Welsh Government: Self-Neglect Practice Guide

July 2024

The role of the independent Older People’s Commissioner for Wales (OPCW) is to protect and promote the rights of older people living in Wales. Stopping the abuse of older people in all its forms, is a key priority for the Older People’s Commissioner.

The Older People’s Commissioner for Wales (OPCW) welcomes the opportunity to respond to the Welsh Government’s consultation of the draft ‘Self-Neglect Practice Guide’. Research shows that older people are at particular risk of self–neglect [i]. The factors that lead to self-neglect can be complex and varied [ii], however, many older people find themselves in situations where there is an increased likelihood of self-neglect. For example, feelings of loneliness are known to increase a risk of self-neglect and older people are more likely to live alone and be socially isolated or lonely ^[iii]. Levels of self-neglect are also higher among those with dementia [iv]. It is also important to recognise that the consequences of self-neglect can be especially damaging and harmful to older people, leading to poorer physical and mental health, and increased rates of mortality [v]. In 2020, the Commissioner set up the Stopping Abuse Action Group[vi]. Members of this group have also raised concerns about increases in the numbers of older people who self-neglect.

The challenges faced by practitioners when working with older people who self-neglect are especially high. When working within such situations, practitioners face many complex, ethical dilemmas, such as the need to carefully balance an individual’s right to autonomy with potentially serious risks to their physical and emotional wellbeing. It is recognised that individual Regional Safeguarding Boards often have their own guidelines and procedures for working with self-neglect. However, it is useful to have this broader practitioner guidance, which will help ensure consistency in approaches to practice.

The Commissioner wishes to make the following points in relation to the guidance:

The principles of the guidance reflect best practice for working with those who self-neglect. It highlights, for example, the need for practitioners to work in relationship-based ways, and to engage with person-centred approaches, which take account of an older person’s biography / history, personality, needs and preferences.

The guidance quite rightly points out the importance of practitioners working collaboratively across organisational boundaries and divisions if they are to work effectively with those who self-neglect. Collaborative, multi—agency practice is, however, always a challenge in safeguarding work. For this reason, it would be helpful if the guidance is supplemented with multi-agency training, which helps promote shared understandings of self-neglect (risk factors and harms), and which facilitates consistent approaches to working with self-neglect.

Anxieties around information sharing are often cited as a barrier to effective safeguarding practice. The Commissioner is aware of the Welsh Government’s intention to produce practitioner guidance on ‘Information Sharing’ (a commitment within the National Action Plan to Prevent to the Abuse of Older People in Wales [vii]). This resource will be a useful addendum to the self-neglect guidance.

It is very important that practitioners build relationships with older people who self-neglect. It is within the context of these relationships, that practitioners can then begin to identify the reasons for self-neglecting behaviour(s). Understanding the rationale for such behaviour(s) will be fundamental to engaging the older person in intervention, reducing risk and if possible, promoting longer-term change. Such work is likely to be time intensive and it is positive that the guidance highlights the need for organisations to allocate practitioners the time and space needed to work with individuals within these situations. Practitioners should be given the opportunity to reflect upon the effectiveness of their approaches to working with self-neglect and to explore ethical dilemmas, within professional supervision.

The guidance is clear concerning the importance of practitioners carefully balancing the wishes / preferences of an older person and the need for intervention / non-intervention. A statement highlighting the importance of robust recording in relation to these decision-making processes would be helpful.

The guidance quite rightly points out that ignoring the signs of self-neglect can have serious consequences [viii]. The signs of self-neglect within the guidance are, however, at the more extreme end of the self-neglect ‘scenario’. It would be helpful to say that self-neglect occurs on a continuum, and that the initial signs of self-neglect may be more subtle. Practitioners need to be able to identify early signs of self-neglect if they are to engage in preventative practice, which helps to reduce longer-term risk [ix].

Older people should be enabled to communicate in a language of their choice when receiving care and support services. Language is a source of distinction and identity; it therefore constitutes a critical element of a personalised approach to service provision ^[x]. At times of emotional stress, older people can find it far easier to describe their situations and to talk about their fears, anxieties, and options for support in their ‘first language’. It is concerning, however, that the number of health and social care practitioners who can work competently through the medium of Welsh is at present, extremely limited ^[xi]. Action will be needed to address this issue in the longer-term.

The guidance on assessing for mental capacity is clear and helpful, with an important distinction between decisional and executive mental capacity.

The practical tools referenced within the guidance (for example, the risk assessment tool) are very helpful. However, supplementing the guidance with other training opportunities to accommodate different learning styles and to promote practitioner competence and confidence in their work in this area would be beneficial.

Conclusion

Overall, the guidance effectively highlights the nature of self-neglect, the pre-disposing risk factors, the potential harms of self-neglect, and the challenges faced by practitioners when working with those who self-neglect. The guidance also makes clear the potentially harmful implications of practitioners’ failing to engage in timely, appropriate, and proportionate interventions within such situations. In summary, the following actions are suggested:

The guidance would work best, if offered alongside other opportunities for practitioner training and reflective discussion.
Training on self-neglect should be multi-agency – this will promote shared understandings of self-neglect and will facilitate effective inter-agency collaboration and joint practice.
The guidance on self-neglect should be supplemented with practitioner guidance on information sharing (again, to promote effective, inter-agency collaboration)
The guidance should highlight the importance of practitioners documenting decision-making processes and outcomes when working within situations of self-neglect. The rationale / justification for intervention / non-intervention must be clearly identified.
The guidance should highlight early indicators (as well as the later signs) of self-neglect. This will encourage practitioners to engage in early intervention and preventative work.
Older people should be able to communicate in the language of their choice, when engaging with health and social care professionals.

The Commissioner’s team would be happy to discuss any of these comments further.

[i] Day, M.R. et al. 2015. Self-Neglect: A Case Study and Implications for Clinical Practice. Care of the Older Person 20(3).

[ii] Dahl, N. et al. 2018. Self-Neglect in Older Populations: A Description and Analysis of Current Approaches. Journal of Aging and Social Policy 32(6).

[iii] ONS (2020). People living alone aged 65 years and over, by specific age group and sex, UK 1996-2019. Available at: People living alone aged 65 years old and over, by specific age group and sex, UK, 1996 to 2019 – Office for National Statistics (ons.gov.uk)

[iv] Day, M.R. et al. 2015. Self-Neglect: A Case Study and Implications for Clinical Practice. Care of the Older Person 20(3).

[v] Day, M.R. et al. 2015. Self-Neglect: A Case Study and Implications for Clinical Practice. Care of the Older Person 20(3).

[vi] The Stopping Abuse Action Group was set up in response to concerns that the levels of abuse affecting older people, would increase throughout the Covid-19 pandemic. The group continues to meet on a bi-monthly basis and is attended by representatives from over thirty different organisations.

[vii] Welsh Government. 2024. National Action Plan to Prevent the Abuse of Older People. Available at : National action plan to prevent the abuse of older people [HTML] | GOV.WALES

[viii] Noblett, K. 2019. Clinical Implications of Self-Neglect Among Patients in Community Settings. Care of the Older Person 24(11).

[ix] Dong, X. 2017. Elder Self-Neglect: Research and Practice. Clinical Interventions in Ageing (12)

[x] Madac-Jones, I. and Dubberley, S. 2005. Language and the provision of health and social care in Wales. Diversity in Health and Social Care (2), pp. 127-134.

[xi] Madoc-Jones, I. 2004. Linguistic sensitivity, indigenous peoples and the mental health system in Wales. International Journal of Mental Health Nursing (13), pp. 216-224