1. Waltham Forest Multi-Agency Conference on Adult Neglect and Child Neglect using a Think Family approach 9 December 2016
Twitter:
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2. Welcome and opening thoughts
Cllr Grace Williams, Lead Member for Children, LBWF and Cllr Angie Bean, Lead Member for Adults, LBWF
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3. Welcome and opening thoughts
Cllr Grace Williams, Lead Member for Children, LBWF
Learning together and from each other is essential to improving practice
Adult neglect and child neglect is a concern to all boards; Safeguarding Adults Board, Waltham Forest Safeguarding Children Board, Health and Wellbeing Board and SafetyNet
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4. Welcome and opening thoughts
Childhood neglect can have long term impact into adulthood
Launch of bite size guide on child neglect to support improving practice
Think Family approach in Waltham Forest
Why child neglect now?
WFSCB: three Serious Case Reviews (SCR) in the last three years
Nationally in 55% of SCRs neglect is present
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5. Welcome and opening thoughts
Cllr Angie Bean, Lead Member for Adults, LBWF
Adults neglect by others and self neglect
Importance of supporting informal carers as well as safeguarding adults in need of care and support
Focus today on self-neglect and challenges practitioners face
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6. Welcome and opening thoughts
Locally one previous review on self-neglect and one Safeguarding Adult Review on self-neglect starting
Self-neglect is emerging as a significant issue which has been helped by the Care Act locating this firmly within a safeguarding arena
Launch of self-neglect policy and bite size guide on self-neglect to support improving practice
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7. House keeping and ground rules
Conference Chair: Fran Pearson, Chair for Waltham Forest Safeguarding Adults Board and Safeguarding Children Board
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8. Housekeeping Toilets and fire exits Mobile phones Multi-agency tables
Evaluations
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9. Ground rules
We want today to be a positive space for learning and development. To enable this we ask all present to agree to:
Be open to new ideas and different ways of working
Take part in debates, discussions and provide constructive professional challenge
Treat all questions as good questions
Enable all voices round the table to be heard
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10. Local context, practice issues and launch of self-neglect policy
Fran Pearson, Conference Chair
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11. Adult neglect
Adults with care and support needs (as defined under the Care Act 2014) can be directly neglected by others who are providing a caring role, family members, or exploited by people not known to them. Types of abuse:
Physical abuse, domestic violence or abuse, sexual abuse, psychological or emotional abuse
Financial or material abuse
Modern slavery
Discriminatory abuse
Organisational or institutional abuse
Neglect or acts of omission
Self-neglect
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12. Adult neglect continued
The Care Act 2014 statutory guidance includes self-neglect and hoarding in the categories of abuse or neglect relevant to safeguarding adults with care and support needs
Self-neglect involves any failure by an adult to take care of him or herself, which causes or is reasonably likely to cause serious physical, mental or emotional harm, or substantial loss of assets. Self-neglect is often defined across three domains – neglect of self, neglect of the environment and a refusal to accept help
Today we are focusing particularly on self-neglect due to the particular complexity and emerging research and practice in this area
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13. Child neglect
The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:
Provide adequate food, clothing and shelter (including exclusion from home or abandonment)
Protect a child from physical and emotional harm or danger
Ensure adequate supervision (including the use of inadequate care-givers)
Ensure access to appropriate medical care or treatment
Respond to a child’s basic emotional need
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14. Waltham Forest Context
271,200 people live in the borough (mid-2015).
Our population is relatively young – 65,100 children & young people (24%) and 75,250 aged (28%)
And growing – to more than 300,000 by 2026
The population is very diverse:
Nearly half of residents (48%) are from a minority ethnic background and over a third were born overseas
Diversity concentrated among children and younger people
Population grown by 50,000 over last 10 years.
Projected growth rate is faster for older people - 23% for over 65s, and 33% for over 85s
Projected population growth is equivalent to 1,600 new households every year.
Child Poverty down from 32.7% in Income deprivation for older people down from 30% in 2005.
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15. Waltham Forest Context
Waltham Forest is relatively deprived:
Ranked 35th most deprived out of 326 LAs in England (7th in London)
Around one-quarter of children and older people living in poverty
But we are also changing:
High population turnover – almost 10% each year
Change is concentrated among young adults and driven by international migration
Population grown by 50,000 over last 10 years.
Projected growth rate is faster for older people - 23% for over 65s, and 33% for over 85s
Projected population growth is equivalent to 1,600 new households every year.
Child Poverty down from 32.7% in Income deprivation for older people down from 30% in 2005.
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16. Child Neglect
There were 2,240 Children in Need (CiN) in Waltham Forest in March 2016 – a similar rate to other areas. But a total of 5,210 throughout 2015/16 – more than other areas.
14% of assessments identified Neglect as a factor – equivalent to 714 children during the year.
This makes it the 7th most common factor in Waltham Forest, and less common than in London.

17. Child Protection
250 children were subject to a child protection plan (CPP) in March 2016 – similar to London.
And 330 children who became subject to a CPP during 2015/16 – slightly higher than in London.
17.3% of child protection plans identified neglect as the primary factor – 43 children.
This is significantly lower than the proportion across London (37%) and England (45%).

18. Adult Neglect
There were around 850 people involved in safeguarding concerns in 2015/16, and around 450 ‘Section 42 Enquiries’.
Older people are much more likely to be at risk – particularly in Waltham Forest. 29% of s.42 Enquiries relate to risk in a Care Home.
47% of s.42 Enquiries identified Neglect and Acts of Omission as a factor – significantly higher than in other areas

19. Self Neglect
45 ‘Section 42 Enquiries’ in 2015/16 identified self-neglect as a concern – 10% of the total
464 adults in Waltham Forest were in treatment for opiate abuse in the year to September % receive effective treatment – lower than in London (94%)
167 adults were in treatment for alcohol abuse in the year to September 2016
Almost 2% of adults in England are considered to be morbidly obese – equivalent to around 4,000 people in Waltham Forest
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20. Evidence based practice messages – adults
Working with Adult neglect and self-neglect:
An adult who is being neglected by someone they know may not want to acknowledge or change the relationship
Multi-agency working generally gets the best outcomes for everybody. Identifying someone in the multi-agency group who is best placed to take time to build a relationship with the person also improves outcomes
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21. Evidence based practice messages – adults
Working with Adult neglect and self-neglect:
Don’t walk away. It’s important to ensure that we don’t just leave the person to it, and that the multi-agency network agree an appropriate method of monitoring
Today we are launching the self neglect policy which includes guidance and tools for working in this complex area. A copy is on your tables and you will receive an copy next week
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22. Evidence based practice messages – children
Neglect is no less harmful than other forms of abuse such as physical and sexual abuse. It is the most prevalent form of child maltreatment in the UK, with an estimated one in 10 young adults having been severely neglected by parents or guardians during childhood
Professional curiosity makes a real difference in identifying neglect
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23. Evidence based practice messages – children
Some families respond to professionals getting involved, but revert to neglectful parenting afterwards. So it is vital to reassess families and understand the impact of neglect from the child’s perspective
The risks of future neglect need to be based on previous neglect, with all concerns / incidents recognised for their cumulative effect. Eileen Munro (2008) Effective Child Protection: “the best predictor of future behaviour is past behaviour”
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24. Emerita Professor of Social Work, University of Sussex
Understanding and responding to self-neglect: what goes wrong and what goes right?
Suzy Braye
Emerita Professor of Social Work, University of Sussex
Waltham Forest
9th December 2016

25. The research Literature review SAB survey Practitioner focus groups
Analysis of SCRs and SARs
Interviews with service users, practitioners and managers

26. What do we mean by self-neglect?
Lack of self-care
Personal hygiene
Nutrition/hydration
Health
Neglect of the living environment
Hoarding (hoarding disorder)
Squalor
Infestation
Risk to safety and wellbeing
Refusal of services that would mitigate harm
“Self-neglect: this covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding” (DH 2016)

27. Bringing self-neglect in from the cold…
SAB oversight of measures to help and protect
Self-neglect
Safeguarding
Adult social care
Multiagency process

28. The key challenges of self-neglect
Interagency cooperation
Legal literacy
Workplace factors
Mental capacity
Ethical/ ideological dilemmas
What’s going on?

29. 1. Understanding what’s going on
No one overarching explanatory model
Complex interplay of physical, mental, social, personal and environmental factors
Unwillingness and inability difficult to distinguish
Need for understanding the meaning of self-neglect in the context of each individual’s life experience

30. Understanding the lived experience: neglect of self-care
I got it into my head that I’m unimportant, so it doesn’t matter what I look like or what I smell like.
Negative self-image: demotivation
Different standards: indifference to social appearance
Inability to self-care:
“I wouldn’t say I let my standards slip; I didn’t have much standards
to start with.”
I’m drinking, I’m not washing; I wouldn’t say I’m losing the will to live, that’s a bit strong, but I don’t care, I just don’t care.
(It) makes me tired ... I get tired because daily routines are exhausting me, to do the simple things like get washed, put on clean clothes, wash my hair.
I always neglected my own feelings for instance, and I didn’t address them, didn’t look at them in fact, I thought ‘no, no, my feelings don’t come into it’.

31. Understanding the lived experience: neglect of domestic environment
Influence of the past: childhood, loss
Positive value of hoarding: a sense of connection, utility
Beyond control: voices, obsessions
The only way I kept toys was hiding them.
“When I was a little boy, the war had just started; everything had a value to me … everything in my eyes then, and indeed now, has potential use
I want things that belonged to people so that they have a connection to me.
The distress of not collecting is more than the distress of doing it.
I don’t have time to make a note of everything in the paper that has an interest to me and so I’m very fearful of throwing something away.

32. 2. Ethical dilemmas Professional codes of ethics
Respect for autonomy & self- determination
Duty to protect and promote dignity
Professional codes of ethics
MCA 2005 ECHR articles 8 and 5
Limitations to state power
Policy context of personalisation
Making safeguarding personal
The duty to protect from foreseeable harm
Human dignity compromised
ECHR articles 2 and 3
Risk to others

33. A more nuanced approach
Respect for autonomy may entail
Questioning ‘lifestyle choice’
Respectful challenge
Protection does not mean
Denial of wishes and feelings
Removal of all risk
“Respecting lifestyle choice isn’t the problem; it's where people don't think they’re worth anything different, or they don’t know what the options are.”
Autonomy does not mean abandonment
Protection entails proportionate risk reduction

34. 3. Mental capacity: affects perception of risk and intervention focus
Respect autonomy ?
Best interests: preventive
Best interests: remedial
Self-care
Self-neglect
Survey: the key challenges
76% identified mental capacity and refusal of services
28% identified service-related factors (eligibility, time, interagency working)
Mental incapacity

35. Understanding mental capacity
Mental capacity involves
The ability to understand and reason through a decision AND the ability to enact it in the moment
Impaired executive function (frontal lobe impairment) affects
Understanding, retaining, using and weighing relevant information in real-time problem-solving
‘Articulate and demonstrate’ models of assessment
GW v A Local Authority [2014] EWCOP20
Decisional capacity
Executive capacity
Capacity

36. 4. Legal literacy: who has what powers & duties
Mental Capacity Act 2005
Mental Health Act 1983
Care Act 2014
Children Act 1989
Inherent jurisdiction
Beyond adult social care
Powers of entry

37. 5. The organisational context: a perfect storm
Reluctance to engage
Organisational pressures
“The combination of people who are terrified of losing their independence or terrified of state intervention, together with a state process that is desperate to apply eligibility criteria and find reasons not to support people, is just lethal.... It’s just like: ‘oh you’re saying it’s all fine, thank goodness, we can go away’”.

38. Creating a supportive organisational environment
Supervision and support
Recognition of the personal impact
Support and challenge
Time for a ‘slow burn’ approach
Workflow that permits repeat visits and longer-term engagement
Shared risk management & decision-making
Places & spaces to discuss: panels/forums

39. 6. Interagency cooperation: SAR findings
Learning about working together
Work on uncoordinated parallel lines
Failures of communication
Lack of leadership and coordination
Service standards
Relationship dynamics
Legal literacy: Mental capacity
Collective omission of ‘the mundane and the obvious’

40. What makes for robust interagency working?
Interagency governance
Referral pathways
Training, supervision, support
Space for relationship-based work
Forum for shared risk management
Case coordination and leadership
Shared strategic ownership and understandings
Clarity on roles and responsibilities
Turning strategy into operational reality
Commissioning

41. Whole system alignment
Multi-agency governance
Organisational infrastucture
Legal literacy
Relationship-based practice
Moral reasoning
The person

42. Service user views: the importance of relationship
“She got it into my head that I am important, that I am on this earth for a reason.”
Intervention delivered through relationship: emotional connection/trust
Support that fits with the individual’s own perception of need/utility: practical input
Respectful engagement
“He has been human, that’s the word I can use; he has been human.”
“He’s down to earth, he doesn’t beat around the bush. If there is something wrong he will tell you.”
“The idea is not to get too pushy about it; people start getting panicky then, you know? ‘You’re interfering in my life,’ that kinda thing.”
With me if you’re too bossy, I will put my feet down and go like a stubborn mule; I will just sit and just fester.

43. Practitioners say … Effective practice involves Sound knowledge base
Qualities brought to the relationship
Finding the latitude
Recognition
Working to contain not eradicate risk
Hands-on/hands-off balance

44. Knowing, Doing and Being
Relationship

45. Integrating negotiated and imposed interventions

46. In summary: practitioner approaches
Practice with people who self-neglect is more effective where practitioners
Build rapport and trust, showing respect, empathy, persistence, and continuity
Seek to understand the meaning and significance of the self-neglect, taking account of the individual’s life experience
Work patiently at the pace of the individual, but know when to make the most of moments of motivation to secure changes
Keep constantly in view the question of the individual’s mental capacity to make self-care decisions
Communicate about risks and options with honesty and openness, particularly where coercive action is a possibility
Ensure that options for intervention are rooted in sound understanding of legal powers and duties
Think flexibly about how family members and community resources can contribute to interventions, building on relationships and networks
Work proactively to engage and co-ordinate agencies with specialist expertise to contribute towards shared goals

47. In summary: organisational approaches
Effective practice is best supported organisationally when
Strategic responsibility for self-neglect is clearly located within a shared interagency governance arrangement such as the SAB
Agencies share definitions and understandings of self-neglect
Interagency coordination and shared risk-management is facilitated by clear referral routes, communication and decision-making systems
Longer-term supportive, relationship-based involvement is accepted as a pattern of work
Training and supervision challenge and support practitioners to engage with the ethical challenges, legal options, skills and emotions involved in self-neglect practice

48. Journal articles Professor Suzy Braye, s.braye@sussex.ac.uk
Braye, S., Orr, D. and Preston-Shoot, M. (2011) ‘Conceptualising and responding to self-neglect: challenges for adult safeguarding’, Journal of Adult Protection, 13, 4,
Braye, S., Preston-Shoot, M. and Orr, D (2012) The governance of adult safeguarding: findings from research’, Journal of Adult Protection, 14, 2,
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.
Braye, S., Orr, D. and Preston-Shoot, M. (2015) ‘Serious case review findings on the challenges of self-neglect: indicators for good practice’, Journal of Adult Protection (17, 2, 75-87).
Preston-Shoot, M. (2016) ‘Towards explanations for the findings of serious case reviews: understanding what happens in self-neglect work,’ Journal of Adult Protection, 18(3),
Professor Suzy Braye,
Dr David Orr,
Professor Michael Preston-Shoot,

49. Break
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50. Table top exercises What does neglect mean to you?
Case study discussion
Tables to identify one strength and one challenge from each discussion in writing and bring to the front table at the break
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51. What does all this mean for how we work with families?
Heather Flinders, Divisional Director of Children and Families Service, LBWF
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52. Facilitators to share strength and challenges from exercises
Buffet Lunch
Facilitators to share strength and challenges from exercises
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53. You said you cared… and you did
Jenny Molloy, a Times Bestseller Author ‘Hackney Child’ and Care Leaver, Adviser and Trainer – Looked After Children and Care Leavers
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54. Bite size guides Videos on adult self-neglect and child neglect
Written briefings on your tables
Guides to be available next week on the strategic boards website (See:
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55. The whole system approach
Acute Services
Targeted Services
Universal Services
Community and family networks
Carers and parents
Adults and children
Protecting and preventing
Protecting and preventing

56. What does this all mean for how we work with families?
What cultures do we want to develop as professionals to allow us to work effectively across the artificial membranes:
Research consistently confirms that the quality of the relationship between a practitioner and the adult/child is central to effecting change and improving outcomes
Balance of and sharing power
Specialism should not be a barrier to different practitioners having different roles
Recognising community resilience and this is individual for each family
Adolescents are often forgotten when recognising neglect
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57. Table top exercise Discussion on how to improve practice
Remember to complete your individual commitment to improving practice
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58. Next steps and comments
Richard Tucker, Chair of SafetyNet and Borough Commander
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59. Next steps and closing comments
Now you have heard the messages and worked through what it means in practice we want to ask that you take it back to your teams/services/agencies
Evaluation of today will inform future work/events
Future audit work will evaluate practice
Bite size guides to be disseminated
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60. Thank you
Thank you to the multi-agency project group who organised the conference, the many facilitators who have guided us skillfully through the agenda, the practitioners who produced the videos and to business support, technical staff and caters for a great day
Thank you for being open to learning and sharing and giving your energy and time
Please don’t forgot what you have committed to do back in your workplace
Each one of us can make a difference. Together we make change.
Barbara Mikulski an American Politician

61. Your evaluation Please complete your evaluation
Hand to your table facilitator to receive your certificate
Please complete your evaluation form, it does have influence and will help us frame the work going forward and then you can get your certificate.
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62. Thank you
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