Self-neglect and capacity: Insights from recent regulatory and safeguarding adult reviews

Self-neglect represents one of the most challenging areas of adult safeguarding practice, sitting at the complex intersection of individual autonomy, mental capacity, and statutory duties to protect vulnerable adults.

In October 2025, we delivered a seminar examining current concerns and effective responses to self-neglect in England, drawing on analysis of Care Quality Commission (CQC) assessments of local authorities and recent Safeguarding Adult Reviews (SARs). This article synthesises key insights from that analysis.

Research suggests self-neglect prevalence rates of 116-211 per 100,000 population, though it is widely acknowledged to be inconsistently and under-reported. The cases reviewed reveal tragic outcomes. 

Current concerns: What the evidence reveals

Understanding and policy gaps

CQC assessments reveal that understanding of self-neglect, and development of effective responses is a work in progress. Some authorities only introduced self-neglect policies in recent years, a number in response to audits or incidents.  

Others recognised this as a "growing trend". It is clear some confusion exists among social work staff about self-neglect as a safeguarding concern, with some staff believing only people already known to services could be referred.

Even where safeguarding is considered, SARs consistently identify uncertainty over thresholds to trigger Section 42 referrals, resulting in lack of multi-agency responses. Some cases were managed through standard processes rather than formal safeguarding procedures, even where individuals were living in highly concerning conditions. 

Training and engagement 

Perhaps the most striking finding is critically low training completion rates: safeguarding training compliance sits below 48% for England, the average with some authorities near 25%, whilst Mental Capacity Act training is even lower, with some authorities below 20% against an England average of 37%. However, the picture varies widely between authorities: some have very high completion rates, showing that improvement is possible. 

Mental capacity assessment 

SARs reveal that adverse outcomes often result from failures in mental capacity assessment practice:

Lack of assessment: SARs identified a number of cases where no formal mental capacity assessment was conducted despite clear indicators. In other cases, capacity was presumed rather than properly assessed.

The role of impairment of executive function: Executive functioning - the cognitive processes enabling planning, organisation, and translating decisions into action - was often poorly understood or not considered. This is particularly problematic in self-neglect cases, where individuals may be able to "talk the talk" about what they need to do but cannot "walk the walk" in implementing those decisions.

Inconsistent practice: Contradictory capacity assessments were documented, with apparently inconsistent conclusions being reached by the same person in relation to different decisions, or differences between partners involved with an individual. These inconsistencies often appear to have been missed or inadequately explored, leading to difficulties in making the important decisions to protect individuals exposed to self-neglect risks. 

Fluctuating capacity ignored: Failures to consider fluctuating capacity due to alcohol use, substance misuse, or variable mental health conditions were common, with capacity often assessed at a single point in time.

The legal framework: Key principles

Self-neglect cases may engage multiple statutory duties. The overarching wellbeing duty will often be engaged where an authority is already working with an individual, and serious concerns regarding neglect may well take this into safeguarding territory. However, this is not the limit of the relevant duties.

In particular, Section 42 enquiry is required where the authority has reasonable cause to suspect an adult has needs for care or support, is experiencing or at risk of abuse or neglect, and as a result of those needs is unable to protect themselves. Contrary to views found in some ASRs, this does not require pre-existing engagement with services. 

Unfortunately, we have seen policies, including some by Safeguarding Adults Boards which, seemingly in an attempt to summarise and simplify process, may give incorrect impressions of the freestanding 42 duty. 

The Mental Capacity Act's five statutory principles bear repeating, as reviews reveal they are frequently misapplied. While the starting point is a presumption of capacity, this cannot be relied upon where there are indicators that an assessment is needed.

When it comes to assessment, it is important that practitioners recognise capacity is decision-specific and may fluctuate over time – both particularly important considerations in self-neglect cases. Staff undertaking capacity assessments need to be able to recognise signs of executive functioning impairments, if they are to reach robust decisions. 

What works: Evidence-based responses

CQC assessments identify several effective interventions which included:

• meta-analysis of SARs with systematic dissemination of learning;
• specialist tools including self-neglect toolkits,
• flowcharts, and clutter index tools;
• Multi-Agency Risk Assessment and Management processes with high-risk panels;
• specialist services involving people with lived experience; and
• concerted training efforts incorporating trauma-informed practice and executive functioning approaches.

For capacity assessments, authorities achieving near-100% MCA/DoLS training completion demonstrate significantly better practice.

In CT v Lambeth, Mrs Justice Theis DBE noted the "excellent example" of a social worker's capacity assessment, which used a structured form promoting compliance with the statutory framework. Some authorities achieved same-day processing of DoLS requests with no waiting lists, contrasting starkly with authorities where people waited far longer for DoLS authorisations.

Person-centred approaches, recognising individuals' rights to make decisions even if considered unwise, conducting assessments over several weeks to allow processing time, and using innovative communication tools such as easy read materials also found favour with CQC. Some authorities achieved 100% advocacy support for people lacking capacity, significantly exceeding the England average of 83%.

The role of legal teams

Legal teams can contribute significantly through:

• policy reviews ensuring legal accuracy on self-neglect thresholds and legal duties;
• training delivery to address concerningly low completion rates;
• supporting development of high quality assessment tools and embedding learning from SARs, complaints, legal challenges or claims, and inquests; and
• empowering frontline staff through policy development and case-specific input.

In particular, for legal teams who find they are receiving multiple routine enquiries, are aware of complaints or backlogs, or know of adverse incidents, interventions to support improved frontline practice can support more and better independent case decisions from the social care client team. 

Conclusion

Self-neglect cases demand a sophisticated understanding of the interplay between individual autonomy and protective duties. The evidence from CQC assessments and SARs demonstrates that effective responses require robust training, clear policies that accurately reflect statutory duties, and systematic approaches to mental capacity assessment that recognise the complexities of executive functioning.

The variations in practice between authorities show that best practice is achievable, but tends to require concerted work to develop the social work team’s capability in dealing with these challenging cases. 

For many authorities, the reports indicate that the place to start will be to ensure policies are legally accurate, address existing misunderstandings and that high quality assessment tools are available.  Save for those few authorities with excellent training rates, concerted work is then required to develop insight and embed policies and processes in social work teams.

For legal teams, the opportunity exists to be catalysts for this improvement, ensuring that the law serves its intended purpose of protecting vulnerable adults while respecting their autonomy. 

How can we help? 

With a team of specialist lawyers who work on these cases with our local authority clients, we have extensive expertise in advising on capacity mental health and self-neglect issues. We have worked with a number of authorities to review and develop policies, assessment tools and training for their teams in order to support improved outcomes for their teams and service users.