Sussex Self-Neglect Practice Guidance for Staff

Version: 2
Date published: December 2025
Review due: December 2028

This guidance provides staff with practice guidance when working with adults who are self-neglecting. It has been created in recognition that in a lot of situations, self-neglect practice sits outside of safeguarding; that is, it does not meet the criteria for a Section 42 safeguarding enquiry under the Care Act 2014.

The guidance does, however, reflect key points on self-neglect from the Sussex Safeguarding Adults Policy and Procedures (2024) and Sussex Safeguarding Thresholds (2023).

What is self-neglect?

Self-neglect refers to a situation where a person may be unable to care for themselves in ways that maintain their health, safety, or overall wellbeing. This can include personal care, nutrition, or medical needs, substance use or living in an environment that has become cluttered, unhygienic, or hazardous.

Signs of self-neglect

• Very unclean surroundings, possibly with signs of vermin.
• Neglecting household maintenance, creating fire risks or hazards, e.g. lack of boiler or dangerous electrics.
• Hoarding objects to the level there is an environmental and/or health risk.
• Poor personal hygiene and poor health (caused by untreated health conditions), e.g. unkempt appearance, long fingernails, pressure ulcers, malnutrition or dehydration. This may include missing important health appointments; this may not necessarily be due to lack of concern, but possibly due to barriers like fear, mobility, or past experiences.
• Declining or not collecting prescribed medication. A person may decline prescribed medication or feel unable to follow health or social care advice. This may reflect mistrust, previous trauma, or feeling overwhelmed.
• Living with multiple animals in conditions that may be unsafe for either the person or the animals.
• Struggling with debt, rent arrears, or risk of eviction. This may include prioritising spending in ways that reflect coping strategies, such as using substances.
• Excessively cluttered environment which poses a fire risk and access difficulties.
• Substance and alcohol use to the point of harm or risk of harm.
• A person’s self-neglecting behaviour is putting them at risk of abuse or discrimination from members of the public or health/care services.
• Children in the home appear to be suffering from neglect.

Please note: This list is not exhaustive.

Possible reasons for self-neglect

There are a range of explanations and contributing factors which may lead to a person self-neglecting, including:

• Physical or mental health problems, or substance dependency
• Psychological and social factors
• Diminished social networks
• Traumatic histories and life-changing events

Often the reasons for self-neglect are complex, multiple, and varied. It is important that we pay attention to mental, physical, social, and environment factors that may be affecting the situation (Braye, Orr, Preston-Shoot, 2015).

Self-neglect and the Care Act

The Care Act (2014) recognises self-neglect as a category of abuse and emphasises the importance of working with the adult to take preventative actions to minimise risk. A safeguarding enquiry (Care Act Section 42) may be required when the person meets the safeguarding three key test, or statutory criteria in the Care Act, which is that the person:

• has needs for care and support (whether or not the local authority is meeting any of those needs), and;
• is experiencing, or is at risk of, abuse or neglect, and;
• as a result of their care and support needs is unable to protect themselves from either the risk of, or the experience of, abuse or neglect.

In order to meet self-neglect safeguarding criteria there may also be risks such as:

• The home environment may have deteriorated to the point where the person’s life or health is at risk.
• Extensive structural deterioration or damage in the property causing risk to life.
• The person may be unable or feel unable to care for themselves or access medical treatment, resulting in serious health consequences.
• High level of clutter/hoarding leading to obstructed access within a property, and fire hazards.
• The use of substances may be causing harm or increasing vulnerability, often as a way of coping with distress or trauma.
• The individual may not feel able to engage with services or accept help, which can be due to past experiences, fear, communication or being overwhelmed.

Remember, self-neglect is sometimes not obvious; it is not associated with a physical need. The Guidance (2024) states further that self-neglect may not prompt a Section 42 enquiry. Decisions are made on a case-by-case basis and ‘the safeguarding response will depend on whether the adult is able to protect themselves by controlling their own behaviour’.

Adults situations which do not meet the three key tests might be addressed through other routes, such as:

• a multi-agency piece of work focusing on reducing risk and improving outcomes
• a Care Act assessment (Care Act 2014, Section 9)
• signposting to alternative services or community resources (Care Act 2014, Section 4)
• arranging for mental health services/support or contact with GP

You should report any concerns which meet the threshold for reporting via safeguarding to the relevant local authority:

• Brighton & Hove Adult Social Care
• East Sussex Adult Social Care
• West Sussex Adult Social Care

What is the aim of the Sussex self-neglect procedure?

The procedures set out a framework and pathway for collaborative multi-agency working. The procedures ensure:

• Adults are empowered, as far as possible, to understand the implications of their self-neglect, even if, at times, they may not fully recognise how their current circumstances are impacting their wellbeing.
• A shared, multi-agency understanding, and recognition of the issues involved in working with adults who self-neglect.
• Effective multi-agency working and practice.
• Agencies uphold their duties of care.

Any professional can request or arrange a multi-agency meeting to support an adult who is self-neglecting. If there is a safeguarding enquiry, the lead agency will likely be the local authority. In other cases, you will need to discuss who is best placed to coordinate a multi-agency meeting.

When multi-agency meetings are called by any agency, there is an expectation that all agencies will contribute or attend, regardless of whether the concern is managed via safeguarding processes or not.

It is acknowledged that, in some cases, multi-agency liaison may be sufficient, in place of a meeting.

What is the self-neglect process in Sussex?

In Sussex we have a five-step process to working with adults who are self-neglecting. These steps are set out in the Pan Sussex Safeguarding Policies and Procedures but are also relevant for self-neglect which, in some cases, sits outside of safeguarding processes. The steps are:

1. Self-neglecting identified

The identifying agency should consider:

• Immediate actions required to minimise risk
• Arranging a multi-agency meeting
• Requesting a social care assessment
• Raising a detailed safeguarding concern with risks clearly documented and narrative that considers the adult’s ability to keep themselves safe and maintain their wellbeing; this should include whether they are able to do so independently or may benefit from external support

2. Identify lead agency

If there is a safeguarding enquiry, this will be the local authority. In other cases, this could be another agency because:

• The agency is already involved
• The agency has a duty of care
• The agency holds significant information
• The adult has shown a likelihood to engage with them
• Needs appear to relate to the service provided by that agency

3. Information sharing

It is crucial to share information and determine who takes responsibility for what part of the process. The lead agency should consider the most appropriate actions to address the concerns raised and consider the adult’s mental capacity to make specific decisions around their self-neglecting behaviour.

4. Multi-agency meeting

The lead agency convenes a meeting to:

• Consider risks and issues of mental capacity
• Share information between agencies
• Devise a shared action plan
• Involve the adult concerned as much as possible and/or their representative or advocate

Multi-agency working is usually needed throughout, whether a meeting is arranged or, not. This means contacts with other agencies involved to share information and assess and decide together on what actions are needed and, as risks change.

Where self-neglect is identified by staff without the seniority to initiate multi-agency working, agencies should have escalation routes and be supported by selecting leads in this process. 

5. Comprehensive assessment of risk

Comprehensive assessment of risk includes considering with all those involved, what the risks are, including any risks to children, other adults, and those with caring responsibilities. Referrals to children’s and adult’s services should be considered.

The assessment should identify who is taking forward actions, within what time frame, and will either lead to:

• Outcomes being determined, and risk addressed, resulting in:
  • Support accepted and implemented
  • Ongoing monitoring, or:
• Outcomes being determined and risk remaining, resulting in:
  • Escalation to risk panels if available/senior managers/legal services, and ongoing monitoring
  • Repeat multi-agency meetings
  • Safeguarding concern raised where required.

It’s important that your risk assessment clearly records rationale for any actions you take, as well as any actions you don’t take, for example, where building relationships is more important than taking immediate steps to clear hoarding.

For further information on risk assessment, please see the West Sussex Safeguarding Adults Board learning resources, including the Sussex Safeguarding Adults Thresholds Guidance for information about assessing risk.

Tips on working with adults who self-neglect

When engaging with an adult who is self-neglecting, and who appears to be unable to make specific decisions about their self-neglecting behaviour or have difficulty with their executive functioning (the ability to plan, organise and complete tasks), consider whether:

• Information is in a format the adult understands.
• It is possible to have conversations over a period of time to build-up a relationship.
• There is someone else who can help support you to engage with the adult. (e.g. family, advocate, or other professional).
• Adults who present with fluctuating capacity, can plan or agree actions or outcomes at a time when they have capacity for that decision.
• There are signs of other forms of abuse and neglect which are contributing to the self-neglect, for example, exploitation, cuckooing, or coercion and control.
• There is anyone else in the home who might be at risk; consider what support might be available to support carers or significant others.
• To seek supervision when working with people who pose serious risk due to self-neglect.

Professionals may face challenges when supporting adults who appear unable to engage with services. This can be due to a range of factors including past trauma, fear, mistrust, or a strong desire to maintain independence.

When adults appear not to be engaging, this can present in a variety of ways, including:

• Missing appointments
• Not responding to visits or communication.
• Feeling unable to agree to a support plan or take steps to reduce risk.
• Struggling to follow through with recommendations due to emotional, cognitive, or practical barriers.
• Substance use that may affect capacity or ability to engage at that time.

It is important that you remain non-judgemental and have a compassionate approach to understanding the complexity of the adult’s history, background, and any traumas, and how this has contributed to their current circumstances.

When an adult appears to decline support, it is important to consider whether they have the mental capacity to make informed decisions about their safety and wellbeing. Ensure they understand the potential implications of declining support. Document these considerations clearly and sensitively. Continue efforts to engage, rather than ending involvement solely based on non-engagement.

Organisations involved in supporting an adult who is self-neglecting may have a non-engagement policy. You must refer to your own organisation’s policies in addition to the self-neglect procedures.

Tips for effective intervention

The information below is based on work by Braye, Orr, and Preston-Shoot (2014), and explains methods and interventions to support effective practice.

• Take time to get to know the person
• Treat them with respect and non-judgement
• Maintain contact and reliability
• Monitor risk(s) and mental capacity to assess the risks associated
• Look out for motivation for change
• Talk to the adult about their interests and stories to build a relationship
• Be honest about potential consequences of actions and your involvement
• Move slowly without forcing things; focus on continued involvement and improvement over time
• Be proportionate to risk and seek agreement to actions at each stage
• Link to the adults’ interests
• Provide small practical help at the outset, for example, household equipment, repairs, benefits, ‘life management’
• Link practical help to another element of agreement/bargaining
• Find something to be the basis of the initial agreement that can be built on later
• Encourage safe drinking strategies or agreement to fire safety measures or repairs
• Facilitate doctors’ appointments or hospital admissions, providing practical support to attend appointments
• Ensure that options for intervention are rooted in sound understanding of legal powers and duties
• Engage with the person’s family, community or social connections
• Consider options for short-term respite if required, for example, to have a ‘new start’
• If the adult declines options suggested, consider any other supportive options including for example, mental health or psychotherapy services

Balancing adults' rights and agencies' duties and responsibilities

All adults have the right to take risks and to live their life as they choose.

Agencies must respect this right and be mindful of this right when considering our duties and responsibilities towards an adult where self-neglecting is taking place. This right should only be overridden when it is clear that the consequences of the risks taken would be detrimental to either the adult’s, or another person’s health or wellbeing.

You must also ensure that you inform adults of their rights and relevant duty of care towards them. This should include the person’s right to privacy and information-sharing under the General Data Protection Regulations.

Assessing mental capacity

The Mental Capacity Act (MCA, 2005) is crucial in determining what action may or may not be taken in self-neglect cases. It is designed to protect adults who cannot make decisions for themselves, whilst protecting their human rights. Anyone working with the adult can assess mental capacity, for example, a care worker, a care service manager, a nurse, a doctor or a social worker.

An adult should be presumed to have capacity. However, when an adult’s presentation or circumstances cast doubt as to whether they have capacity to make a decision, then a mental capacity assessment should be carried out, in order to evidence the adult’s understanding of risks and consequences.

Robust mental capacity assessments are critical in determining the approach to be taken by professionals, either to support the decision-making of an adult with capacity or to intervene to protect the best interests of an adult who lacks capacity. Any mental capacity assessment in relation to self-neglect must be time-specific and relate to a specific intervention or action. The assessment should be carried out by the staff member needing to take action or an intervention, and it needs to be appropriately recorded. Where there are a number of agencies working with an individual, you can consider a multi-agency assessment of mental capacity. This can help to reach an agreement about capacity status, and improve subsequent planning and actions.

It is important to clearly document how you have maximised an adult’s autonomy and involvement within the capacity assessment, ensuring they have been given all practical support to help them reach a decision for themselves. This will include exploration of their understanding of their presentation and associated risks, including:

• Can they tell you what the risks are?
• What is their understanding or view of their actions which place them at risk?
• What is their understanding of the consequences of taking these risks?
• If the risk is death, explore what the adult’s understanding and beliefs are regarding their death.

Good practice is to record the actual information provided and the questions as they were asked, and the adult’s responses.

In circumstances where there is difficulty engaging the adult, it is important to distinguish between the situation where the person is unwilling to take part in the assessment, and the one where they are unable to take part.

The assessor will need to consider and document clearly:

• what steps have been taken to assist the adult to engage;
• what the person’s wishes and feelings are or were, where known, and
• what alternative strategies have been used.

If it has not been possible to engage the adult in an assessment, it is important to consider if you have enough supporting evidence to come to a reasonable belief about capacity or incapacity. If the presenting risk/s are high, to the adult or others, consider an application to the court to decide whether the adult has or lacks the capacity to make the relevant decision.

For further information on how to assess mental capacity, please see the self-neglect section of the Sussex Safeguarding Adults Policy and Procedures, and West Sussex Safeguarding Adults Board’s learning resources on mental capacity.

Fluctuating capacity

Some adults may have fluctuating capacity. This is particularly common in situations of self-neglect. It may occur because of their circumstances, which may result in an unwise decision being made, for example:

• Declining medical treatment while under the influence of alcohol or other substances.
• Prioritising immediate coping strategies, such as substance use, over urgent health needs.
• Experiencing high levels of emotional distress that affect decision-making and engagement with support.

This fluctuation can take place over days or weeks, or over the course of a day. Temporary impairment of decision-making ability may be down to an acute infection.

It is best practice to undertake the mental capacity assessment at a time when the adult is at their highest level of functioning. For adults who have ongoing fluctuating capacity, the approach taken will depend on the ‘cycle’ of the fluctuation in terms of its length and severity. It may be necessary to review the capacity assessments over a period of time. In complex cases, you should seek legal advice.

Decisional capacity and executive functioning

There is a difference between capacity to make a decision (decisional capacity) and capacity to actually carry out the decision (executive functioning).

Where decisional capacity is not accompanied by executive functioning, overall capacity is impaired and interventions by professionals to reduce risk and safeguard wellbeing may be legitimate.

Decisional capacity and executive functioning may be impacted by a range of factors, such as acquired brain injury, prolonged substance use, or emotional distress. These challenges can impact how someone processes information, plans, or responds to risk to themselves and/or others.

Unwise decisions

If an adult has capacity and is making what others consider to be an ‘unwise decision’, it does not mean that no further action regarding the self-neglect is required.

You must gather all the necessary information to inform a comprehensive risk assessment. You may determine that there are no legal powers to intervene, but you must demonstrate that the risks, and possible actions, have been fully considered on a multi-agency basis.

An ongoing reviewing system may need to be considered, as the adult, at a future date may decide to accept support or may lose capacity relating to their care. As part of the reviewing system, the adult may consent to an agency speaking with a friend or neighbour (who is able to monitor the adult’s wellbeing) to request they contact the relevant agency if the adult’s condition deteriorates in the future.

Multi-Agency Risk Management meetings

Across Sussex there are Multi-agency Risk Management (MARM) protocols that should be considered when working with adults with multiple compound needs, who remain at high risk of harm despite previous interventions.

For further information on MARMs please go to the relevant website:

• Home | Brighton & Hove SAB
• Home | East Sussex SAB
• Home | West Sussex SAB

Inherent jurisdiction

Taking a case to the High Court for a decision regarding interventions can be considered in extreme cases of self-neglect, i.e. where a person with capacity is not consenting to interventions and is:

• at risk of serious harm or death, and;
• refuses all offers of support or interventions, or;
• is unduly influenced by someone else.

The High Court has powers to intervene in such cases, although the presumption is always to protect the adult’s human rights. Legal advice should be sought before taking this option.

Best interests decision-making

If an adult is assessed as not having capacity to make decisions in relation to their self-neglect, any subsequent decisions or acts should be made in the adult’s best interests.

Any best interests decisions should be taken formally and involve relevant professionals, as well as anyone with an interest in the adult’s welfare, such as their family. The person’s past and current wishes and feelings need to be considered, and consideration should also be given as to whether an Independent Mental Capacity Advocate (IMCA) should be instructed.

Best interests must be determined by what the person would want were they to have capacity; “Lacking capacity is not an off switch for freedoms” (Wye Valley NHS Trust v Mr B, 2015, EWOCP 60).

It may be necessary to make a referral to the Court of Protection for a best interests decision. Any referral to the Court of Protection should be discussed with your Legal Services.