2.8 Self-neglect, hoarding and risk management policy guidance

Self-neglect policy guidance

1. Introduction

There is a balance to be struck by those providing support, care and interventions, of an adult’s right to self-determination, with the duty to safeguard adults at risk. This guidance developed using current legislation and guidance has been written to provide a clear pathway for agencies to follow in response to adults at risk of self-neglect.

Adults may make lifestyle choices that are perceived by others to not be in their best interest or unwise; fundamental freedoms exist so that people are able to live their lives without interference unless it is necessary and proportionate to do so. However it may be necessary and legitimate in safeguarding where required for safety of individuals or others, or where the person lacks mental capacity for a decision as to what is in their best interest.

2. Care Act 2014 and Self-Neglect

The Care Act and Making Safeguarding Personal set out guiding principles to consider when applying this policy to individuals who may self-neglect::

1. Beginning with the assumption that the individual is best placed to judge their wellbeing
2. The individuals view, wishes, feelings and belief
3. Preventing or delaying development of needs for care and support and reducing needs that exist
4. Need to protect people from abuse and neglect
5. Any restrictions on the individuals rights or freedom or action that is involved in the exercise of the function is kept to a minimum
6. Importance of individuals participation as fully as possible in decisions about them.

In brief, self-neglect has been defined by the Department of Health (2014) as “…a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding”.

Braye et al, 2011 - 2013, self-neglect centres on:

• Lack of self-care, neglect of personal hygiene, nutrition, hydration, and health
• Lack of care of one’s environment i.e. unsanitary, hoarding
• Refusal of services that would mitigate risk of harm to safety and wellbeing

Self-neglect differs from other safeguarding concerns as there is no perpetrators of abuse, however abuse cannot be ruled out as a purpose for becoming self-neglecting; part of the Care Act requirements are to address what has caused the self-neglect. .

Often associated with self-neglect, hoarding can be described as collecting and being unable to discard excessive quantities of possessions or objects. Please refer to the Hoarding Policy Guidance.

3. Principles

There are a number of principles which underpin this guidance:

1. Adults can make lifestyle choices contrary to what is perceived to be common sense. Attempts to intervene must be proportionate and reasonable
2. Partnership approach should be used in cases where appropriate to enable powers and abilities of difference organisations to be implemented
3. Emergency responses will still require immediate contact with fire, police or ambulance service
4. A multi-agency Risk Management Meeting to discuss concerns, with the involvement of the adult at risk, should be a starting point. Organisation’s remain responsible for their role in supporting adult at risk to address the concerns
5. Doing nothing and/or closing a case before risk has been reduced to an acceptable level with actions to minimise harm and repeat occurrences is not an option; this exposes the adult at risk to ongoing or increased harm and organisations to a failing in their duty.

Self neglect is a complex area; it requires confidence, persistence and resilience. This includes a willingness to engage in practical but unpleasant tasks at times, sometimes assertive outreach, sometimes to ask what has been described as ‘care-frontational questions’. Therefore greater account should be taken in the allocation of such work of practitioners’ special interests and skills. Moreover the work can prove emotional, challenging, anxiety-provoking and frustrating. This requires recognition and containment so supervision, which includes checking out the practitioner’s own emotional and physical wellbeing, and health and safety, is essential. It enables practitioners to reflect, to talk through cases and the dilemmas they present, and to explore possible innovative ways to engage and practise. The support of team and multi-agency colleagues is therefore critical too, for sharing ideas and debriefing.

4. Mental Capacity

Adults should be presumed to have capacity; there may be cases where a person may lack understanding and insight into the impact of their actions / inactions on their or other’s wellbeing. When an individual’s behaviour or circumstances cast doubt as to whether they have capacity to make a decision, then a capacity assessment should be carried out in line with the Mental Capacity Act (MCA) 2005. Professionals must act in accordance with the MCA and the overriding principle that every action is carried out in the best interest of the person concerned, including regard to what are believed to be the person’s wishes and feelings.

Braye at al. (2011) note in ‘Self-Neglect and Adult Safeguarding: Findings from Research’ that mental capacity affects perception of risk and intervention focus. Mental capacity involves not only weighing up information and being able to understand consequences of decisions and actions, but also the ability to implement those actions. For those who self-neglect and lack mental capacity for the particular decision, the intervention focus will be to reduce risk through a best interest decision.

Any capacity assessment in relation to self-neglect or hoarding behaviour must be time specific and relate to a specific intervention or action. They should be appropriately recorded. Best interest decisions should be taken formally with the person, the professionals involved and anyone with an interest in the person’s welfare, such as members of the family. The Mental Capacity Act provides that taking of those steps needed to remove the risks and provide care will not be unlawful, provided that the taking of them does not involving using any methods of restriction that would deprive that person of their liberty. In particularly challenging circumstances it may be necessary to refer to the Court of Protection to make the best interest decision. Any referral to the Court of Protection should be discussed with legal services and service management.

5. Responses to Concerns about Self Neglect

People may be successfully supported under usual case management or single / multi-agency support, using the principles of adult safeguarding in its broader terms. Where the risk to the safety and wellbeing of an adult or others are becoming more critical, a more formal adult safeguarding approach will be required.

5.1 Engaging with the adult at risk

Regardless of what organisational process or pathway is used to work with an adult at risk who is self-neglecting, the starting point will always be engaging with the individual. Positive outcomes can be achieved through operational approaches informed by an understanding of the unique experience of each individual balanced with strategic and management input.

In engaging with the adult consider whether:

• They have the necessary information in a format they can understand
• Check whether they understand options and consequences of their choices
• Listen to their reasons for mistrust, disengagement, declining support  and their choices
• There is the time to have conversations over a period and building up of a relationship
• Consider whom (whether family, advocate, other professional) can support you to engage with the adult
• Always involve solicitors, receivers, Court of Protection appointed deputies or representatives if the adult has one
• Determine if plan for agreed actions / outcome for person who has fluctuating capacity is in place during a time when they had capacity for that decision
• Person to attend meetings where possible

The family member or carer of an adult at risk should be engaged where the adult at risk has provided consent. This will include being part of planning, decision making and whether they are willing and able to provide support. There are duties under the Care Act for carers and in relation to Carers Assessments.

5.2 Managing single agency or multi-agency outside of safeguarding

Self-neglect concerns can be managed outside of adult safeguarding procedures; professional judgement is needed to consider the level of risk, how this is being managed, the capacity of the adult at risk, and any other person / child affected.

This could potentially be address through mechanisms such as engagement with and support the person to address their concern, engagement with community activities, or access to health care and counselling.

Professional judgement is key, any factor or issue may move a low risk situation into a higher threshold which would warrant consideration under adult safeguarding.

5.3 Referrals under adult safeguarding policy

The Plymouth Multi Agency Adult Safeguarding Policy & Procedures should be used to inform the process for raising an adult safeguarding concern and the response. Referrals can consider concerns with respect to the welfare of the person; state of the property and effect on their own health / property; concerns for children at the property and or concerns for animals at the property. Also assist with:

• Identifying with the adult at risk their wishes, views, beliefs and the outcome they want to achieve;
• Discussions and assessments around capacity and best interest decisions;
• Multi-agency sharing of information to address the risk assessment and risk management plan;
• Looking at what may be contributing to the behaviour and working to address this from a preventative framework.

Any concerns with respect to children, and the potential for harm or neglect, should be referred to children’s services.

If an adult at risk declines an assessment, services or support, a risk assessment under safeguarding must be carried out by the local authority or the organisation that has been caused to undertake the enquiry, to determine the level of seriousness of each identified risk.

Intervention must be person centred, involving the individual as far as possible in understanding the risk assessment and the alternatives for managing the risk. Information should be shared with other relevant professionals who may have a contribution to make in managing or monitoring the risks.

Consideration must be given to the mental capacity of the individual and whether they require support in their decision making or, following an assessment that the individual lacks capacity, whether a best interest decision might be appropriate.

There are a number of mechanisms for managing self neglect and hoarding within adult safeguarding, which are set out below.

5.3.1 Risk Management Meetings (RMM)

The Risk Management meetings, whether single or multi agency may be successful in identifying and managing risk in a range of concerns, developing and coordinating a risk management action plan. This approach should be explored in the first instance where appropriate.

5.3.2 Creative Solutions Forum

The Creative Solutions Forum has developed from the need to establish a way to support individuals, staff and agencies to understand and manage risk fluidly.

The Forum supports partners to consider creative options for people with highly complex needs and presentations that require a multi-agency response and where other single or multi-agency processes have been exhausted. Typically this will include people experiencing multiple disadvantage, including substance use, serious physical health or psychiatric co-morbidities, complex PTSD, housing issues, people who are self-neglecting and people presenting high levels of risk to themselves and the community. It may also include people that are on an end of life pathway.

It is the aim of Forum for tailored packages of care to be created for the person. This will be a bespoke offer to meet their needs, which could include alternative care options, out of hour’s activities, whole family therapeutic or behavioural support, support in the home and parent/carer support and planned inpatient services.

The Creative Solutions Forum (CSF) will also seek to identify gaps in provision to meet need which may be used to inform commissioning plans.

The forum should not be used as a common risk management tool and replace existing risk management processes. The process may be applied when there are high level concerns from partner agencies and all interventions and safeguarding actions have been unsuccessful in achieving a positive, safe outcome.

A referral under adult safeguarding does not have to precede a referral to the Creative Solutions Forum by a partner agency.

For further information please email creativesolutionsfor@plymouth.gov.uk.

5.3.3 Interventions under Care Act Section 42 Enquiries

Section 42 enquiries provide an opportunity to work with the adult at risk to obtain the outcome they have identified, while addressing areas of risk through the safeguarding plan.

Section 42 enquiries in relation to self-neglect and hoarding can include, but are not limited to:

• Any enquiry into abuse and neglect that may have contributed to or precipitated the self-neglecting behaviour or hoarding;
• Therapeutic responses, such as access to mental health, drug and alcohol services, bereavement services;
• Brief interventions, particularly those that work to enable changes in attitude or behaviour and to handle underlying issues.

Making Safeguarding Personal toolkit has a range of options available. In addition, Braye et al. (2005) suggested the following intervention options can be applied:

5.3.4 Legal processes

Legal processes can be implemented via single agency and not under adult safeguarding procedures. Where a person lacks capacity (refer to section 4) to undertake a specific decision or they have capacity but there is significant level of risk, legal processes can be considered under the adult safeguarding procedures.

Legal processes are used to compel an individual to remove risk and or permit service access. This is again where there is a very fine balance between the rights of the individuals and the rights of others who have be affected by the behaviour, particularly in cases of hoarding. However using legal processes should be carefully considered as actions can increase the trauma the person has already experienced in their life. This increased trauma can escalate the rate of self-neglect and hoarding.

In brief some of the legal options may include:

1. Public Health Act 1936, Section 79: Power to require removal of noxious matter by occupier of premises;
2. Public Health Act 1936, Section 83: Cleansing of filthy or verminous premises;
3. Public Health Act 1936, Section 84: Cleansing or destruction of filthy or verminous articles;
4. Prevention of Damage by Pests Act 1949, Section 4: Power of LA to require action to prevent or treat rats and mice;
5. Environmental Protection Act 1990, Section 80: Dealing with statutory nuisances;
6. Mental Health Act 1983, Section 2 & 3: for health and safety and protection of others;
7. Mental Health Act 1983, Section 135: removal of person to place of safety for assessment to take place.

There are additional powers through housing, such as the Town and Country Planning Act and the Housing Act 2004, in which orders for repairs or enforcement action for hazards exist in any building or land posing a risk.

It is important to know when we can/may act (have the power to do so) and where we shall/must act (have a duty to do so). The first step will always be to try to gain the consent of the person being affected and to accept the necessary services to meet their needs.

Gaining access to an adult suspected to be at risk of neglect or abuse, please refer to the following SCIE guidance: Gaining access to an adult suspected to be at risk of neglect or abuse: a guide for social workers and their managers in England.

6. Responses to declining support

The most frequent concern raised by professionals when working with adults who may self-neglect, is the challenge when the person declines to engage or accept support or services.  

Self-neglect needs to be understood in the context of each individual’s life experience; there is no one overarching explanatory model for why people self-neglect or hoard. It is a complex interplay of association with physical, mental, social, personal and environmental factors. A starting point is in trying to understand why the person is disengaging, may mistrust the service and their history.

Braye et al. (2005) display the difficulty due to the changing response and engagement by the adult at risk in the following:

Actions which can help to get engagement in self-neglect are suggested by Braye et al. (2015) as:

It is important to consider in multi-agency partnership settings whom may be best placed to work with the person who is not engaging and can build the most links to resolving the concerns.

If a person has capacity, is declining engagement and there remains ongoing significant harm to a person’s health, safety or wellbeing then a Risk Management meeting should be convened to ensure all available options, powers and duties are exhausted. Again, this needs to be balanced, proportionate and take into account a person’s right to self-determination. If a person lacks capacity the need for Court of Protection involvement should be considered.

References

MCA references

Braye, S., Orr, D. and Preston-Shoot, M. (2014).
Self-Neglect Policy & Practice: Building an Evidence Base for Adult Social Care. London: SCIE.

Braye, S., Orr, D. and Preston-Shoot, M. (2015). ‘Learning lessons about self-neglect? An analysis of serious case reviews.’ Journal of Adult Protection. 17, 1, 3-18.

Making Safeguarding Personal Toolkit on the Local Government Association (LGA) website

Hoarding policy guidance

1. Introduction

There is a balance to be struck by those providing support, care and interventions, of an adult’s right to self-determination, with the duty to safeguard adults at risk. This guidance developed using current legislation and guidance (see appendices) has been written to provide a clear pathway for agencies to follow in response to adults at risk that are self-neglecting or hoarding.

Adults may make lifestyle choices that are perceived by others to not be in their best interest or unwise; fundamental freedoms exist so that people are able to live their lives without interference unless it is necessary and proportionate to do so. Inference may be necessary and legitimate in safeguarding where required for safety of individuals or others, or where the person lacks mental capacity for a decision as to what is in their best interest.

2. Care Act 2014

The Care Act and Making Safeguarding Personal set out guiding principles to consider when applying this policy to individuals who may self-neglect or collect possessions, characterised as hoarding:

1. Beginning with the assumption that the individual is best placed to judge their wellbeing;
2. The individuals view, wishes, feelings and belief;
3. Preventing or delaying development of needs for care and support and reducing needs that exist;
4. Need to protect people from abuse and neglect;
5. Any restrictions on the individuals rights or freedom or action that is involved in the exercise of the function is kept to a minimum;
6. Importance of individuals participation as fully as possible in decisions about them.

This guidance does not provide in depth background information on hoarding; there is a wealth of information available and links to documents at the end of this policy.

In brief, self-neglect and hoarding has been defined by the Department of Health as “… a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding.” Care Act Statutory Guidance 2014 (DH: 2016; 14.18)

According to Braye et al, 2011 - 2013, self-neglect centres on:

• Lack of self-care, neglect of personal hygiene, nutrition, hydration, and health
• Lack of care of one’s environment i.e. unsanitary, hoarding
• Refusal of services that would mitigate risk of harm to safety and wellbeing

Self-neglect and hoarding differs from other safeguarding concerns, however part of the Care Act requirements are to consider why and how support a person who may self-neglect.

Often associated with self-neglect, hoarding can be described as collecting and being unable to discard excessive quantities of possessions or objects.

Hoarding can be described where a person is collecting and being unable to discard excessive quantities of possessions or objects. Many people who hoard possessions do not have a psychiatric disorder, however, in some cases the problem may progress to become so severe that it causes significant distress and impairment. Though usually covert, hoarding can also become a concern for others health and safety, by the nature or amount of possessions accumulating within, and sometimes overflowing from, the person’s environment.

The reasons why someone begins hoarding aren't fully understood. It can be a symptom of another condition. For example, someone with mobility problems may be physically unable to clear the huge amounts of possessions they have acquired. People with learning disabilities or people developing dementia may be unable to categorise and dispose of items. Mental health problems associated with hoarding include:

• Severe depression;
• Complex Post Traumatic Stress Disorder (PTSD)
• Psychosis;
• Obsessive compulsive disorder (OCD).

In some circumstances, hoarding is a condition in itself and often associated with self-neglect.

3. Principles

There are a number of principles which underpin this guidance:

1. Adults can make lifestyle choices contrary to what is perceived to be common sense. Attempts to intervene must be proportionate and reasonable;
2. Partnership approach should be used  to enable powers and abilities of different organisations to be implemented;
3. Emergency responses will still require immediate contact with fire, police or ambulance service;
4. A multi-agency Risk Management Meeting to discuss concerns, with the involvement of the adult at risk, should be a starting point. Organisation’s remain responsible for their role in supporting adult at risk to address the concerns;
5. Doing nothing and/or closing a case before risk has been reduced to an acceptable level with actions to minimise harm and repeat occurrences is not an option; this exposes the adult at risk to ongoing or increased harm and organisations to a failing in their duty.

Hoarding is a complex area; it requires confidence, persistence and resilience. This includes a willingness to engage in practical but challenging  tasks at times, sometimes assertive outreach, sometimes to ask what has been described as ‘care-frontational questions’. Therefore greater account should be taken in the allocation of such work of practitioners’ special interests and skills. Moreover the work can prove emotional, challenging, anxiety-provoking and frustrating. This requires recognition and containment so supervision, which includes checking out the practitioner’s own emotional and physical wellbeing, and health and safety, is essential. It enables practitioners to reflect, to talk through cases and the dilemmas they present, and to explore possible innovative ways to engage and practise. The support of team and multi-agency colleagues is therefore critical too, for sharing ideas and debriefing.

4. Mental Capacity

Adults should be presumed to have capacity; there may be cases where a person may lack understanding and insight into the impact of their actions / inactions on their or other’s wellbeing. When an individual’s behaviour or circumstances cast doubt as to whether they have capacity to make a decision, then a capacity assessment should be carried out in line with the Mental Capacity Act (MCA) 2005. Professionals must act in accordance with the MCA and the overriding principle that every action is carried out in the best interest of the person concerned, including regard to what are believed to be the person’s wishes and feelings.

Braye at al. (2011) note in ‘Self-Neglect and Adult Safeguarding: Findings from Research’ that mental capacity affects perception of risk and intervention focus. Mental capacity involves not only weighing up information and being able to understand consequences of decisions and actions, but also the ability to implement those actions. For those who self-neglect and lack mental capacity for the particular decision, the intervention focus will be to reduce risk through a best interest decision.

Any capacity assessment in relation to hoarding behaviour must be time specific and relate to a specific intervention or action. They should be appropriately recorded. Best interest decisions should be taken formally with the person, the professionals involved and anyone with an interest in the person’s welfare, such as members of the family or advocate. The Mental Capacity Act provides that taking of those steps needed to remove the risks and provide care will not be unlawful, provided that the taking of them does not involving using any methods of restriction that would deprive that person of their liberty. In particularly challenging circumstances it may be necessary to refer to the Court of Protection to make the best interest decision. Any referral to the Court of Protection should be discussed with legal services and service management.

5. Responses to Concerns about Hoarding

People may be successfully supported under usual case management or single / multi-agency support, using the principles of adult safeguarding in its broader terms. Where the risk to the safety and wellbeing of an adult or others are becoming more critical, a more formal adult safeguarding approach will be required. However any enforced action is likely to increase the rate of hoarding and add to the person’s trauma. Responses to hoarding that are enforced may initially reduce the risk, but over time they become counter-productive. Enforced actions, such as deep clean or threat of eviction should only be used as a last resort.

6. Engaging the person

Regardless of what process, organisations or pathway is used to work with an adult at risk who is self-neglecting or hoarding, the starting point will always be engaging with the individual. Positive outcomes can be achieved through operational approaches informed by an understanding of the unique experience of each individual balanced with strategic and management input.

In engaging with the adult consider whether:

• They have the necessary information in a format they can understand;
• Check whether they understand options and consequences of their choices;
• Listen to their reasons for mistrust, disengagement, refusal and their choices;
• There is the time to have conversations over a period and building up of a relationship;
• Consider whom (whether family, advocate, other professional) can support you to engage with the adult;
• Always involve solicitors, receivers, Court of Protection appointed deputies or representatives if the adult has one;
• Determine if plan for agreed actions / outcome for person who has fluctuating capacity is in place during a time when they had capacity for that decision;
• Person to attend meetings where possible.

The family member or carer of an adult at risk should be engaged where the adult at risk has provided consent. This will include being part of planning, decision making and whether they are willing and able to provide support. There are duties under the Care Act for carers and in relation to Carers Assessments.

Risk assessment in cases of hoarding should take into account the Clutter Image Scale.

If an adult at risk declines an assessment, services or support, a risk assessment under safeguarding must be carried out by the local authority or the organisation that has been caused to undertake the enquiry, to determine the level of seriousness of each identified risk.

Intervention must be person centred, involving the individual as far as possible in understanding the risk assessment and the alternatives for managing the risk. Information should be shared with other relevant professionals who may have a contribution to make in managing or monitoring the risks.

Consideration must be given to the mental capacity of the individual and whether they require support in their decision making or, following an assessment that the individual lacks capacity, whether a best interest decision might be appropriate.

Risk management policy guidance

1. Introduction

There is a balance to be struck by those providing support, care and treatment on an adult’s right to self-determination with the duty to safeguard adults at risk. This guidance developed using current legislation and guidance, has been written to provide a clear pathway for agencies to follow.

Adults may make lifestyle choices that are perceived by others to not be in their best interest or unwise; fundamental freedoms exist so that people are able to live their lives without interference unless it is necessary and proportionate to do so. It may be necessary and legitimate in safeguarding, where required, to share information, without consent, for the safety of individuals or others, or where the person lacks mental capacity for a decision as to what is in their best interest.

2. Risk Management

Risk management meetings are intended as a multi-agency response to risk where the person concerned may or may not lack Capacity to make decisions about their care and safety. It provides a platform to discuss, identify and document risk for high risk concerns, formulate a safety plan identifying the appropriate agencies responsibility for actions, and provide a mechanism for review and re-evaluation of the plan.

Each agency should consider when it may be necessary and proportionate to hold a risk management meeting without the consent of the person involved. The meeting is intended to ensure that all agencies fulfil their duty of care in a robust manner as far as is reasonable given the level of risk.

Applying this process should ensure all reasonable steps are taken to ensure the person’s safety by all agencies involved. The purpose of this meeting will be for all agencies involved with the person to consider creatively how best to support the person to reduce, moderate and manage risk. It will give a formal process for recording concerns and actions to be taken by various agencies in response to the concerns.

If the person concerned lacks capacity to make decisions about their care and safety, then it would be more appropriate for discussions about risk management to be held in the framework of a Best Interest meeting.

If concerns relate to third-party abuse or neglect, or if concern arise from the person placing themselves in situations where they are at risk from abuse, then it would be more appropriate to hold a Safeguarding Strategy meeting within the Safeguarding Adults Process.

In the majority of circumstances, a health and social care assessment, or review and risk assessment procedures will be the best route to provide an appropriate intervention.  However, there are circumstances where this approach has not been able to mitigate risks that could result in significant harm, and where the person has capacity related to their care and safety, however declined support, without which their care and safety needs cannot be met.

It is a significant challenge for all agencies to balance their duty of care to protect adults at risk from self-neglect with the person’s autonomy, right to self-determination and the promotion of dignity. This challenge is most effectively addressed by a multi-disciplinary, person-centred risk management approach.

The process should not be seen as a substitute to existing legislation and guidance, including the Mental Health Act 1983, Human Rights Act 1998 and Mental Capacity Act 2005.

All agencies involved with the person should be invited. Agencies that are not yet involved may be invited on the basis that the person is in need of an assessment or support by that agency. For example, representatives from housing providers, GP or community health professionals, mental health services, environmental health teams, the voluntary and community sector, Independent Mental Capacity Advocate or other advocacy services, substance use specialist agencies.

The person and or their representative should be informed that the meeting is taking place, and be invited to attend and participate in discussions; however the meeting should proceed whether the person chooses to attend. This process will not affect an individual’s human rights but it will ensure that partner agencies exercise their duty of care in a robust manner and as far as is reasonable.

2.1 Agenda guidance:

2.1.1 Capacity

Confirm whether the person has mental capacity to make decisions relating to their care and safety including when, where and by whom the assessment was carried out. This is particularly relevant where the person has any impairment of the mind or brain that may affect their decision-making and there are concerns over whether they understand the risks and consequences of refusing support. If the assessment has not already taken place, then it should be an action from the meeting to be completed within a reasonable timescale depending on the level of risk involved.

2.1.2 Concerns / Risks

Discuss the concerns or risks which have led to the meeting including discussion of the harm which may occur as well as the likelihood and seriousness of the harm.

2.1.3 Care Plan or Other Arrangements

Discuss and critique the care plan or arrangements that are currently in place and discuss alternative options for encouraging engagement with the Adult at Risk.

For example:

• Which worker or agency is best placed to successfully engage with the person?
• Would the person respond more positively to an independent or a voluntary agency worker?
• Has the person had a negative experience of services in the past which have led them to distrust certain professional groups?

The proposals should specifically address how best to engage with the person as well as what specific actions will be taken (or offered) in response to the risks identified. If the risk cannot be eliminated, can it be reduced or moderated? Oversight, coordination and monitoring arrangements should be agreed along with arrangements for communicating further concerns to workers and agencies involved. Where there is high risk of serious harm to an individual declining support, all agencies should consider whether it is possible to offer support in a more flexible way. The meeting should agree and record timescales for all proposed actions.

2.1.4 Developing a Plan

Listen to the views of the person or their representative about the risk and what, if any, support they would find helpful. If a plan cannot be agreed with the person during the meeting, it will be necessary to arrange for someone to follow up the discussions outside the meeting.

If the person is not at the meeting, or a plan is not agreed with the person, the workers and agencies involved should propose a holistic and person-centred plan.

It should be agreed at the meeting who will discuss the plan with the person to seek their consent and within what timeframe this discussion should take place. It is important to agree which professional is the best placed to discuss the offer with the person at risk (in some cases this will be a worker from a private or voluntary organisation). It may be that the person agrees to some measures, but not others. The person should be given information about what support and services are available if they choose to take up the services at a later date.

2.1.5 Re-convening the Risk Management Meeting

If all or part of the plan is rejected, the meeting should reconvene to review the plan. This will be an on-going process of developing or establishing trust with the person, maximising any opportunities for positive engagement, re-introducing new offers of support and testing the person’s resistance to support.

In summary, the following should be applied:

• Assess mental capacity;
• Suggest an alternate Care/Support Plan;
• Seek consent and engagement
• Review and suggest further alternatives.

All workers and agencies should refer to their management or the PCC Adult Safeguarding Team, before taking a decision to close their involvement with the person because they have declined support, recognising the increased risk where a person is not engaging with any services. Agencies should also consider where a person appears not to meet the eligibility criteria for their services, this is discussed and shared with others, to avoid an assumption that an agency has oversight.

If there are any concerns over the participation of any agency in the process, the agency who has convened the meeting should consult with their line manager and a senior manager within their own organisation and consider the use of the escalation procedure. Contact should be made at an appropriately senior level within the organisation to request their involvement. The Safeguarding Lead for that organisation may be able to assist to facilitate these discussions. Where required, please refer to the PSAP escalation process: section 2.10 of the Multi-agency Adult Safeguarding Manual.