There is no single operational definition of self-neglect however, the Care Act makes clear it comes within the statutory definition of abuse or neglect, if the individual concerned has care and support needs and is unable to protect him or herself. The Department of Health defines it as, ‘a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding’.
The Department of Health commissioned the universities of Sussex and Bedford to undertake research into interventions with those that self-neglect . This demonstrates how staff can assist individuals to achieve positive outcomes.
Skills for Care provided a framework for research into self-neglect identifying three distinct areas that are characteristic of self-neglect:
- Lack of self-care - this includes neglect of one’s personal hygiene, nutrition and hydration, or health, to an extent that may endanger safety or well-being;
- Lack of care of one’s environment - this includes situations that may lead to domestic squalor or elevated levels of risk in the domestic environment (e.g. health or fire risks caused by hoarding);
- Refusal of assistance that might alleviate these issues. This might include, for example, refusal of care services in either their home or a care environment or of health assessments or interventions, even if previously agreed, which could potentially improve self-care or care of one’s environment.
Self-neglect is a behavioural condition in which an individual neglects to attend to their basic needs such as personal hygiene, or tending appropriately to any medical conditions, or keeping their environment safe to carry out what is seen as usual activities of daily living. It can occur as a result of mental health issues, personality disorders, substance abuse, dementia, advancing age, social isolation, and cognitive impairment or through personal choice. It can be triggered by trauma and significant life events. Self-neglect is an issue that affects people from all backgrounds.
Hoarding does not fall under adult safeguarding but might be considered as safeguarding in the wider sense under the umbrella of prevention which is in the remit of the Safeguarding Adults Board. Most people associate hoarding with 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.
Compulsive hoarding (more accurately described as ‘hoarding disorder’) is a pattern of behaviour characterised by 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. Hoarding can include new items that are purchased e.g. food items, refuse and animals. 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.
Compulsive hoarding behaviour has been associated with health risks, impaired functioning, economic burden, and adverse effects on friends and family members. When clinically significant enough to impair functioning, hoarding can prevent typical uses of space, enough so that it can limit activities such as cooking, cleaning, moving through the house and sleeping. It could also potentially put the adult and others at risk of causing fires.
The Clutter Index Rating (CIR) is a rising pictorial scale of nine equidistant photos showing clutter in three rooms – living room, bedroom and kitchen. It is an internationally recognised assessment tool produced by the International OCD Association – Hoarding Center, and used by psychologists working with people who hoard and commonly used by the health and social care sector in the UK. This can be accessed via the following link Clutter Index Rating.
2.6.2 Environmental Health Service (EHS)
The EHS has 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. These powers do not rely on a presumption that the individual affected by such intervention lacks mental capacity. It is anticipated that EHS will have a crucial role as a frontline service in raising concerns and early identification. In addition, where properties are verminous or pose a statutory nuisance, EHS 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 pose a threat only to their own welfare the powers available to the EHS may have limited or no effect. In cases involving persistent hoarders the powers may only temporarily address and/or contain the problem. It must therefore be recognised that utilising powers under public health legislation in isolation may not be the most effective use of resources, particularly where a coordinated approach might provide immediate safeguards for the adult and others affected by the situation, and promote a long term solution. The Chartered Institute of Environmental Health have produced guidance for Environmental Health staff, Hoarding and how to approach it.
2.6.3 Response 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 staff working with the person at risk 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.
Crucial to all decision making is a robust risk assessment, preferably multi-agency, that includes the views of the adult and their personal network. The risk assessment might cover:
- Capacity and consent;
- Indications of mental health issues;
- The level of risk to the person's physical health;
- The level of risk to their overall wellbeing;
- Effects on other people’s health and wellbeing;
- Serious risk of fire;
- Serious environmental risk e.g. destruction or partial destruction of accommodation.
A significant element of self-neglect and hoarding is the risk that these behaviours pose to others. This might include members of the public, family members or professionals. Partnerships may wish to invest in agreeing local procedures with the involvement of carers and the adult.