support needs of family, and their ability to provide support to the person at risk. 

When the person with mental capacity does not give consent to engage with a relative / unpaid carer, the carer however is nonetheless still entitled to a carer’s assessment in relation to their own needs (See Section 3.2). If they raise concerns in their own right, or if they have made the referral about the self-neglect, these concerns should still be discussed and their concerns heard.

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The underlying causes of self-neglect and the person’s unique circumstances, history, wishes and perspectives mean that there is no single response that will work in every situation. Individually tailored and creative approaches are most likely to achieve the best outcomes.

Key considerations:

• The starting point for all interventions should be to encourage the person to do things for themselves. Where this fails in the first instance, the approach should be revisited regularly throughout the intervention and consideration given to the reasons for this failing.                                                                                                                                                                       
• Efforts should be made to build and maintain supportive relationships through which services can in time be negotiated. This involves a person centred approach that listens to the person’s views of their circumstances and seeks informed consent where possible before any intervention.                                                                                                                              
• It is important to note that a gradual approach to gaining improvements in a person’s health, wellbeing and home conditions is more likely to be successful than an attempt to achieve substantial change all of a sudden. This may be too much for the person to accept or tolerate.                                                                                                                                                                                   

• Creativity is key to all interventions involving self-neglect; this involves:

  o    Flexibility (to fit individual circumstances)
  o    Negotiation (of what the individual might accept / cope with / tolerate)
  o    Proportionality (to act only to contain risk, rather than to remove it altogether, in a way that preserves autonomy

• Sometimes this involves understanding and recognising the limitations of what is possible, with practitioners need to focus on reducing harm in the first instance rather than achieving the ideal outcome.                                                                                                                                                           
• Interventions will need to be unique to the situation, but might involve:                                                                    
  o    Being there, for example
  o    Maintaining contact; building relationships
  o    Monitoring risk and wellbeing
  o    Identifying opportunities and motivations

Practical assistance, for example

• Help to support with daily living activities e.g. safe food storage or preparation areas; that improve wellbeing and reduce risks whilst providing opportunities to build up trust
• Assistance and support look after the welfare of pets

Risk reduction, for example

• Fire safety measures – addressing immediate risks, including those caused by smoking in unsafe environments.
• Responses to immediate health risks e.g. preventative actions relating to deteriorating health conditions, such as skin integrity, diabetes and or safe use of medication.  Adaptations and repairs to the home that make the accommodation more habitable, safer and help build trust.
• Safe substance use schemes (support for a set level of consumption)

Therapeutic interventions, for example

• Support with specific mental health conditions or support to change the way in which an individual might think about themselves

Change of environment, for example

• Moving home (together with support to minimise the risk of future
  environments deteriorating)
• Short-term respite

Building social networks and interests, for example

• Building upon the person’s interests, including any that led to self-neglect
• Reducing social isolation
• A forward-looking focus on lifestyle, companionship and activities (helping to let go of / replace previous lifestyles).

Cleaning / clearing, for example

• Deep cleaning or removal of hoarded material (although often this is found to work best when done in agreement and as part of an overall planned intervention). Sometimes a partial reduction will be more easily achievable – the aim is proportionate risk-reduction.

Health matters, for example

• Assistance with specific health conditions; GP / medical appointments

Enforced action, for example

• Setting boundaries on risks to self and others
• Recognising and working with the possibility of enforcement action

Care and support, for example

• As self-neglect can often be linked to poor physical functioning a key intervention can be assistance with activities of daily living. For example:

  o Support with bills and paperwork – often along with the identification of benefits that can be applied for
  o Negotiations around assistance with cleaning, laundry, medication management and personal care
  o Prompting around daily living tasks.

• Agencies will need to work with people to offer support in ways the person feels able to accept

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Mental capacity is a key factor in understanding people’s circumstances and how they
respond in practice. That is:

• When a person is presumed to have mental capacity or has been assessed as having capacity, their autonomy must be respected, and efforts should be directed to building and maintaining supportive relationships through which services can in time be negotiated if required.                                                                  
• When a person has been assessed not to have capacity to understand and make specific choices and decisions, interventions and services can be provided in the person’s best interests.

The information provided here cannot act as a full guide to best practice in relation to issues of mental capacity, but serves to highlight some important areas of consideration when working with people who self neglect.

The Mental Capacity Act principles

All work with people who self-neglect must be undertaken with due regard to the Mental Capacity Act 200513, which is underpinned by five clear principles. It can be helpful to consider the principles in order. The first three principles support the process before or at the point of determining whether someone lacks capacity. If it is decided that someone lacks capacity in relation to a specific decision, then the last two principles inform the decision-making process.

1. A person must be assumed to have capacity unless it is established that he lacks capacity.
2. A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success.
3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision.
4. An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.
5. Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action.

Assessing mental capacity

The Act sets out a two stage test mental capacity for whether someone lacks mental capacity to make a specific decision, at the time it needs to be made.

Section 2 of the Act states that a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain

Section 3 of the Act clarifies that for the purposes of section 2, a person is unable to make a decision for himself if he is unable —

• to understand the information relevant to the decision
• to retain that information (for as long as required to make the decision).
• to use or weigh that information as part of the process of making the decision, or
• to communicate their decision (whether by talking, using sign language or any other means)

Thus it is important to assessment whether any inability in understanding, retaining, using or weighing relevant information, or in communicating the decisions, results from an impairment or disturbance in the functioning of the mind or brain.

Furthermore mental capacity is time- and decision- specific. This means that a person may be able to make some decisions but not others. A person’s mental capacity to make a decision may also fluctuate over time. It is also important to be aware however, that when assessing mental capacity people can be initially articulate and superficially convincing regarding their decision making but as issues are explored, may actually be unable to identify risks or understand how these could be addressed.

The Mental Capacity Act; Code of Practice should be referred to for further guidance.

Executive functioning

The term, ‘executive functioning’ refers to the ability to carry out decisions and intentions, for example in relation to one’s own welfare. Where tasks involve several steps or decisions a person may have difficulties carrying these out if the person’s mental processes involved are affected, for example, by brain injury or illness. This is commonly called ‘executive dysfunction’.

Executive dysfunction may be evident when a person give coherent answers to questions, but it is clear from their actions that they are unable to carry into effect the intentions expressed in those answers. It may also be that there is evidence that the person cannot bring to mind relevant information at the point when they might need to implement a decision that they have considered in the abstract16
.
This will be relevant to assessments of mental capacity; as it raises the question as to whether someone can ‘understand’ and ‘use or weigh relevant information’ in the moment when a decision needs to be enacted. 

For these reasons, assessments of capacity may need to be supplemented by real world observation of the person's functioning and decision-making ability in order to provide the assessor with a complete picture of an individual's decision-making ability.

It can also helpful to not only ask the person to articulate what they would do, but to demonstrate how they would do something in practice. Where a person is unable to carry out their expressed intentions, a key question in the mental capacity assessment is whether the person is aware of their own deficits – in
other words, whether they are able to use and weigh (or understand) the fact that there is a mismatch between their ability to respond to questions in the abstract and to act when faced by concrete situations

This is complex area and practitioners should seek advice from their lead practitioners, and legal advisers as and when required.

Best Interests Decision

For adults who have been assessed as lacking the mental capacity to make specific decisions about their health and welfare, the Mental Capacity Act 2005 allows for agency intervention in the person’s best interests. Chapter 5 of Mental Capacity Act:

Code of Practice sets out a non-exhaustive list of consideration for such decisions. In urgent cases, where there is a view that an adult lacks mental capacity (and this has not yet been satisfactorily assessed and concluded), and the home situation requires urgent intervention, the Court of Protection can make an interim order and allow intervention to take place.

Court of Protection

Where an individual without mental capacity, resolutely refuses to any intervention, will not accept any amount of persuasion, and the use of restrictive methods not permitted under the Mental Capacity Act are anticipated, it may be necessary to apply to the Court of Protection for an order authorising such protective measures. Legal advice should be sought where such actions and interventions are being considered.

The Court of Protection deals with decisions and orders affecting people who lack mental capacity. The court can make major decisions about health and welfare, as well as property and financial affairs, that the person lacks the mental capacity to make (Mental Capacity Act 2005; Sections 15-23).

Fluctuating capacity

Fluctuating capacity is when a person’s ability to make a specific decision changes frequently or occasionally. Such changes could be brought on by the impact of a mental illness, physical illness, the use or withdrawal of medication, the use of illicit substances or alcohol. 

Where an adult has fluctuating capacity, it may be possible to support them to appoint a lasting power of attorney or produce an advanced statement that sets out what they want to happen when they lack capacity in the future.

Unwise decisions

Circumstances of self-neglect will often involve decisions, including those to take actions, or not take actions or decline support that others consider unwise. However a person is not to be treated as unable to make a decision merely because he makes an unwise decision. This applies even if family members, friends or healthcare or social care staff are unhappy with a decision.

There may be cause for concern however, if somebody repeatedly makes unwise decisions that put them at significant risk of harm or exploitation or makes a particular unwise decision that is obviously irrational or out of character. These things may not necessarily mean that someone lacks capacity but there might be need for further investigation, taking into account the person’s past decisions and choices.

For example, further investigation may reveal whether a person may need more information to help them understand the options available to them or the consequences of the decision they are making; or whether the person has a mental disorder or illness that is impacting on their decision. 

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Self-neglect involves situations where a person places themselves at risk due to difficulties providing for their own health and care needs, and a reluctance or refusal to accept support. The impact or consequences of these decisions however, may sometimes also place others at risk and hence there may be a need to take actions, to ensure the rights and safety of others are also protected.

For example;

A person living in circumstances of squalor could result in an environmental health risk to neighbours, as well as themselves. In such cases, Leeds City Council Environmental Health Services, alongside other key agencies such as housing, should be included in multi-agency planning meetings. There may be actions required to protect others that are contrary to the person’s own wishes.

• A person’s hoarding behaviour may result in a fire hazard to neighbours, as well as themselves. In such cases, West Yorkshire Fire and Rescue Service should be included in multi-agency planning meetings to advise on appropriate responses, and actions may be required in the public interest.
   
• A person’s self-neglect behaviour may pose a risk to a young child living in their direct care. In such cases, Leeds Children’s Services should be alerted immediately and subsequently included within multi-agency planning meetings.

Similarly, where living conditions impact on the safety and welfare of another adult with care and support needs being cared for within a household, Leeds City Council: Adults & Health should be consulted on the need to follow the Safeguarding Adults Procedures.

Article 8 of the Human Rights Act allows for someone’s right to his private and family life, his home and correspondence to be restricted, circumstances such as where necessary to protect public safety, health, or for the protection of rights and freedoms of others.

Where a person poses a risk to others, it remains important to work with them as far as possible to support them to bring about change in their circumstances. However, actions may be necessary that are contrary to their wishes, including the enforcement actions of agencies to protect the safety of others. Practitioners should seek to explain to the person why the actions have had to be taken and talk through the implications for the person concerned. 

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Situations of self-neglect will usually require agencies to work together in order to have shared understanding of issues, risks, concerns and to develop a consistent approach to working with the person at risk.

A formalised multi-agency meeting may not always be necessary or pragmatic, and depending on the circumstances, this may be achieved by close liaison between agencies. Where a meeting is not held, the guidance below will however remain relevant to the approach developed.

In complex circumstances it will however be necessary to bring together a range of agencies who can bring their collective knowledge, skills and resources to assess the risk and offer/provide effective interventions, in the way the person is most likely to feel able to accept.

A multi-disciplinary meeting provides an opportunity to:

• Recognise and understand the person at risk’s views and wishes, their assessment of their circumstances, and what outcomes they would like to achieve, if any
• Share information about issues and concerns, to form a shared understanding
• Seek to understand the underlying reasons for the self-neglecting behaviour
• Consider issues of mental capacity
• Consider how best to engage with the person at risk
• Develop a multi-agency assessment of risk and risk management plan
• Establish a multi-agency risk management plan
• Ensure there is clarity about who is monitoring and updating on any identified risks
• Consider the need for further meetings to review plans and risks
• Provide / plan how to provide mutual support to agencies, relatives and unpaid carers
• Continually evaluate the need for legal advice
• Develop a multi-agency approach informed by the Practice Principles identified in Sections 5.1 -5.7.
   

Important to this will be:

• Ensuring the adult at risk is invited to meetings or if this is not possible, or considered appropriate, ensure they are consulted and that their views and wishes are represented and are a focus of discussion within the meeting
• Ensuring advocacy representation is provided for where necessary to facilitate the person’s involvement
• Providing for people’s need for support with communication, such as translation services
• that the views of family members are considered as appropriate that all agencies that have been involved with the adult at risk, or may need to be, are consulted / invited to the meeting

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Key points:

1. Practitioners should always work to engage with people, offer all the support they are able to without causing distress, and understand their limits to intervention if the person does not wish to engage.

2. Where someone is assessed as not having capacity in relation to relevant decisions, actions should be taken in the persons best interests, in accordance with the Mental Capacity Act 2005.

3. Where mental capacity is presumed or has been assessed as being present, and the person is expressing that they do not wish to engage with services, any actions taken should be proportionate to the risk and with due consideration of Article 8 of the Human Rights Act.

Where a person is declining support assessed to be essential to their health or wellbeing, then further actions may still be appropriate to assess risk, offer support and support their engagement. However, in each case practitioners must weigh up whether their actions are proportionate to the risks, and no more intrusive than is necessary to achieve a legitimate aim.

‘Talk to me, Hear my voice’ is the citizen-led practice principle adopted in Leeds. This is a phrase given to us by citizen groups, and is a short-hand term for working alongside someone to understand the person’s views, wishes, circumstances and desired outcomes. It is not always the case however, that people say, ‘Talk to me’. Sometimes they will say ‘I don’t want your help’, or simply ‘go away’ instead. This can be the biggest challenge for practitioners when working with adults who have self-neglecting behaviours as they may refuse to engage or accept support.

The Leeds ‘Talk to me, Hear my voice’ principle is one of trying get alongside and work with people, and this includes seeking to understand why the person is reluctant or unwilling to seek or accept support. Practitioners should seek to engage with people who are self-neglect with due consideration of the best practice principles set out in Section 4.

Before disengaging with a person declining support or services:

• Consider if the person has been provided with all the necessary information in a format they can understand
• Assess the risk as far as is possible given the person’s limited engagement - Be open and honest; share concerns about these risks with the person self-neglecting
• Check as far as possible, if the person has understood the options and the consequences of their choices
• Listen to and show understanding of the person’s reasons for mistrust, disengagement, refusal and their choices and consider if there are ways to provide support in the way the person feels able to accept
• Where the person is willing, ensure there is the time to have conversations over a period of time to develop a trusting relationship
• Check out your concerns with other relevant agencies in accordance with the Safeguarding Adults Board: LSAB Information Sharing Policy
• Consider who (whether family, advocate, other professional) can support engagement with the person at risk. You may not be the best person.
• Formally assess a person’s mental capacity if there is evidence to indicate this is lacking in relation to these specific decisions.
• Formally record decisions, actions, attempts to engage and peoples responses.

However, where there significant threat to the person’s health and wellbeing, practitioners and services should seek to provide continued support and take further actions in accordance with this policy.

• Where there is limited or partial engagement and risks are low, seek to provide continued engagement and support in to help the person to identify and overcome barriers they may experience in accepting support, as set out in Section 6.2.
• Where there is a significant threat to the persons health and wellbeing, consider whether a multi-agency meeting is needed to understand the issues, concerns, and assess and respond to the risks, as set out in Section 6.3.
• In circumstances where the person appears to be unable to protect themselves from the self-neglect they are experiencing; concerns should be reported in line with multi-agency safeguarding adults policy and procedures (Section 6.4)

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In some circumstances, a person may only periodically or partially engage with services, but the impact on their health and wellbeing is low. Although individual circumstances, would need to be considered, low impact, may be illustrated by examples such as:

• Health care and attendance at appointments is intermittent 
• There is a minor impact on the person’s wellbeing
• Personal hygiene is becoming an issue
• The person does not engage with social or community activities and this is having an impact on the health and wellbeing of the individual
• The person does not manage daily living activities
• Hygiene is poor and causing skin problems
• Aids and adaptations refused or not accessed

Incidents such as these are usually best managed by positive engagement with the person using the key practice principles set out in this policy. This may involve supporting the person to address their concern, engage with community activities, or access social care services, health care and counselling.

There may need to be good communication and a level of coordination across different agencies involved with the person, in order to have a consistent approach but this will be consistent with usual agency assessment and support roles. Agencies currently involved should aim to work with the person over time to understand their
concerns and to support their engagement with appropriate services.

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Where there are significant concerns that a person with capacity or who lacks capacity is self-neglecting, to an that this poses a significant threat to their health and wellbeing, concerns should be reported to Leeds City Council: Adults & Health.

Where it appears the adult has needs for care and support; the local authority must carry out an assessment of eligible care and support needs, under Section 9 (and Section 11) of the Care Act.

Where it is established via this assessment and/or other agency assessments, that the person has care and support needs and finds it difficult or is reluctant to accept essential services which threaten their health and wellbeing, the local authority will need to consider whether to initiate a multi-agency meeting/discussion to assess and respond to the concerns.

Such decision-making should take into consideration issues of mental capacity to make decisions, risk and the person’s wishes. Actions taken should be proportionate to the concerns. Multi-agency responses as determined by the local authority, dependent on the circumstances, may take the form of:

1. Multi-agency meeting/discussion lead by LCC: Adults & Health within their care management function
2. Multi-agency meeting chaired by a partner agency. This may be more appropriate, for example, where the person at risk has mainly health needs.
3. Multi-agency safeguarding adults policy and procedures where the criteria set out in Section 6.4 is met.

All agencies would be expected to support such meeting/discussions consistent with the Care Act: Duty to Cooperate, in the exercise of respective functions relating to adults with needs for care and support and carers.

Multi-agency responses should be undertaken with due consideration of the best practice principles set out in Section 5.7 in relation to multi-agency meetings. The format for such meetings, templates and agendas used however, will those of the lead agency. 

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The multi-agency safeguarding adults policies and procedures should be followed in specific circumstances, where there is reasonable cause to suspect that the person is unable to protect themselves from the self-neglect.

The Care Act 2014 states:

Section 42.1 Where a local authority has reasonable cause to suspect that an adult in its area (whether or not ordinarily resident there)-

• has needs for care and support
• is experiencing, or is at risk of, [self-neglect], and
• as a result of those needs is unable to protect himself or herself against the
  [self-neglect] or the risk of it.

Section 42.2 The local authority must make (or cause to be made) whatever enquiries it thinks necessary to enable it to decide whether any action should be taken in the adult’s case (whether under this Part or otherwise) and, if so, what and by whom.

The Care and Support Statutory guidance further states:

“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” 21

Practitioners will need to consider this provision, as to whether someone is able to control their own behaviour, based upon the unique circumstances of each person. It should also be noted that self-neglect may occur alongside abuse and neglect caused by another party, for example, where self-neglect occurs alongside neglect by a carer; or the person is experiencing coercion and control or other forms of domestic abuse, that prevent the person from accessing support and services they would otherwise wish to accept. These situations would further indicate the need to follow the multi-agency safeguarding adults procedures as opposed to other multiagency responses.

Safeguarding adults relating to abuse, neglect or self-neglect should be reported to the Leeds City Council: Adults Social Care: 0113 222 4401

The Leeds Multi-Agency Safeguarding Adults Policy and Procedures set out subsequent processes to be followed. The following summary describes key elements of the approach.

Wider duties and responsibilities of organisations, such as in relation to needs assessments under Section 9 (and Section 11) may also be indicated. These should be incorporated within the multi-agency response safeguarding procedures. These

1. Information gathering

The local authority will lead a process of information gathering, to establish the cause for concern (that is, whether Section 42.1 above is met) and the need for further actions:

This will involve:

• Gathering information from key partners, the individual and their relatives/informal carers
• Establish persons views and desired outcomes
• Involvement of representation/independent advocacy

At this point, the local authority may be satisfied that a different level of response is appropriate, as for example, set out 6.1 – 6.3. However, where they are satisfied that Section 42.1 is met, they will undertake enquiries to determine the appropriate response.

The local authority should also consider if its duty to undertake a needs assessment
under Section 9 (or Section 11) is met at this stage and subsequent ones.

2. Planning meeting / discussion

Planning a response will involve a planning meeting/discussion with key agencies, and where possible the person at risk and their representatives to consider appropriate responses.

This could be a specific meeting; but it may also be a discussion as to the need for arrangements relating to a multi-agency risk management meeting and how this should be managed.

3. Multi-agency risk management meeting

In circumstances of self-neglect, a multi-agency discussion/meeting must be convened to coordinate any support or intervention. Or indeed, to agree no further intervention where that is indicated by the assessment and specific circumstances.

The Risk Assessment & Management Meeting Agenda and Template should be used to assess risk and plan responses. The key principles (Sections 4) should be used to inform discussions and plan appropriate interventions. All relevant agencies have an obligation to participate and support the development
of a multi-agency approach to the concerns. Such meetings may be chaired by the local authority; however, where it is more appropriate another agency may be asked to do so22, for example, where they have relevant expertise or are in practice leading on the response. 

In cases of self-neglect more than one multi-agency risk management meeting may be required to assess concerns, engage with the person at risk, and to re-evaluate the risk or approach.

4. Outcome Meeting/Discussion

In situations of self-neglect, an outcomes meeting / discussion provides the forum to review actions taken, reassess risk, identify learning and whether the desired outcomes of the person have or can be achieved.
In practice, where a Multi-Agency Risk Management Meeting has been held, a further meeting may not always be required, providing that outcomes have been reviewed during the meeting.

However, where a relevant party is not present, in particular, the person at risk, their representative, or their relative / unpaid carer, then a further outcomes discussion/meeting would be appropriate to ensure outcomes and the need for further actions are agreed

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